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Inferior vena cava filters (IVC filters) are indicated as a treatment to prevent pulmonary embolism in a select group of patients that have venous thromboembolism (VTE) and absolute contraindication to anticoagulation, failure of anticoagulation, complications resulting from anticoagulation or progression of deep vein thrombosis (DVT) despite adequate anticoagulation. This activity focuses on the basic knowledge about IVC filters, with emphasis on their indications, contraindications, complications, and clinical significance. It also highlights the role of the healthcare team in managing these patients. Objectives: Review the anatomical structures, indications, and contraindications of inferior vena cava filter placement. Outline the technique for inferior vena cava filter placement. Describe the potential complications and clinical significance of inferior vena cava filters. Summarize interprofessional team strategies for improving care coordination and communication to advance inferior vena cava filters and improve outcomes with their use. Access free multiple choice questions on this topic.

Pulmonary embolism (PE) secondary to venous thromboembolism (VTE) is a major preventable cause of mortality in hospitalized patients. Prophylactic anticoagulation with mechanical and pharmacological therapies is indicated for high-risk patients. Pharmacological anticoagulation is the first-line treatment for newly diagnosed VTE and pulmonary embolism. Inferior vena cava (IVC) filter is a treatment option to prevent pulmonary embolism in a select group of patients that have venous thromboembolism (VTE) and absolute contraindication to anticoagulation, failure of anticoagulation, complications resulting from anticoagulation or progression of deep vein thrombosis (DVT) despite adequate anticoagulation.[1][2] The Greenfield inferior vena cava filter came on the market in 1973. Currently, there are two categories of IVC filters in use: permanent and retrievable. The use of IVC filters has increased since the advent of retrievable IVC filters that were approved by the FDA in 2003 and 2004.[3] Most studies have not shown any difference in the all-cause mortality in deep venous thrombosis (DVT) patients treated with IVC filters compared to the ones treated with anticoagulation therapy alone. Prophylactic IVC filters are sometimes inserted in patients at high risk of developing venous thromboembolism (VTE), especially if there is a contraindication to anticoagulation. These studies have not shown any mortality benefit. In fact, IVC filters correlate with an increased risk of recurrent deep vein thrombosis and other complications.[4]

Complications related to using inferior vena cava filters fall into the following categories; those occurring during the procedure, following the procedure, and during retrieval. Procedure: During the vascular access for IVC filter insertion, bleeding and thrombosis are the most common complications. Other complications that can occur during this time include filter tilt (angulation of more than 15 degrees along the longitudinal axis of IVC), filter migration (change in position of the filter by more than 2 cm) or operator error (filter placement in the inaccurate location or incorrect orientation); these can result in a difficult to retrieve as well as an ineffective IVC filter. Post-procedure: 1) IVC thrombosis can occur, resulting in pain and edema of bilateral lower extremities; this can also result in an increased risk of a pulmonary embolism due to the thrombus extending above the filter and embolizing to the lungs. 2) Renal failure is another dreaded complication that can occur in case the thrombus extends to the suprarenal IVC. 3) There is a possibility of inferior vena cava penetration by the IVC filter. Hooks were added to the filters to decrease the incidence of filter migration, but this has shown to increase inferior vena cava perforation rates significantly. 4) Filter fracture can occur, resulting in fragmentation of the filter. These fragments can embolize to the heart and lungs. Retrieval: The longer the time that the filter remains in place, the greater the rate of complications during retrieval. Some of the most commonly noted complications during filter retrieval include fracture and IVC injury (e.g., dissection). Thus removal of IVC filter as soon as it is no longer needed is highly recommended.[10] As compared to permanent IVC filters, complications occur much more frequently with the use of retrievable IVC filters.[11] Fracture is the most common complication of retrievable IVC filters, and placement malfunction occurs more commonly with permanent IVC filters.[12]

Considering the low retrieval rates of inferior vena cava (IVC) filters, complications associated with their use and lack of randomized controlled trials to show their efficacy in different subsets of patients, it is important to involve an interprofessional team consisting of an interventional radiologist, vascular surgeon, hospitalists, primary care providers, interventional cardiologist, hematologists, nurse practitioners and nurses to develop protocols that can result in improved retrieval rates and better patient selection for IVC filter placement.[14][15] Patient education by nurses and physicians before the procedure, implementation of protocols, and post-procedure follow-up with a hematologist have all shown to improve the retrieval rate for IVC filters significantly.[15] [Level IV] Nurses should also be alert and aware of potential signs of adverse events, so they can intervene and inform the surgeon, preventing negative outcomes. Pharmacists will weigh in on anti-coagulant therapy, making dose adjustments, and performing a medication reconciliation to ensure there are no issues that can affect the IVC filter therapy. Effective communication between hospitalists, primary care providers, nurses, and interventional radiologists has the potential for decreasing unnecessary filter insertion and improving retrieval rates, especially in situations of prophylactic use. A thorough history by the hospitalists and primary care providers can help in making a better decision regarding IVC filter insertion. IVC filters have not shown any mortality benefit over anticoagulation alone. They have shown some advantage in preventing pulmonary embolism recurrence but at the expense of significantly increased risk of deep vein thrombosis recurrence.[7] [Level II] All of the above highlights the need for interprofessional team coordination between all disciplines when considering IVC filters in the management of a patient; this will result in improved outcomes. [Level V]

During the pre-procedure time, patient education by the nurses has shown to improve follow-up and IVC filter retrieval rates. Nurses can play a vital part in the formation of a structured program for effective and timely removal of the inferior vena cava (IVC) filters. They can maintain a comprehensive chart and call patients for follow-up. [15]

Nurses should have a strong fundamental knowledge of complications related to inferior vena cava (IVC) filter use. Close monitoring for the development of complications can decrease both morbidity and mortality in patients.