Chapter 13 Endovenous Placement of Inferior Vena Caval Filters
Patient Selection
The accepted and relative indications1 for placement of an IVC filter are shown in Table 13-1. Although anticoagulation is the mainstay of therapy in patients with acute deep venous thrombosis (DVT) or pulmonary embolism, it may be contraindicated for several reasons. Active internal bleeding is an absolute contraindication to therapeutic anticoagulation. However, an increased risk of bleeding due to recent trauma or major surgery (especially neurologic or ocular surgery) more often is a relative contraindication that is subject to clinical judgment. In the era when unfractionated heparin and vitamin K antagonists were the only available antithrombotic agents, nonhemorrhagic complications of anticoagulation (e.g., heparin-induced thrombocytopenia, warfarin-induced skin necrosis) were more common indications for IVC filter insertion. Currently, however, several alternative anticoagulants are available, and they should be considered prior to insertion of an IVC filter. Direct-thrombin inhibitors are very effective antithrombotic alternatives to heparin or low-molecular-weight heparin in patients who develop heparin-induced thrombocytopenia. Subcutaneously injected low-molecular-weight heparins and pentasaccharides, as well as oral direct-thrombin inhibitors, are potential alternatives in patients with warfarin-induced skin necrosis.
DVT, Deep venous thrombosis; IVC, inferior vena cava; LE, lower extremity; VTE, venous thromboembolism.
An often-cited indication for IVC filter insertion is “failure of anticoagulation.” Significant proximal DVT extension and pulmonary embolism may occur in up to 4% to 11% of patients who receive anticoagulation for acute lower extremity DVT. Over 70% of these failures occur in the first 3 weeks after initiation of therapy. However, there should be a distinction between patients who are receiving adequate versus those receiving inadequate antithrombotic therapy. Patients should be carefully questioned, and the anticoagulation records should be reviewed to determine whether dosages and frequency of antithrombotic medications were adequate (Table 13-2; Fig. 13-1; see also Table 13-1).
Name | Diameter | Length |
---|---|---|
Guidewires | ||
Bentson/Rosen | .035 in | 150-180 cm |
Angled glidewire | .035 in | 150-180 cm |
Catheters | ||
Pigtail (with 2-cm calibration) | 5-Fr | 65-90 cm |
Kumpe (or other angled catheter) | 5-Fr | 65-90 cm |
Ancillary Supplies | ||
Heparinized saline | 1000 units/ 1000 mL of normal saline | |
Syringes (2) | 20 mL, Luer Lock | |
Dilators | 5-Fr and 6-Fr | |
Injectable nonionic contrast, high-flow power injector |
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