Greenfield filter...why?

[Idiopathic]

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60-year old man w/Hx of Parkinsons and closed head trauma in the ICU X 10 days. No Hx of DVT or PE. Px cannot be placed on oral anticoagulants, due to ongoing subdural bleed. Interventional jumps on the chance to put in a Greenfield filter (which obviously comes with its own complications) even though they have ordered q7 lower extremity US for DVT and have found none. Was this warranted? Is there literature that supports prophylactic placement of IVC filters for individuals who cannot be anticoagulated but have no Hx of, and no current symptoms of, DVT/PE?

 

[MustafaMond]

The role of temporary inferior vena cava filters in critically ill surgical patients.

Offner PJ, Hawkes A, Madayag R, Seale F, Maines C.

Trauma Service, St Anthony Central Hospital, Denver, Colo 80204, USA. [email protected]

HYPOTHESIS: Prophylactic temporary inferior vena cava (IVC) filters are safe and effective in critically ill patients at high risk for venous thromboembolism. DESIGN: Prospective cohort study. SETTING: Urban level I trauma center. SUBJECTS: Multiple-trauma patients and critically ill surgical patients undergoing prophylactic temporary IVC filter placement. All patients were at high risk for venous thromboembolism but had contraindications to low-dose heparin therapy. INTERVENTIONS: The interventional radiologist used the femoral or internal jugular approach to place a removable IVC filter in all patients. The filter was removed when the patient could safely be treated with heparin. If the filter could not be removed by 14 days, it was relocated to prevent incorporation precluding retrieval. MAIN OUTCOME MEASURES: Complications of filter insertion and removal, deep venous thrombosis, and pulmonary embolism. RESULTS: From May 1, 2001, to October 1, 2002, 44 patients underwent placement of temporary IVC filters. Thirty-seven patients (84%) were severely injured. The mean +/- SD age was 37 +/- 3 years, and 55% were men. The mean +/- SD Injury Severity Score of the trauma patients was 33 +/- 2, and all had blunt injury. There were no complications associated with filter insertion or removal. Nine patients required filter relocation prior to retrieval. Three filters could not be removed: 2 secondary to significant clots trapped below the filter and 1 because of angulation resulting in the inability to grasp the filter. There were no documented instances of venous thromboembolism following IVC filter placement and removal. CONCLUSIONS: Temporary IVC filters are safe and effective in critically ill surgical and trauma patients and allow an aggressive approach to prevention of venous thromboembolism in this challenging group of patients..

Was it a temporary or permanent filter?

 

[Docxter]

60-year old man w/Hx of Parkinsons and closed head trauma in the ICU X 10 days. No Hx of DVT or PE. Px cannot be placed on oral anticoagulants, due to ongoing subdural bleed. Interventional jumps on the chance to put in a Greenfield filter (which obviously comes with its own complications) even though they have ordered q7 lower extremity US for DVT and have found none. Was this warranted? Is there literature that supports prophylactic placement of IVC filters for individuals who cannot be anticoagulated but have no Hx of, and no current symptoms of, DVT/PE?

How can interventional "jump" on putting in a filter?? Surely someone from neurosurgery has asked them to put one in; IR is not chasing patients around the hospital to put in IVC filters!!

And yes, for patients whom prolonged immobilization is anticipated but have contraindications to any form of anticoagulation, e.g. severe multiple trauma, certain neurosurgical patients, etc. , a prophylactic filter is placed. Up until a few years ago, these were "permanent" filters, i.e. removing them was not manufacturer or FDA approved/advised, though some were removed anyway by some IR people, expecially in young patients once they got somewhat better. Nowadays, there are "removable temporary" filters available, although for a 60 y/o, you could also put in a permanent filter.

 

[Idiopathic]

I was told that they were 'removable' but still carried enough risk to question why it was being done. Of course they were consulted by NS, but they were skeptical about it at first, until they heard "head injury + unable to anticoagulate". I dont mean to imply that anything shady went on, but some of the IM residents questioned this procedure in someone with no Hx of DVT and no symptoms.