Presentation Details
| A Survey of Clinician Practice Patterns on the Use of Inferior Vena Cava Filters for Venous Thromboembolism Jillian Calandra1, Rahman Ladak2, Massimo Sementilli3, Alejandro Lazo-Langner2, 4, Deborah Siegal5, 6, Tzu-Fei Wang5, 6, Rong Luo7, Andrea Cervi7. 1WE-SPARK Health Institute, Windsor, ON, Canada.2Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.3Department of Biomedical Sciences, University of Windsor, Windsor, ON, Canada.4Lawson Health Research Institute, London, ON, Canada.5Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.6Ottawa Hospital Research Institute, Ottawa, ON, Canada.7Windsor Regional Hospital, Windsor, ON, Canada |
Abstract
Background: While anticoagulation remains the first line of treatment for acute deep vein thrombosis (DVT) and pulmonary embolism (PE), use of inferior vena cava filters (IVCFs) has increased in recent decades. IVCFs were designed to trap thrombus originating in lower extremity veins to prevent the development of clinically-significant PE. Data demonstrating the effectiveness of IVCFs in reducing thrombosis-related morbidity are lacking, however. While current guidelines agree that IVCFs should be considered in instances of acute venous thromboembolism (VTE) and an absolute contraindication to anticoagulation, details surrounding indiciations for their use vary among guideline societies which contributes to the heterogeneity in use of IVCFs in practice. Given that IVCFs may be associated with significant harm and costs, further efforts toward defining clear indications for IVCF use are needed. Objectives: As a first step toward defining best practices, we developed a survey of clinicians to characterize current IVCF use in various VTE scenarios. Specifically, we aimed to evaluate clinician use of IVCFs according to (1) acuity of VTE and absolute contraindication to anticoagulation; (2) isolaed PE without concurrent lower extremity DVT; and (3) anticoagulation failure. Methods: We conducted an online, cross-sectional survey of clinicians using Qualtrics software. The survey was publicized via emails to international organizations of hematologists, thrombosis specialists and interventional radiologists, including the Anticoagualtion Forum, Thrombosis Canada, Canadian Hematology Society (CHS), International Society on Thrombosis and Hematosis (ISTH), and the Society of Interventional Radiology (SIR). Results: We received 188 survey responses in total. The majority of respondents specialize in interventional radiology (38.7%) and hematology/thrombosis (34.1%), with half practicing in an academic facility (49.6%) versus community setting. Approzimately half (53.4%) of respondents indicated having established protocols for IVCF removal post-insertion. When provided with a case of acute PE with contraindication to anticoagulation but no concurrent leg DVT, 44% responded that they would proceed with a filter as opposed to observation with serial leg ultrasounds. Most (61%) respondents would consider filter placement for a proximal leg DVT diagnosed 2-days before an absolute contraindication to anticoagulation, but only 24% would proceed with a filter if the DVT was diagnosed 3-weeks earlier. In the setting of recurrent PE and acute proximal leg DVT despite therapeutic anticoagulation, 44% of clinicians would advocate for IVCF insertion. Across fictional case scenarios, thrombosis specialists/hematologists were less likely to proceed with filter insertion compared to other specialists (p=0.024). There was no impact of practice setting (i.e. academic versus community) on responses (p=0.512). Conclusions: Our survey highlights the heterogeneity in the use of IVCFs in clinical practice, particularly in instances of acute PE without lower extremity DVT and anticoagulation failure. The variability in survey responses is reflective of the discrepancy that exists among current practice guidelines which contradict one another in certain settings relating to filter use, or lack clarity in other indications. Moreover, most clinical guidelines do not provide recommendation on monitoring post-IVCF insertion to optimize filter removal rates and minimize risk of complications. Futher prospective data relating to the use of IVCFs in controversial settings is warranted.
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