Survival Effects of Inferior Vena Cava Filter in Patients With Acute Symptomatic Venous Thromboembolism and a Significant Bleeding Risk

Study Questions:

What is the association between insertion of an inferior vena cava (IVC) filter and morbidity and mortality during the first month after treatment for acute venous thromboembolism (VTE) in patients who had known significant bleeding risk?

Methods:

This was a retrospective study of prospectively collected data from patients enrolled in the RIETE registry (Registro Informatizado de la Enfermedad TromboEmbolica). The current analysis included only those with symptomatic VTE. Only those patients who had an IVC filter inserted during the first 30 days after VTE diagnosis (because of an absolute or relative contraindication to anticoagulation) were included. “Treated” patients were those who received an IVC filter with or without concomitant anticoagulation. Control patients were those with similar distributions of covariates (including baseline risk of bleeding) who did not receive a filter, but did receive anticoagulant therapy. The primary endpoint was 30-day all-cause mortality after initiation of anticoagulation or filter insertion. Secondary outcomes included 30-day pulmonary embolism (PE)-related mortality, recurrent VTE, and major bleeding.

Results:

In the matched cohort of patients presenting with VTE, 344 patients were treated with filters and 344 patients were treated without filters. Filter insertion was associated with a nonstatistically significant lower mortality than nonfilter treatment in the matched cohort of patients with any VTE (6.6% vs. 10.2%; 95% confidence interval [CI], -7.7% to 0.7%; p = 0.12). There was a statistically significant decreased risk of PE-related mortality for filter insertion compared with no insertion (1.7% vs. 4.9%; 95% CI, -6.2% to -0.5%; p = 0.03). There was no significant difference in the rate of major bleeding at 30 days between patients receiving filters and those not receiving filters. The rates of recurrent VTE at 30 days in the matched cohort of patients with any VTE were significantly higher among patients receiving filters than among those not receiving filters (6.1% vs. 0.6%; 95% CI, 2.8% to 8.2%; p < 0.001). The impact of IVC filter therapy was similar in subgroups of patients who presented solely with deep venous thrombosis (DVT) or with PE (with or without DVT).

Conclusions:

The authors concluded that IVC-filter insertion was associated with a lower risk of PE-related death, but a higher risk of recurrent VTE, in patients presenting with symptomatic VTE and a contraindication to anticoagulation.

Perspective:

There is a paucity of data to inform the efficacy and safety of IVC filters in patients with acute symptomatic VTE. Although the analysis is a useful contribution and helps establish that IVC filter insertion reduces PE-related mortality (presumably by not allowing large PE to occur), the authors acknowledge that the study ‘did not address the value of IVC filters versus anticoagulant therapy in those situations in which filters are commonly advocated.’

Clinical Topics: Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine

Keywords: Vena Cava, Inferior, Vena Cava Filters, Pulmonary Embolism, Venous Thromboembolism


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