Predictors of Interventional Treatment Use for Venous Thromboembolism in Cancer Patients.
ABSTRACT: Venous thromboembolic disease is a major cause of morbidity in cancer patients. The Perspective database was used to identify patients with solid tumors and a diagnosis of VTE from 2006 to 2012. We examined use of IVC filters, thrombolysis, and thrombectomy. Among 32,545 patients, 23.1% received an IVC filter, 1.9% thrombolytic therapy, and 0.4% underwent thrombectomy. Use of IVC filters decreased between 2006 and 2012 (23.4% to 21.2%, p = 0.012). Older patients, uninsured patients, Hispanics, and those with more comorbidities were more likely to undergo filter placement while patients at rural hospitals were less likely to receive an IVC filter (p < 0.05 for all).
Project description:Inferior vena cava (IVC) filters are commonly used in select high-risk patients for the prevention of pulmonary embolism. Potentially serious complications can arise from the use of IVC filters, including thrombosis of the filter itself and filter fragment embolization. This article discusses the utility of IVC filters and reviews the management of two cases of filter-related complications.
Project description:Inferior vena cava (IVC) filters are placed to prevent pulmonary embolism, however, some studies have suggested that IVC filters are associated with exacerbated risks of deep vein/IVC thrombosis in cancer patients. The purpose of this study is to determine if cancer patients develop higher than expected rates of venous thromboembolism complications after filter placement compared with noncancer patients.A retrospective cohort study of consecutive patients who received filters (2002 to 2006) at Johns Hopkins was conducted. Exposures and outcomes were obtained by chart review. Relative risks (RR, 95% confidence interval [CI]) for outcomes in cancer versus noncancer patients were estimated using multistate models.The cohort included 702 patients-246 with cancer and 456 without cancer. Cancer patients were older, more likely to be white and have filters placed for contraindications to anticoagulation (P<0.01). The most common cancers were lung (11.8%) and colorectal (10.6%). Cancer patients had an increase in venous thromboembolism (RR 1.9 [95% CI, 1.1, 3.2]) due to more deep venous thrombosis/IVC thrombosis (RR 1.7 [95% CI, 1.0, 3.0]). Higher pulmonary embolism rates in cancer were not statistically significant (RR 2.2 [95% CI, 0.8, 5.8]).Cancer patients have elevated risks of thrombotic complications compared with noncancer patients; however, these risks are not higher than expected based on historical controls.
Project description:Our study objective was to describe the frequency, indications, and outcomes after inferior vena cava (IVC) filter placement in a population-based sample of residents of the Worcester, Massachusetts, metropolitan area who had been diagnosed as having acute venous thromboembolism (VTE) in 1999, 2001, and 2003.A retrospective chart review of inpatient and outpatient medical records was conducted. Recorded indication(s) for IVC filter placement was determined among a subset of cases from 3 Worcester tertiary care hospitals. Three thrombosis specialists assessed the appropriateness of IVC filter placement.Of 1547 greater Worcester residents with validated acute VTE and without a prior IVC filter, 203 (13.1%) had an IVC filter placed after acute VTE. Patients with an IVC filter were older, had more comorbidities, and had a higher mortality rate during 3 years of follow-up. There was unanimous agreement by panel members that the use of an IVC filter was appropriate in 51% of cases and inappropriate in 26% of cases, with no consensus in the remaining 23%.In this community-based study, IVC filters were frequently used in the treatment of patients with acute VTE. Placement was deemed to be appropriate in approximately 50% of the patients but was not appropriate or debatable in the remaining cases. Given the increasing use of IVC filters, prospective studies are clearly needed to better define the indications for, and efficacy of, IVC filter placement.
Project description:The role of inferior vena cava filter (IVC) filters for prevention of pulmonary embolism (PE) is controversial. This study evaluated outcomes of IVC filter placement in a managed care population. This retrospective cohort study evaluated data for individuals with Humana healthcare coverage 2013-2014. The study population included 435 recipients of prophylactic IVC filters, 4376 recipients of therapeutic filters, and two control groups, each matched to filter recipients. Patients were followed for up to 2 years. Post-index anticoagulant use, mortality, filter removal, device-related complications, and all-cause utilization. Adjusted regression analyses showed a positive association between filter placement and anticoagulant use at 3 months: odds ratio (ORs) 3.403 (95% CI 1.912-6.059), prophylactic; OR, 1.356 (95% CI 1.164-1.58), therapeutic. Filters were removed in 15.67% of prophylactic and 5.69% of therapeutic filter cases. Complication rates were higher with prophylactic procedures than with therapeutic procedures and typically exceeded 2% in the prophylactic group. Each form of filter placement was associated with increases in all-cause hospitalization (regression coefficient 0.295 [95% CI 0.093-0.498], prophylactic; 0.673 [95% CI 0.547-0.798], therapeutic) and readmissions (OR 2.444 [95% CI 1.298-4.602], prophylactic; 2.074 [95% CI 1.644-2.616], therapeutic). IVC filter placement in this managed care population was associated with increased use of anticoagulants and greater healthcare utilization compared to controls, low rates of retrieval, and notable rates of device-related complications, with effects especially pronounced in assessments of prophylactic filters. These findings underscore the need for appropriate use of IVC filters.
Project description:<h4>Importance</h4>Venous thromboembolism is the second overall leading cause of death for patients with cancer, and there is an approximately 2-fold increase in fatal pulmonary embolism (PE) in patients with cancer. Inferior vena cava (IVC) filters are designed to prevent PE, but defining the appropriate use of IVC filters in patients with cancer remains a substantial unmet clinical need.<h4>Objective</h4>To evaluate the association of IVC filters with the development of PE in patients with cancer and deep venous thrombosis (DVT).<h4>Design, setting, and participants</h4>A population-based cohort study was conducted using administrative data on 88 585 patients from the state inpatient databases for California (2005-2011) and Florida (2005-2014). Based on diagnostic and procedure codes, patients with cancer and acute lower extremity DVT were identified. All subsequent hospital visits for these patients were evaluated for the placement of an IVC filter, the development of new PE, the development of new DVT, and in-hospital mortality. Data analysis was performed from September 1 to December 1, 2019.<h4>Exposures</h4>Placement of an IVC filter.<h4>Main outcomes and measures</h4>The association of IVC filter placement with rates of new PE and DVT was estimated using a propensity score matching algorithm and competing risk analysis.<h4>Results</h4>The study cohort comprised 88 585 patients (45 074 male; median age, 71.0 years [range, 1.0-104.0 years]) with malignant neoplasms who presented to a health care institution with a diagnosis of acute lower extremity DVT. Of these patients, 33 740 (38.1%) underwent IVC filter placement; patients with risk factors such as upper gastrointestinal bleeding (odds ratio, 1.32; 95% CI, 1.29-1.37), intracranial hemorrhage (odds ratio, 1.21; 95% CI, 1.19-1.24), and coagulopathy (odds ratio, 1.09; 95% CI, 1.08-1.10) were more likely to receive an IVC filter. A total of 4492 patients (5.1%) developed a new PE after their initial DVT diagnosis. There was a significant improvement in PE-free survival for these patients compared with those who did not receive IVC filters across the full, unbalanced study cohort as well as after propensity score matching and competing risk analysis (hazard ratio, 0.69; 95% CI, 0.64-0.75; P < .001). Furthermore, IVC filter placement reduced the development of PE in patients with very high-risk malignant neoplasms (eg, pancreaticobiliary cancer), high-risk malignant neoplasms (eg, lung cancer), and low-risk malignant neoplasms (eg, prostate cancer). After accounting for anticoagulation use and imbalanced risk factors, IVC filter placement did not increase the risk of new DVT development.<h4>Conclusions and relevance</h4>This study suggests that, for patients with cancer and DVT and bleeding risk factors, IVC filter placement is associated with an increased rate of PE-free survival.
Project description:Background:Bariatric surgery patients are at increased risk for VTE, but potential risks versus benefits of IVC filters in this group remain unclear. Indwelling filters may increase risk of VTE, and removal of filters in obese patients can be challenging. This study evaluated the incidence of VTE in select bariatric patients receiving prophylactic IVC filters, their risk of filter-related complications, and outcomes from attempted filter retrieval. Results:Postsurgical DVT occurred in 3 patients within 3 months postoperatively (3%)(95%CI:1-9%), and 1 patient(1%)(95%CI:0-5%) developed acute low-risk PE at 31 days postoperatively, prior to filter removal. All VTE patients were successfully managed with therapeutic anticoagulation alone except one who required thrombolysis. Median filter dwell time was 54 days (range:22-1548), and there were no major filter-related complications (0%)(95%CI:0-3%). Retrieval was attempted in 104 cases (97%)(95%CI:92-99%) and successful in 104 cases (100%)(95%CI:97-100%). Thirty-three patients (32%)(95%CI:23-42%) required advanced techniques for filter removal, and there were no major procedural complications (0%)(95%CI:0-3%). Median follow-up occurred at 344 days (range:3-1570) days after filter retrieval. Conclusions:No cases of life-threatening post-op PE occurred in this cohort of high-risk bariatric surgery patients receiving prophylactic IVC filters in combination with mechanical and chemoprophylaxis. The risk of filter-related complications was low and retrieval success was high with adjunctive use of advanced techniques. Clinical trial registration:NCT01158482.
Project description:Appropriate placement of an inferior vena cava (IVC) filter necessitates imaging of the renal veins because when an IVC filter is deployed its tip should be at or below the inferior aspect of the inferiormost renal vein. Traditionally, imaging during placement of IVC filters has been with conventional cavography and fluoroscopy. Recently, intravascular ultrasound has been used for the same purpose but with additional expense. Morbidly obese patients often exceed the weight limit of fluoroscopy tables. In addition, short obese patients are at risk of falling from narrow fluoroscopy tables. For such patients, computed tomography (CT) guidance is a viable alternative to conventional fluoroscopic guidance. IVC placement was performed in the CT suite for two obese patients who exceeded the weight limits of the available fluoroscopy tables. In one case, a Vena-Tech filter (Braun Medical, Melsungen, Germany) was placed using CT fluoroscopy. In the second case, a Recovery (Bard, Murray Hill, NJ) filter was placed using intermittent limited z-axis scanning. In the first case, the filter was placed below the level of the renal veins and above the confluence of the iliac veins, which is acceptable placement. In the second case, with refinement of technique, the filter tip was placed less than 1 cm below the inferiormost renal vein, which is considered optimal placement. CT of the IVC precisely images the renal veins and can characterize their number and their confluence with the IVC. CT guidance is a viable alternative to fluoroscopic guidance for the placement of IVC filters in morbidly obese patients.
Project description:Inferior vena cava filter (IVCF) placement appears to be expanding over time despite absence of clear directing evidence.Two populations were studied. The first population included patients who received an IVCF between January 2005 and August 2013 at our community hospital center. Demographic information, indications for placement, and retrieval rate was recorded among other variables. The second population comprised of patients receiving an IVCF from 2005 to 2012 according to the Nationwide Inpatient Sample (NIS) using ICD-9CM coding. Patients were divided into 2 groups based on the year of admission for comparison, that is, first group from 2005 to 2008 and the second from 2009 to 2012. In addition, we analyzed annual trends in filter placement, acute venothromboembolic events (VTE) and several underlying comorbidities within this population.At our center, 802 IVCFs were placed (55.2% retrievable); 34% for absolute, 61% for relative, and 5% for prophylactic indications. Major bleeding (27.5%), minor self-limited bleeding (13.7%), and fall history (11.2%) were the commonest indications. Periprocedural complication rate was 0.7%, and filter retrieval rate was 7%. The NIS population (811,487 filters) saw a decline in IVCF placement after year 2009, following an initial uptrend (Ptrend?<?0.01). IVCF use among patients with neither acute VTE nor bleeding among prior VTE saw a 3-fold absolute reduction from 2005 to 2012 (33,075-11,655; Ptrend?<?0.01). Patients from 2009 to 2012 were more likely to be male and had higher rates of acute VTE, thrombolytic use, cancer, bleeding, hypotension, acute cardiorespiratory failure, shock, prior falls, blood product transfusion, hospital mortality including higher Charlson comorbidity scores. The patients were younger, had shorter length of stay, and were less likely to be associated with strokes including hemorrhagic or require ventilator support. Prior falls (adjusted odds ratio-aOR 2.8), thrombolytic use (aOR 1.76), and shock (aOR 1.45) were most predictive of IVCF placement between 2009 and 2012 on regression analysis.Recent trends suggest that a higher proportion of patients receive temporary IVCF, for predominantly relative indications. Nationally, the number of filters being placed is decreasing, especially among those who did not experience acute VTE or bleeding events. Prior falls, thrombolytic therapy, and shock were most predictive of IVCF placement in latter half of the study period.
Project description:Venous thromboembolism (VTE) is a common cause of morbidity and mortality. This is especially true for hospitalized patients. Pulmonary embolism (PE) is the leading preventable cause of in-hospital mortality. The preferred method of both treatment and prophylaxis for VTE is anticoagulation. However, in a subset of patients, anticoagulation therapy is contraindicated or ineffective, and these patients often receive an inferior vena cava (IVC) filter. The sole purpose of an IVC filter is prevention of clinically significant PE. IVC filter usage has increased every year, most recently due to the availability of retrievable devices and a relaxation of thresholds for placement. Much of this recent growth has occurred in the trauma patient population given the high potential for VTE and frequent contraindication to anticoagulation. Retrievable filters, which strive to offer the benefits of permanent filters without time-sensitive complications, come with a new set of challenges including methods for filter follow-up and retrieval.
Project description:Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Placement of a retrievable inferior vena cava (IVC) filter is used when patients have contraindications to anticoagulation or recurrent pulmonary embolism despite therapeutic anticoagulation. Although retrievable IVC filters are often used, they carry a unique set of risks.A 67-year-old man presents to the Emergency Room (ER) following large volume melena and complaining of syncope. One year prior, the patient had been diagnosed with Glioblastoma multiforme, for which he underwent a craniotomy with near-total resection of the mass. He subsequently developed a deep vein thrombosis and underwent placement of a retrievable inferior vena cava (IVC) filter. Computerized tomography (CT) and esophagogastroduodenoscopy showed duodenal perforation by the retrievable IVC filter. The filter was successfully retrieved through an endovascular approach.Retrievable IVC filter placement is the preferred method of pulmonary embolism prevention in patients with significant risk for bleeding. Duodenal perforation by a retrievable IVC filter is a rare and serious complication. It is usually managed surgically, but can also be managed non-operatively.For patients with significant comorbidities or patients who are poor surgical candidates, non-operative management with close monitoring can serve as an initial approach to the patient with a caval enteric perforation secondary to a retrievable IVC filter.