The authors present an important paper, summarizing the literature on a potentially serious adverse outcome from inferior vena cava (IVC) filter placement, that being embolization to the cardiopulmonary system.1 The United States still outpaces many other countries with the number of IVC filters placed annually. Although this has decreased slightly after United States Food and Drug Administration communications in 2014, plateauing around 55,000 to 60,000 per year, down from over 100,000 per year,2 filters can still lead to serious adverse events.
This article may actually underestimate the true incidence of serious complications, as they did not assess the Manufacturer and User Facility Device Experience (MAUDE) database or other similar international databases looking at all filter complications, merely those reported in the literature. On the MAUDE database, filter fracture is one of the most common filter complications reported (27%), whereas migration or limb embolization has been less commonly reported, at 369 documented.3 As the authors pointed out, filter dwell time is directly related to increased risk of strut fracture and embolization.1 Procedural complication rates for retrieval range from 0% to 20%, including access site complications, leg fracture and embolization, and IVC injury, with advanced techniques being associated with a four-fold higher rate of complication.4 Advanced techniques are more frequently required in certain types of filters, specifically those that have greater risk of tilt or end up with the hook embedded in the IVC wall.5,6 Further, the retrieval process also exposes patients to risk, as noted by the authors, with 4.7% of reported embolization to the cardiopulmonary system occurring during retrieval attempts—either of the entire filter or filter struts.
Early generation retrievable filters appeared to have had a higher rate of complications, including up to 16% incidence of strut fracture and 25% strut embolization of those that fractured, with 71% of embolized struts lodging in the heart for one of the first-generation filters.3 A recent study found the rate of fracture of struts at 14% when filters are in place for at least 4 years, higher in retrievable filters than permanent (70% vs 15%).7
In conclusion, vascular surgeons and others who are placing and retrieving IVC filters need to consider patient anatomy, true indication for filter placement, potential complications, filter type, risk of tilt or embedment of the hook in the IVC wall, and length of time necessary for the filter, as well as carefully coordinating retrieval when choosing a filter for placement. At retrieval, extreme care is important to avoid strut fracture with risk of embolization, especially if and when advanced techniques are needed, as embolization to the heart can be fatal.
The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery: Venous and Lymphatic Disorders or the Society for Vascular Surgery.
Funding
None.
Disclosures
None.
Footnotes
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
References
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