Venous Thromboembolism: Vena Cava Filter in the Prophylaxis and Treatment of PE--old

Archived PMG

Published 1998
Citation: J Trauma. 53(1):142-164, July 2002.



EAST Practice Parameter Workgroup for DVT Prophylaxis

Frederick B. Rogers, MD, FACS
University of Vermont Department of Surgery
Director of Trauma and Critical Care
Fletcher Allen Heath Care
Burlington, VT

Mark D. Cipolle, MD, Ph.D.
Surgical Practice Center
Allentown, PA

George Velmahos, MD, Ph.D.
Department of Surgery, Division of Trauma and Critical Care
University of Southern California
Los Angeles, CA

Grace Rozycki, MD
Emory USM, Department of Surgery
Atlanta, GA

I. Statement of the Problem

Venacavalinterruption is a form of PE prophylaxis that is being used more frequently in trauma patients. Patients with ongoing bleeding or those with recent brain, spinal cord or ocular injury will not tolerate even minor amounts of bleeding. Furthermore, multiply injured patients often have extremity injuries which preclude the use of sequential compression devices (SCDs). The decision to place a “prophylactic”venacavafilter in a trauma patient requires a fundamental understanding of the risk:benefit ratio.The data included in this review indicate the risk:benefit ratio is favorable in a high-risk trauma patient.Therefore, the problem becomes defining the “high-risk” patient and the short and long-term complication rates ofvenacavalinterruption.

The literature is somewhat difficult to interpret because each author differs in their definition of a “prophylactic”venacavafilter.It is probably more accurate to use the terms “traditional” and “extended” indications forvenacavafilter placement. This review is designed to examine the data available for the use ofvenacavafilters for “extended” indications in the trauma patient, that is, filter placement early after injury, before the patient has clinical orradiographicevidence of a DVT or PE.

II. Process

AMedlinesearch from 1980 to 1999 showed ten articles when “venacavafilter” was cross-referenced with “trauma”.An additional personal review of the literature revealed seven additional articles and two abstracts that address extended indications ofvenacavafilter placement in trauma patients. Also, there were four articles that specifically addressed complications and long-term follow up withvenacavafilters which are included in this review.

III. Recommendations

A. Level I

There is a large body of evidence not reviewed in this section to support insertion of avenacavafilter for “traditional” indications in trauma patients.These indications include:

  • Recurrent PE despite fullanticoagulation,
  • Proximal DVT and contraindications to fullanticoagulation,
  • Proximal DVT and major bleeding while on full anticoagulation,
  • Progression ofiliofemoralclot despiteanticoagulation (rare).

B. Level II

“Extended” indications for prophylacticvenacavafilter placement in apatientwithestablishedDVT or PE include:

  • Large free-floating thrombus in theiliacvein or IVC,
  • Following massive PE in which recurrentembolimay prove fatal,
  • During/after surgical embolectomy.

C. Level III

Insertion of a “prophylactic”venacavalfilter should be considered in very high risk trauma patients.

  1. Who cannot receive anticoagulation because of increased bleeding risk, and
  2. Have one or more of the following injury patterns:
    1. Severe closed head injury (GCS < 8),
    2. Incomplete spinal cord injury with para or quadriplegia,
    3. Complex pelvic fractures with associated long-bone fractures,
    4. Multiple long-bone fractures,

Patients at high risk for bleeding complications for 5 to 10 days after injury would include those withintracranialhemorrhage, ocular injury with associated hemorrhage, solidintraabdominalorgan injury (ie. liver, spleen, kidney), and/or pelvic orretroperitonealhematomarequiring transfusion.Other risk factors for bleeding include cirrhosis, active peptic ulcer disease, end-stage renal disease, andcoagulopathydue to injury, medication, or congenital/hereditary.

IV. Scientific Foundation

The placement of a venacavafilter in a trauma patient who does not have an established DVT or PE is certainly controversial. There is no question that venacavafilters are efficacious. They prevent the occurrence of PE from lower extremity DVT with about a 98% success rate.[1] The real issue is defining who should receive these filters, and whether it is without significant complications and cost-effective.There is no data at this point to address the latter, and some recent papers do address the risk factor issue.

Several recent studies have reported on the use of venacavalfilters for extended indications. Goluekeand coworkers[2] reported on 21 filters placed prophylactically before total joint replacement. All patients also received low dose heparin, aspirin, and, when possible, graduated compression stockings.There were no filter-related complications or episodes of PE in this group. Likewise, Webb et al. in 1992 reported their results of using a “prophylactic” filter in 24 of 52 patients undergoing acetabular fracture repair with sufficient risk factors.[3] They had no insertion complications. Four patients had leg edema, one with phlegmasia, and no PEs. In the 27 patients who did not receive a filter, there were 2 PEs, one of which was fatal. Rohrer and coworkers reported on the use of vena caval filters for “extended” indications in 66 patients (many of whom were trauma patients).[4] There was only one fatal PE in this group, and 22 patients had no documented DVT before filter insertion. The recurrent nonfatal PE rate was 3%, and symptomatic occlusion of the IVC occurred 4.5% of the time in this study. Major limitations of this study include the retrospective design, inability to distinguish outcomes in the 21 patients with VCF used as prophylaxis from the 45 others, and unspecified follow-up duration. Jarrell and coworkers[5] reported a favorable experience with 21 Greenfield filters that were placed in spinal-cord-injured patients with documented DVT or PE and a “traditional” indication for filter insertion.There was only one PE death in this group and two instances of IVC thrombus, both of which were well tolerated.

There are now several reports in the literature of the use of “prophylactic” venacavalfilters for extended indications in trauma patients.[5] [6] [8] [9] [10] [11] [12] [13] [14] [15] [20] [22] [23] [24] [25] [26] To date. 14 studies have reported on inferior vena cava (IVC) filter insertion in trauma patients. Five of these studies[8] [9] [10] [22] [23] demonstrated a demonstrated a significant reduction in the indicence of PE in their trauma population compared to historical controls. None of these studies were Level I studies, however. Further McMurty et al [25] in a retrospective review of 299 patients who had prophylactic filters placed over an 8 year period, failed to demonstrate an overall decrease in their trauma population compared to historical controls. There have been minimal insertion and short-term complications reported; one-year patency rates ranged from 82% to 96%,[9] [11] and two-year patency rates have been reported in 96%[9] of prophylactic filters inserted in trauma patients.Moreover, there does not seem to be a higher DVT rate in prophylactic filter patients compared to non-filter patients.[7] [8] A recent followup study with a minimal of 5 years followup in 199 patients showed that the filters are well tolerated, patients can go on to active life, and their was a minimal migration or caval thromboses in the patients studied.[26] The efficacy ofvenacava filters preventingPEs is not an issue. The long-range complications and cost-effectiveness of this therapy does need to be studied.

The decision to place a prophylactic filter in a trauma patient requires a fundamental understanding of its risk-benefit ratio. The data would indicate that the risk-benefit ratio is favorable in the high-risk trauma patients.The problem is defining the high-risk patient.One trauma study[14] identified four injury patterns that accounted for 92% of PEs: (1) spinal cord injury with Paraplegia or quadriplegia, (2) severe closed head injury with a Glasgow Coma Score ? 8, (3) age > 55 years with isolated long bone fractures, and (4) complex pelvic fractures associated with long bone fractures. Another retrospective review including 9,721 patients[12] showed that the high risk categories include head injury plus spinal cord injury, head injury plus long bone fracture, severe pelvic fracture plus long bone fracture, and multiple long bone fractures. These authors estimate that if they would have utilized a prophylactic filter in these 2% of patients, there would have been a very dramatic reduction in PE. They suggested that patients with an estimated risk of PE of 2% to 5%, despite prophylaxis, are reasonable candidates for prophylactic vena caval filter placement, especially if conventional prophylactic measures cannot be used. Many years of experience with the Greenfield filter indicate that it has a patency rate of about 96%, a recurrent PE rate of 3% to 5%, and a caval penetration rate of about 2%. [7] These are reasonable complication rates, but multiplied over the lifetime of a young patient, these rates could become important.There is one study that indicates a significant amount of chronic venous insufficiency in long-term follow up of prophylactic filter patients.[15]However, there was no non-filter group to compare to, so it is not clear if the filter was the cause of this chronic venous insufficiency in this very high risk group.

More recently, interest and experience have been gaining for the many types of retrievable filters. Much of this early work has been done in Europe.[27] [28] [29] The use of retrievable filters are particularly appealing to trauma surgeons whose patients are at high risk for PE for a relatively short period of time. Technical problems with theretrievable filters have prevented their widespread application at the present time.Nevertheless, they may have potential in the future. A recent survey of 620 trauma surgeons across the United States revealed that the potentialremovability of filters would significantly increase (P < .01) prophylactic filter placement from 29% to 53%.

V. Summary

There is no Class I literature to support insertion of avenacavafilter in a trauma patient without an established DVT or PE. There is starting to accumulate a fair amount of Class II and III data which may support its use in “high-risk” trauma patients without a documented occurrence of a DVT or PE.At this time, we recommend consideration of IVC filter insertion in patients without a documented DVT or PE who meet high -risk criteria and cannot beanticoagulated.

VI. Future Investigation

There is an obvious need of Class I randomized, prospective controlled data to either support or refute the use ofvenacavalinterruption in trauma patients. Such studies need to enroll only high risk patients with a sufficiently high enough PE rate to attempt to prove filter efficacy and improve outcome in the patients who receive a truly prophylacticvenacavafilter. This study would need to be large andmulticenterin nature. The pilot portion of such a study has been completed, and the largemulticentertrial should involve many investigators from trauma associations. Other important unresolved issues include the following:

  • Dovenacavafilters significantly reduce the incidence of clinically important PE in patients who receive “optimal” prophylaxis?
  • If so, can a group of patients be identified who have a high failure rate with “optimal” prophylaxis?
  • What are the short-term and long-term complications ofvenacavafilter insertion used as primary prophylaxis in trauma patients?
  • Is vena cava filter insertion cost-effective?

VII. References

  1. Greenfield LJ, MichnaBA: Twelve-year clinical experience with the Greenfield venacavalfilter.Surgery 104:706-12, 1988
  2. GoluekePJ, Garrett WV, Thompson JE, etal: Interruption of the venacavaby means of the Greenfield filter: Expanding the indications. Surgery 103:111-7, 1988
  3. Webb LX, Rush PT, Fuller SB, etal: Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabularfracture. J Orthop Trauma 6:139 -45, 1992
  4. RohrerMJ, ScheidlerMG, Wheeler HB, etal: Extended indications for placement of inferior venacavafilter. J Vasc Surgery 10:44-50, 1989
  5. JarrellBE, PosuniakE, Roberts J, etal: A new method of management using the Kim-Ray Greenfield filter for deep venous thrombosis and pulmonary embolism in spinal cord injury. Surg Gynecol Obstet 157:316-20, 1983
  6. CipolleM, MarcinczykM, Pasquale M, etal: Prophylactic venacavalfilters reduce pulmonary embolism in trauma patients. [Abstract] Critical Care Medicine 23:A93, 1995
  7. Greenfield LJ: Post traumathromboembolismprophylaxis. Eighth Annual American Venous Forum, 1996
  8. Rodriguez JL, Lopez JM, Proctor MC, etal: Early placement of prophylactic venacavalfilters in injured patients at high risk for pulmonary embolism. J Trauma 40:797-804, 1996
  9. Rogers FB, ShackfordSR, RicciMA, etal: Routine prophylactic venacavafilter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism. J Am Coll Surg 180:641-7, 1995
  10. RosenthalD, McKinseyJF, Levy AM, etal: Use of the Greenfield filter in patients with major trauma. CardioVasc Surg 2:52-5, 1994
  11. Wilson JT, Rogers FB, Wald SL, etal: Prophylactic venacavafilter insertion in patients with traumatic spinal cord injury: Preliminary results. Neurosurgery 35:234-9, 1994
  12. Winchell RJ, Hoyt DB, Walsh JC, etal: Risk factors associated with pulmonary embolism despite routine prophylaxis: Implications for improved protection. J Trauma 37:600-6, 1994
  13. ZolfaghariD, Johnson B, WeireterLJ, etal: Expanded use of inferior venacavafilters in the trauma population. Surgery Annual 27:99-105, 1995
  14. Rogers FB, ShackfordSR, Wilson J, etal: Prophylactic venacavafilter insertion in severely injured trauma patients: Indications and preliminary results. J Trauma 35:637-42, 1993
  15. Patton JH Jr, Fabian TC, Croce MA, etal: Prophylactic Greenfield filter: Acute complications and long-term follow up. J Trauma 41:231-7, 1996
  16. CarabasiRA III, Moritz MJ, JarrellBE: Complications encountered with the use of the Greenfield filter. Am J Surg 154:163-8, 1987
  17. Greenfield LJ, ChoKJ, Proctor MC, etal: Late results of suprarenalGreenfield venacavafilter placement. Arch Surg 127:969-73, 1992
  18. Ferris EJ, McCowanTC, Carver DK, etal: Percutaneousinferior venacavafilters: Follow-up of seven designs in 320 patients. Radiology 188:851-6, 1993
  19. Leach TA, PastenaJA, Swan KG: Surgical prophylaxis for pulmonary embolism. Am Surg60:292-5, 1994
  20. NunnCR, NeuzilD, NaslundT, Bass JG, Jenkins JM, Pierce R, etal. Cost-effective method for bedside insertion of venacavafilters in trauma patients. J Trauma 1997;45:752-758.
  21. TolaJC, HotzmanR, LottenbergL. Bedside placement of inferior venacavafilters in the intensive care unit. American Surg. 1999;65:833-837.
  22. KhansariniaS, Dennis JW, VeldenzHC, Butcher JL, HartlandL. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J Vasc Surg 1995;22: 235-236.
  23. GosinJS, Graham AM, CioccaRG, Hammond JS. Efficacy of prophylactic venacavafilters in high-risk trauma patients. Ann Vasc Surg 1997;11:100-105.
  24. HeadrickJR, Barker DE, Pate LM, Horne K, Russell WL, Burns RP. The role of ultrasonographyand inferior venacavafilter placement in high-risk trauma patients. Am Surg1997;63:1-8.
  25. McMurtryAL, OwingsJT, Anderson JT, BattistellaFD, GosselinR. Increase use of prophylactic venacavafilters in trauma patients failed to decrease overall incidence of pulmonary embolism. J Am Coll Surg 1999;189:314-20.
  26. SekharanJ, Dennis JW, Miranda FE, VeldenzHC, DovganPS, FrykbergER. Long term follow up of prophylactic greenfield filters in multisystemtrauma patients. J Trauma 2000; 49: 374
  27. LorchH, WelgerD, Wagner V, etal: Current practice of temporary venacavafilter insertion: a multicentreregistry. J Vasc. Intervent. Rad. 2000; 11:83-88.
  28. NeuerburgJM, Gunther RW, VorwerkD, DondelingerF, JagerH, LacknerKJ, etal. Results of a multicenterstudy of the retrievable tulip venacavafilter: early clinical experience.CardiovascIntervent Radiol 1997;20:10-16.
  29. BovynG, Gory P, ReynaudP, RiccoJB. The tempofilter: a multicenterstudy of a new temporary cavalfilter implantable for up to six weeks. Ann Vasc Surg 1997;11:520-528.


Deep Venous Thrombosis (DVT) in Trauma: A Literature Review

Vena Cava Filters
First Author Year Reference Title Class Conclusions

Carabasi RA III


Complications encountered with the use of the Greenfield filter.

Am J Surg 154:163-8


200 filters in 193 patients, unspecified long -term follow-up. Complications: venous anomalies 2.5%; insertion compilations 9.2%; Postoperative: 2.5% minor, 4.1% major; 0.5% m ortality secondary to distal migration. Stress importance of preop venography, visualization of thrombus, marking of renal veins, diagnosing venous anomalies, knowing accurate size of vena cava.

Greenfield LJ


Twelve-year clinical experience with t he Greenfield vena cava filter.

Surgery 104:706-12


Long-term follow-up of 469 patients with mean follow -up of 43 months (0.3-138) from 1974-1986. 81 filters placed for “extended” indications (17%), 40 trauma patients included in follow -up. 96% IVC patency, 98% filter patency rate, 4% misplacement rate, 3% recurrent PE rate.

Greenfield LJ


Late results of suprarenal Greenfield vena cava filter placement.

Arch Surg 127:969-73


Review of 71 patients who had suprarenal placement of Greenfield filter. 60 available for follow-up, mean=53 months (18 months -16 yrs). 24 deaths, none secondary to recurrent embolism or renal failure. Recurrent embolism rate was 4% which is identical to infrarenal experience. Duplex exam (n=22) showed all filters were patent. 16 patients (41%) had lower extremity edema that predated filter insertion. Filter fracture in 2 patients and distal migration in 2 patients with no clinical symptoms. Suprarenal placement of Greenfield filter is safe and effective for thrombus e xtending above renal veins and for pregnant patients or women of childbearing age.

Ferris EJ


Percutaneous inferior vena cava filters: Follow ­up of seven designs in 320 patients.

Radiology 188:851-6


324 filters placed over 7 yrs. No placement-related mortality or morbidity. Average follow-up=404 days (1-2392). 19% caval thrombosis; 9% delayed penetration through IVC wall; 6% migration more than 1 cm, 2% fracture strut. Insertion site DVT was 2%. Long -term radiologic follow-up recommended for IVC filters.

VENA CAVA FILTERS - “Traditional” Indications

First Author Year Reference Title Class Conclusions

Jarrell BE


A new method of management using the Kim -Ray Greenfield filter for deep venous thrombosis and pulmonary embolism in s pinal cord injury.

Surg Gynecol Obstet 157:316-20


21 SCI patients with filter placed for “traditional” indications. 1 death secondary to PE in filter patients secondary to misplacement in right iliac vein. 2 thrombosed IVCs. Overall DVT rate in SCI p opulation 62%.  Emphasis on knowing exact location of DVT, anatomy of IVC, that filter must protect from all sources of emboli in lower extremity, and that there is a risk of thrombosis through large collateral vessels.

Leach TA


Surgical prophylax is for pulmonary embolism.

Am Surg 16:292-5


205 vena cava filters placed for indications that were outlined prospective -ly, although many were inserted for “traditional” indications. No PEs in these filter patients and minimal insertion complications.

“Extended” Indications:






Golueke PJ


Interruption of the vena cava by means of the Greenfield filter: Expanding the indications.

Surgery 103:111-7


16 filters inserted prophylactically before joint replacement surgery in patients with history of VTE. 72 filters inserted for “traditional” indications. Mean follow-up=16.4 months (1 -60) in 65 patients. Complications: 3% recurrent PE, 9% leg edema, 7.5% caval occlusion, 92.5% patency. No PEs in prophylactic group that received anti -platelet and sequential compression therapy. Indications should be extended for vena cava filter to help reduce preventable deaths secondary to PE.

Webb LX


Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture.

J Orthop Trauma 6:139-45


Outlined predisposing factors for VTE. In patients undergoing acetabular fracture repair with 2 or more risk factors, prophylactic filter was placed (24/51). No insertion complications and no PEs. 4 patients had leg edema and 1 had phlegmasia. 27 patients did not receive preop filter; 2 PEs in this group, 1 fatal. All patients had SQ heparin and aspirin.

Rogers FB


Prophylactic vena cava filter insertion in severely injured trauma patients: Indications and preliminary results.

J Trauma 35:637-42


Prospective criteria for prophylactic filter insertion after retrospective review of trauma registry. Prophylactic filters placed in patients who could not receive anticoagulation and grouped:1) age>55 with long bone fracture; 2) severe closed head injury and coma; 3) multiple long bone fractures and pelvic fractures; 4) spinal cord injury. 34 patients had prophylactic filters placed. No PEs, 17.6% DVT rate. 30 day patency 100%, 1-year patency 89% (n=17).

VENA CAVA FILTERS -“Extended” Indications: Trauma

First Author Year Reference Title Class Conclusions

Rogers FB


Routine prophylactic vena cava filter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism.

J Am Coll Surg 180:641-7


Continued follow-up from J Trauma ’93. 63 prophylactic vena cava filters placed in high risk patients as previously outlined. DVT rate:30%; 1 PE (fatal). No insertion complications, 3.5% insertion related thromboses. 30 -day patency­100% (n=36), 1 year-96% (n=34), 2 year-96% (n=16).

Wilson JT


Prophylactic vena cava filter insertion in patients with traumatic spinal cord injury: Preliminary results.

Neurosurgery 35:234-9


Retrospective analysis of 111 SCI patients showed 7 PEs (6.3%) accounting for 31% of trauma PEs. 6 PEs occurred after patient discharge, mean time 78 days (9-5993). 15 prophylactic filters placed in SCI patients. No insertion problems or PEs. 30-day patency rate 100% (n=14), 1-year 82% (n=9).

Winchell RJ


Risk factors associated with pulmonary embolism despite routine prophylaxis: Implications for improved protection.

J Trauma 37:600-6


8-year retrospective registry review at Level 1 trauma center (9721 patients). Overall PE rate=37%. 29 prophylactic vena cava filters placed with no PEs or short-term complications. Average time to PE in this group was 14.5 days. High risk categories: head+spinal cord injury (4.5%); head+long bone fracture (8.8%); severe pelvis plus long bone fracture (12%); multiple long bone fracture (10%). Patients with estimated risk of PE, despite prophylaxis of > 2 -5%, are reasonable candidates for prophylactic vena cava filter placement, especially if conventional measures cannot be used.

Rosenthal D


Use of the Greenfield filter in patients with major trauma.

Cardiovasc Surg 2:52-5


Control group 1984-88, 94 patients with 22 PEs (23%) and 5% fatal PE rate. 1988-92, after adoption of protocol to place prophylactic filters, 67 patients with only 1 PE and no fatal PEs.  Minimal insertion morbidity. No long -term follow-up reported.

Zolfaghari D


Expanded use of inferior vena cava filters in the trauma population.

Surgery Annual 27:99-105


Retrospective analysis of 45 filters placed in 3005 patients. 38/45 had extend -ed indications for filter placement as they were placed for no DVT or in patients with DVT or PE but no contraindication to anticoagulation. No PEs after filter placement, and there was 1 death secondary to closed head injury.

Cipolle M


Prophylactic vena caval filters reduce pulmonary embolism in trauma patients [Abstract].

Critical Care Medicine 23:A93.


Review of 43 high risk trauma patients who had vena cava filters placed, 16 for “traditional” indications and 27 for “extended” indications.  0 PEs in prophylactic group and 5 PEs in “traditional” indications group. Overall PE rate was 11.6%.

Patton JH Jr


Prophylactic Greenfield filter: Acute complications and long-term follow-up.

J Trauma 41:231-7


Follow-up of prophylactic filters placed between 1991-1994. 69 filters with 9% insertion rate. 15 patients died. 30 patients were locate d and 19 returned for follow-up evaluation (35%).  Average follow -up was 770 days (246-1255).  No caval thrombosis. 14 patients had chronic DVT. 11/14 had chronic venous insufficiency. No long -term caval thromboses.  Not clear, however, if filter caused chronic venous insufficiency because there was no nonfilter group.

Rodriguez JL


Early placement of prophylactic vena cava filters in injured patients at high risk for pulmonary embolism.

J Trauma 40:797-804


40 vena cava filters placed in cons ecutive patients with 3 or more risk factors compared to 80 matched historic controls. 1 PE in VCF group, 14 PEs in non -VCF group.  PE related mortality and overall mortality was the same in each group as was the incidence of DVT, 15% in VCF group and 19% in no VCF group. 

Greenfield LJ


Posttrauma thromboembolism prophylaxis. 8th

Annual American Venous Forum


Pilot study for large, multicenter trial. 53 patients randomized to receive SCD, LMWH, or unfractionated heparin and 1/2 randomized to receive vena cava filter. Inclusion criteria were ISS>9 and VTE risk factor score developed by investigators. 26 patients got VCF. No complications of filter placement or evidence of vena caval occlusion. No PEs in either groups. 12 DVTs in nonfilter pat ients and 11 DVTs in filter patients.

Nunn CR


Cost-effective method for bedside insertion of vena cava filters in trauma patients.

J Trauma 45:752-758


Ultrasound-guided IVC filter insertion in 55 trauma patients.  49 successful; 6 failed.

Tola JC


Bedside placement of inferior vena cava filters in the intensive care unit.

American Surg. 65:833-837


25 patients underwent prophylactic IVC filters in the ICU with digital C -arm with no postop or intraop complications. Average s aving of $1844 when filters were placed in ICU vs. OR.

Khansarinia S


Prophylactic Greenfield filter placement in selected high -risk trauma patients. 

J Vasc Surg 22: 235-236


108 filters placed in high risk trauma patients over a two -year period with injury matched controls who did not receive a filter. OPEs in filter group vs. 13 PES in control group, 9 of which were fatal. The differences were significant for both PE (P<0.009) and PE -related death (p<0.03).

Gosin JS


Efficacy of prophylactic vena cava filters in high ­risk trauma patients.

Ann Vasc Surg 11:100-105


99 prophylactic filters placed in high risk trauma population over 2 year period. This decreased PE in trauma population to 1.6% from 4.8% in historical controls (p<0.04 5 Fischer's Exact).

Headrick JR


The role of ultrasonography and inferior vena cava filter placement in high -risk trauma patients. 

Am Surg 1997;63:1-8


228 high -risk patients were followed with serial ultrasound. 39 (17%) developed DVT with 29 undergoing immediate IVC filter placement.  Decreased incidence of PE compared to historical controls.

McMurtry AL


Increase use of prophylactic vena cava filters in trauma patients failed to decrease overall incidence of pulmonary embolism.

J Am Coll Surg; 189:314-20.


Review of 299 patients with prophylactic filters over an 8 year period, yeilded no demonstrable decrease in PE incidence compared to historical controls.

Sekharan J


Long term follow up of prophylactic greenfield filters in multisystem trauma patients. 

J Trauma 49: 374


5 year followup study of 199 patients showed that filters are well-tolerated in trauma patients with minimal migration on caval thrombosis

“Extended” Indications:






Rohrer MJ


Extended indications for placement of inferior vena cava filters.

J Vasc Surg 10:44-50


264 filters placed in all types of patients. 66 placed prophylactically. “Extended” indications: 1) no documented DVT but high risk; 2) small PE would be fatal due to poor cardiopulmonary reserve; 3) large ileofemoral thrombus; 4) procedure in conjunction with venous thrombectomy; 5) thrombus above previously placed IVC filter. No deaths in either group. Prophylactic group had minimal morbidity. 3 Pes (4.5%) despite filter, 1 mortality, and 4.5% occlusion.  Recommend liberalizing indications for insertion of Greenfield filter since they had an insertion mortality rate of 0% and fatal PE rate of 1.5% in high risk prophylactic group.


First Author Year Reference Title Class Conclusions

Lorch H


Current practice of temporary vena cava filter insertion: a multicenter registry.

J Vasc Interv Rad 11:83-88 


188 patients (Antheor filter 54%, Guenthe r filter 26%, Prolyser filter 18%). 4 patients died of PE. 16% filter thrombosis; filter dislodgement 4.8%

Neuerburg JM


Results of a multicenter study of the retrievable tulip vena cava filter: early clinical experience.

Cardiovasc Intervent Radiol 20:10-16.


83 patients implanted with retreivable Tulip filter; 3 filter insertion problems, 1 fatal recurrent PE; 2 non -fatal PE; 8 caval occlusions.

Bovyn G


The tempofilter: a multicenter study of a new temporary caval filter implantable for up to six weeks.

Ann Vasc Surg 11:520-528.


66 patients at high risk for PE had filter implanted for up to 6 weeks. Filter migration occurred in 7.5 of the cases.


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