Asymptomatic Patients with Inferior Vena Cava Filter Penetration Through the Wall May Be Managed Conservatively
Wande B. Pratt, MD, Sam S. Leake, Shaikh Afaq, MD, Harleen K. Sandhu, MD, Hazim J. Safi, MD, Ali Azizzadeh, MD, Kristofer M. Charlton-Ouw, MD.
University of Texas Health Science Center at Houston, Houston, TX, USA.
OBJECTIVES: Current recommendations are for retrieval of optional inferior vena cava (IVC) filters when the risk of pulmonary embolism subsides. However, recent studies called into question the utility of removing all filters. When percutaneous retrieval fails, we only recommend open surgical removal for symptoms and other complications. We examined our outcomes with conservative management of unsuccessful percutaneous retrieval and open surgical removal for symptomatic/complicated IVC filters.
METHODS: In 2010, we began a formal program for IVC filter retrieval. Patients were referred for enrollment by the implanting physicians. Prior to retrieval, patients were evaluated for risk of future venous thromboembolic events and ongoing need for IVC filtration. Asymptomatic patients with unsuccessful percutaneous filter retrieval were recommended to have annual follow-up with plain abdominal x-ray and to take daily low-dose aspirin. Patients with symptoms referable to the indwelling filter, and those with complications, were offered open surgical removal.
RESULTS: 221 patients had 225 percutaneous filter retrieval attempts. Four patients had 2 attempts. Technical success in percutaneously retrieving the filter was 200/225 (89%) at mean of 6 +/- 4 months from implant. Of the 21 patients whose filters could not be percutaneously retrieved, all but one had significant filter barb penetration through the caval wall with tilting. Most (19 of 21; 90%) were asymptomatic and none had further complications over a mean follow-up of 3.9 years (range 9-66 months). The two patients with abdominal pain whose filters could not be retrieved percutaneously underwent open surgical removal via mini-laparotomy. An additional 5 patients who failed percutaneous retrieval at other institutions were referred to us for open surgical removal due to symptoms/complications. Technical success for all open surgical removal of IVC filters was 100%. There were no perioperative deaths or significant morbidities. All patients had resolution of their symptoms after percutaneous or open surgical removal.
CONCLUSIONS: Asymptomatic patients with unsuccessful percutaneous IVC filter retrieval appear to have low complications in midterm follow-up despite significant filter strut penetration through the caval wall into adjacent structures. Without symptoms or other complications, such patients do not require referral for open surgical filter removal. Symptomatic patients can expect low morbidity and resolution of symptoms after percutaneous or open surgical removal. Further studies are needed to determine the cost-effectiveness of routinely removing asymptomatic IVC filters.
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