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Desai KR, Lewandowski RJ, Salem R, et al. Retrieval of Inferior Vena Cava Filters With Prolonged Dwell TimeA Single-Center Experience in 648 Retrieval Procedures. JAMA Intern Med. 2015;175(9):1572–1574. doi:10.1001/jamainternmed.2015.2561
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Retrievable inferior vena cava filters (IVCFs) offer temporary protection from pulmonary embolism without the long-term sequelae of a permanent implant; however, most are never removed.1 Prolonged presence of IVCFs has been associated with retrieval failure rates as high as 43%2 and device-related complications, including fracture, device migration, organ penetration, and an increased risk for venous thrombosis.3
We aimed to evaluate the technical success rate of IVCF retrieval after prolonged dwell times. We hypothesized that the retrieval success rate is independent of IVCF dwell time and that there is no significant difference in procedure-related rates of adverse events.
We included all IVCF retrieval procedures performed from January 1, 2009, through December 1, 2014. A standard retrieval technique (vascular sheath and snare device) was used in all cases. When standard techniques failed, adjunctive techniques included a directional sheath, loop wire, balloon disruption, endobronchial forceps, and laser sheath–assisted photothermal ablation. Primary study outcomes included technical success and procedure-related adverse events. This study was approved by the institutional review board of Northwestern University. All patients provided written informed consent.
We identified potential factors that affected technical success and adverse events, including IVCF dwell time, use of adjunctive techniques, and patient characteristics. We constructed binary logistic regression models to estimate odds ratios (ORs) with 95% CIs for the examined covariates. We examined the relationship between filter dwell time and use of an adjunctive technique with multivariable analysis.
We separated the cohort into 2 subgroups with dwell times of less than and at least 6 months. We used the χ2 test to examine the covariates and procedural fluoroscopy time. Significance was accepted at P < .05. Our data analysis was performed on February 15, 2015.
We identified 648 retrieval procedures (Table 1), of which 143 were outside referrals. Mean (SD) age of the patients was 56 (16.4) years, and 318 were male (49.1%). Mean (SD) fluoroscopy time was 9.2 (12.7) minutes.
We achieved technical success with standard retrieval techniques in 536 procedures (82.7%); with adjunctive techniques, 631 (97.4%). Dwell time did not affect technical success (OR, 0.98 [95% CI, 0.95-1.01]; P = .12). Adjunctive techniques were necessary for IVCF retrieval in 95 procedures (14.7%) and were significantly associated with technical success (OR, 3.97 [95% CI, 1.31-11.95]; P = .01). Table 2 summarizes the findings of the subgroup and logistic regression analyses. Multivariable analysis revealed a significant relationship between filter dwell time and the use of adjunctive techniques (P < .001).
No procedure-related mortality occurred. Three patients required brief hospital admission; the remaining patients underwent outpatient procedures. Eighteen procedure-related adverse events (3 major and 15 minor) occurred; major events were related to access site complications. The rate of adverse events was not associated with filter dwell time (OR, 1.00 [95% CI, 0.98-1.01]; P = .17).
Reports of device-related complications have increased with the growing use of retrievable IVCFs,3 resulting in a 2010 safety communication from the US Food and Drug Administration urging removal of these devices when their use is no longer indicated.4 Prolonged IVCF dwell times have been associated with increased risks for device-related complications5 and retrieval failure,2 resulting in the perception that retrieval of IVCFs with prolonged dwell times should not be attempted.
Smaller studies have described high rates of technical success when retrieving IVCFs with prolonged dwell times,6 now corroborated in our larger study. Retrievable IVCFs with prolonged dwell times can be removed with a high degree of technical success without increasing the rate of procedural adverse events. Adjunctive retrieval techniques positively affect retrieval rates and are often needed for retrieval of IVCFs with prolonged dwell times.
Study limitations include the evolution of adjunctive techniques during the study period. The use of these techniques was operator dependent and was not objectively assigned. In addition, this single-center experience may not translate broadly.
Retrievable IVCFs can be removed safely with a high rate of technical success, regardless of dwell time. These findings support the US Food and Drug Administration’s goal of removing devices that are no longer necessary by eliminating a limit on dwell times. Weighed against the risks of prolonged dwell times of retrievable IVCFs, removal of these devices should always be attempted.
Corresponding Author: Robert J. Lewandowski, MD, Section of Interventional Radiology, Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Ste 800, Chicago, IL 60611 (firstname.lastname@example.org).
Published Online: June 22, 2015. doi:10.1001/jamainternmed.2015.2561.
Author Contributions: Drs Desai and Lewandowski had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Desai, Lewandowski, Salem, Karp, Ryu.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: Desai, Lewandowski, Salem, Mouli, Laws, Ryu.
Statistical analysis: Desai, Lewandowski, Mouli.
Administrative, technical, or material support: Desai, Salem, Karp, Ryu.
Study supervision: Desai, Lewandowski, Salem, Laws, Ryu.
Conflict of Interest Disclosures: Dr Lewandowski reports being a paid consultant for Cook Medical, Inc. No other disclosures were reported.
Previous Presentation: Preliminary results of this study were presented at the 40th Annual Meeting of the Society of Interventional Radiology; March 2, 2015; Atlanta, Georgia.