IVC Filter vs. Anticoagulation for Secondary Prevention of Pulmonary Embolism | Journal Scan
What is the efficacy and safety of retrievable inferior vena cava (IVC) filters plus anticoagulation versus anticoagulation alone for the prevention of pulmonary embolism (PE) recurrence in patients presenting with acute PE and a high risk of recurrence?
In a randomized, open-label, blinded, endpoints adjudication trial (PREPIC2) at 17 centers with 6 months of follow-up between 2006 and 2013, 399 hospitalized patients with an acute symptomatic PE and associated lower extremity venous thrombus were randomized to receive either an IVC filter plus anticoagulation or anticoagulation alone (primarily with a vitamin K antagonist). All patients had at least one criterion for severity. The primary outcome was symptomatic recurrent PE at 3 months with secondary outcomes of recurrent PE at 6 months, symptomatic deep venous thrombosis, major bleeding, death, and IVC filter complications.
Successful IVC filter placement was achieved in 193/200 (96.5%) patients in the intervention arm with retrieval as planned in 153/164 (93.3%) patients in whom retrieval was attempted. At 3 months, recurrent PE occurred in six patients (3.0%, all fatal) in the IVC filter compared to three patients (1.5%, 2/3 fatal) in the control group (relative risk, 2.00; 95% confidence interval, 0.51-7.89). Similar results were seen at 6 months of follow-up. No difference was noted in any secondary outcomes between the two groups.
The authors concluded that among hospitalized patients with severe acute PE, the use of a retrievable IVC filter in addition to anticoagulation did not reduce the risk of recurrent PE as compared to anticoagulation alone. The authors concluded that this study’s results do not support the use of IVC filters in patients who can receive anticoagulation following an acute PE.
This well-designed multicenter, randomized trial adds to the growing literature demonstrating no additional benefit of IVC filter placement in patients with acute PE who are able to receive systemic anticoagulation. Given contentious debate in current practice, the authors purposefully selected high-risk acute PE patients for whom a retrievable filter is often placed to prevent a subsequent, presumably fatal, recurrent PE. Important to note, all patients were instructed to have their IVC filter removed at the 3-month interval, with successful removal in nearly 80% of patients who initially received an IVC filter placement. This success in filter retrieval is likely responsible for the low rate of deep venous thrombosis seen in the IVC filter arm of the trial. The trial also demonstrated the success of modern anticoagulation strategies to reduce the risk of PE recurrence, as low as 1.5% at 3 months of follow-up. Clinicians are urged to be judicious when selecting patients for IVC filter placement, especially when systemic anticoagulation is a viable treatment strategy.
Keywords: Anticoagulants, Control Groups, Follow-Up Studies, Lower Extremity, Pulmonary Embolism, Risk, Secondary Prevention, Thrombosis, Vena Cava Filters, Vena Cava, Inferior, Venous Thrombosis, Vitamin K
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