ivc filters what you need to know n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
IVC filters what you need to know PowerPoint Presentation
Download Presentation
IVC filters what you need to know

Loading in 2 Seconds...

play fullscreen
1 / 37

IVC filters what you need to know - PowerPoint PPT Presentation


  • 147 Views
  • Uploaded on

IVC filters what you need to know. Sam Chakraverty Consultant Radiologist Ninewells Hospital Dundee, Scotland. IVC filters. When rather than How. IVC filters. Placed to prevent significant PE from deep veins of the leg, pelvis or IVC

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'IVC filters what you need to know' - christian-workman


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
ivc filters what you need to know

IVC filterswhat you need to know

Sam Chakraverty

Consultant Radiologist

Ninewells Hospital

Dundee, Scotland

ivc filters

IVC filters

When rather than How

ivc filters1
IVC filters
  • Placed to prevent significant PE from deep veins of the leg, pelvis or IVC
  • The best method of preventing such PE is anticoagulation
ivc filters2
IVC filters
  • RITI module 1c_027
  • Clinical Radiology (2009) 64:502-509
    • 3 centre audit in UK over 12 years
  • BSIR IVC Registry
venous thrombo embolic disease
Venous thrombo-embolic disease
  • 30% of patients with venous TED die within 30 days
  • 1 in 5 die of PE
  • 1% hospital admissions from any cause
  • 1 in 5 of these have PE
  • Isolated calf vein thrombosis not always benign
venous thrombo embolic disease1
Venous thrombo-embolic disease
  • Multiple controlled trials confirm benefit of anticoagulation
  • Repeated confirmation of efficacy for newer agents
  • The best method of preventing such PE is anticoagulation
evolution
Evolution
  • Prevention of possible embolism from deep veins to lungs
    • Surgical caval interruption
    • Surgical caval clips/plication
    • Insertion of filter with surgical access
    • Insertion of filter with percutaneous access
    • Possibility of retrieval
    • Most permanent filters retrievable
indications
Indications
  • Absolute / “definite”
  • Relative
  • Prophylactic
  • Evidence base is poor
ivc filter definite indications
IVC filter – “definite” indications
  • Recurrent PE despite adequate therapeutic anticoagulation
  • DVT or PE when anticoagulation is or has become contraindicated
ivc filter relative indications
IVC filter - relative indications
  • Patients with PE and limited cardiorespiratory reserve
  • Patients with massive PE requiring thrombectomy or thrombolysis
  • “free-floating” iliofemoral DVT
ivc filter prophylactic indications
IVC filter - prophylactic indications
  • surgery / delivery in patients with DVT or recent PE
  • Spinal cord trauma
  • High risk polytrauma
ivc filter prophylactic indications1
IVC filter - prophylactic indications
  • surgery / delivery in patients with DVT or recent PE
  • Spinal cord trauma
  • High risk polytrauma
  • Evidence base = 0
ivc filter use variable
IVC filter use variable
  • USA 140 per 1 million
ivc filter use
IVC filter use
  • USA 140 per 1 million
  • Sweden 3 per million
  • UK ?
ivc filter use1
IVC filter use
  • USA 140 per 1 million
  • Sweden 3 per million
  • UK ? ?30 per million
    • But increasing x3 1996-2004
evidence base is poor
Evidence base is poor
  • 1 RCT patients with DVT
  • Combined with trial of LMWH and iv heparin
  • 200 pts anticoagulation
  • 200 pts anticoagulation + filter
  • Day 12
    • 2 patients had PE in filter group
    • 9 patients had PE in non-filter group
    • Odds ratio 0.22 (0.05- 0.9)
evidence base is poor1
Evidence base is poor
  • 1 RCT patients with DVT
  • Combined with trial of LMWH and iv heparin
  • 200 pts anticoagulation
  • 200 pts anticoagulation + filter
  • 2 years
    • 37 patients had recurrent DVT in filter group
    • 21 patients had recurrent DVT in non-filter group
    • Odds ratio 1.87 (1.1-3.3)
evidence base is poor2
Evidence base is poor
  • 1 RCT patients with DVT
  • Combined with trial of LMWH and iv heparin
  • 200 pts anticoagulation
  • 200 pts anticoagulation + filter
  • 2 years
    • 37 patients had recurrent DVT in filter group
    • 21 patients had recurrent DVT in non-filter group
  • NO difference in mortality
what does this tell us
What does this tell us?
  • IVC filters unlikely to stop all PE when inserted in other groups of patients
  • Associated with some increased incidence of recurrent DVT
what does this not tell us
What does this not tell us?
  • Whether any of our definite or absolute indications for filter insertion are correct
  • Whether our relative indications for filter insertion are correct
assumptions
Assumptions
  • IVC filters don’t stop all PE but hopefully stop large life-threatening PE
  • May therefore have some impact on mortality
  • The increased risk of recurrent DVT is acceptable

Are parachutes effective?

multiple single airplane studies only

No RCT

Unlikely to get a RCT for filter

use in patients who are not

anticoagulated

procedure
Procedure
  • Definite indications
    • Reasonable to proceed
    • Check patient has has the best, most cost-effective and evidence-based treatment
  • Relative indications
    • Always discuss pros and cons
    • No right answer
  • Importance of audit and registry data over time
procedure1
Procedure
  • Usually aim to place below renal veins
  • suprarenal placement if IVC thrombus
  • small (6F) sheaths
  • local anaesthetic
procedure2
Procedure
  • no sedation
  • no starvation
  • ? stay therapeutically anticoagulated
  • bed rest 1 hour
procedure3
Procedure
  • Review imaging before you start
    • Where is DVT?
    • How big is IVC?
    • May give you information re IVC anatomical variation
  • Check you know how to deploy filter
    • Some easier than others to remember
    • Keep instructions to hand
procedure4
Procedure
  • Usually R CFV or R IJV
  • Modern filters tolerant of other approaches
  • Check anatomy normal (iliac vein confluence)
  • Check position of renal veins
procedure5
Procedure
  • Mark site below renal veins
  • Deploy filter
  • Remove sheath
  • Finish
permanent or temporary
Permanent or temporary?
  • Place a potentially-retrievable filter anyway
  • window for retrieval used to be 2 weeks, now longer periods possible
  • can remain as a permanent filter if becomes appropriate
  • anticoagulation if possible
permanent or temporary1
Permanent or temporary?
  • Decision and timing can be left until later, but don’t lose patients
  • Best is as early as possible e.g. mobilizing and therapeutically anticoagulated ??
  • Only 1/3 of retrievable filters end up being removed
retrieval
Retrieval
  • Potentially retrievable filters not always retrievable
    • IVC thrombus (doing its job)
      • Or the cause...
    • technical failure 5-10%
    • Complication rate of removal is not zero
    • Do you need to retrieve it?
complications
Complications
  • Access site thrombosis
  • IVC perforation
  • Migration
    • rare but catastrophic
  • Structural failure
  • IVC thrombosis
    • ?10-20% at 5 years
    • anticoagulate if possible
ivc filters3
IVC filters
  • Discuss non-definite indications
  • The best method of preventing such PE is anticoagulation