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

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

Download

Authors

Rogers, Frederick B. MD; Cipolle, Mark D. MD, PhD; Velmahos, George MD, PhD; Rozycki, Grace MD; Luchette, Fred A. MD

Author Information

From the University of Vermont, Department of Surgery, Fletcher Allen Health Care (F.B.R.), Burlington, Vermont, Department of Surgery, Lehigh Valley Hospital (M.D.C.), Allentown, Pennsylvania, Department of Surgery, Division of Trauma and Critical Care, University of Southern California (G.V.), Los Angeles, California, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, and Department of Surgery, Division of Trauma, Critical Care, and Burns, Loyola University Medical Center (F.A.L.), Maywood, Illinois.

Submitted for publication September 1, 2001.

Accepted for publication March 15, 2002.

Any reference in this guideline to a specific commercial product, process, or service by trade name, trademark, or manufacturer does not constitute or imply an endorsement, recommendation, or any favoritism by the authors or EAST. The views and opinions of the authors do not necessarily state or reflect those of EAST and shall not be used for advertising or product endorsement purposes.

Address for reprints: Frederick B. Rogers, MD, University of Vermont Department of Surgery, Fletcher Allen Health Care, 111 Colchester Avenue, Burlington, VT 05401; email: frederick.rogers@vtmednet.org.

Statement of the Problem

Vena caval interruption is a form of PE prophylaxis that is being used more frequently in trauma patients. Many trauma patients have ongoing bleeding or recent brain, spinal cord, or ocular injury that will not tolerate even minor amounts of bleeding. These patients cannot have pharmacologic prophylaxis with heparin or heparin-like derivatives. Furthermore, patients with multiple injuries often have extremity injuries, which preclude the use of PCDs. The decision to place a prophylactic vena cava filter (VCF) in a trauma patient requires a fundamental understanding of the risk/benefit ratio. In this review, the risk/benefit ratio is explored in the high-risk trauma patient.

Process

A MEDLINE search from 1980 to 2001 was performed in which vena cava filter was cross-referenced with trauma. Four articles specifically addressed complications and long-term follow up and are included in this review (Table 6).

Recommendations

A. Level I: A Level I recommendation on this topic cannot be supported because of insufficient data.

B. Level II: A Level II recommendation on this topic cannot be supported because of insufficient data.

C. Level III: Insertion of a prophylactic VCF should be considered in very-high-risk trauma patients:

D. 1. Who cannot receive anticoagulation because of increased bleeding risk, and

E. 2. Have an injury patterns rendering them immobilized for a prolonged period of time, including the following:52-69]

F. a. Severe closed head injury (GCS score < 8).

G. b. Incomplete spinal cord injury with paraplegia or quadriplegia.

H. c. Complex pelvic fractures with associated long bone fractures.

I. d. Multiple long bone fractures.

Patients at high risk for bleeding complications for 5 to 10 days after injury would include those with intracranial hemorrhage, ocular injury with associated hemorrhage, solid intra-abdominal organ injury (i.e., liver, spleen, kidney), and/or pelvic or retroperitoneal hematoma requiring transfusion. Other risk factors for bleeding include cirrhosis; active peptic ulcer disease; end-stage renal disease; and coagulopathy caused by injury, medication, or congenital/hereditary. In addition, it appears that age is a significant risk factor for VTE, but it is unclear at what age risk of VTE significantly increases. The need to place a prophylactic VCF may be increased in an older patient with one of the above-mentioned injuries.[70]

Scientific Foundation

The placement of a VCF in a trauma patient who does not have an established DVT or PE is certainly controversial; however, there is no question that VCFs are efficacious. They prevent the occurrence of PE from lower extremity DVT with a success rate of about 98%.[71] The real issue is defining who should receive these filters, and whether they are without significant complications and are cost-effective.

Several studies have reported on the use of VCFs for prophylactic indications. Golueke et al.[72] reported on 21 filters placed prophylactically before total joint replacement. All patients received LDH, aspirin and, when possible, graduated compression stockings. No filter-related complications or episodes of PE occurred in this group. Likewise, in 1992, Webb et al.52] reported their results of using a prophylactic filter in 24 of 52 patients undergoing acetabular fracture repair with sufficient risk factors. No insertion complications were reported. Four patients had leg edema, one with phlegmasia, and no PEs. In the 27 patients who did not receive a filter, 2 PEs were noted, one of which was fatal. Rohrer et al.[73] reported on the use of VCFs for extended indications in 66 patients (many of whom were trauma patients). Only one PE was fatal 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 inferior vena cava (IVC) occurred 4.5% of the time in this study. Major limitations of this study include the retrospective design, the inability to distinguish outcomes in the 21 patients with VCF used as prophylaxis from the 45 others, and unspecified follow-up duration. Jarrell et al.[53] reported a favorable experience with 21 Greenfield filters that were placed in spinal cord-injured patients with documented DVT or PE. Only one PE death occurred in this group, and two instances of IVC thrombus were noted, both of which were well tolerated.

Several reports now exist in the literature on the use of prophylactic vena caval filters in trauma pa-tients.[53-62][64-69][74-78] Six of these studies[55][56][63][64][69] demonstrated a significant reduction in the incidence of PE in their trauma population compared with historical controls. Minimal insertion and short-term complications were reported, with 1-year patency rates ranging from 82% to 96%,[56][58] and 2-year patency rates at 96%56] in prophylactic filters inserted in trauma patients. Moreover, a higher DVT rate was not seen in prophylactic filter patients compared with nonfilter patients.[55][79] A recent follow-up study with a minimum of 5 years in 199 patients showed that the filters were well tolerated. Patients went on to live active lives, with a minimal migration or cava thromboses.[66] Likewise, Greenfield et al.[67] reported on 249 prophylactic VCFs for trauma and noted an incidence of PE in 1.5%, a caval occlusion rate of 3.5%, and good outcome with regard to the mechanical stability of the filter. The authors concluded that the prophylactic VCF placement was associated with a low incidence of adverse outcomes and provided protection from fatal PE. However, none of these studies were Class I studies.

In contrast to the above-mentioned studies, McMurty et al.,[77] 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 with historical controls. This is the only study to date that failed to report a benefit of prophylactic VCFs in high-risk trauma patients. This study only looked at the incidence of PE in their overall trauma population and could have missed a significant decrease of PE in their high-risk population if subset analysis was performed.

The data presented herein would indicate that the risk/benefit ratio is favorable in the high-risk trauma patients. The problem is defining the high-risk patient. In the first section of this review (Risk Factors for Venous Thromboembolism after Trauma), we defined the high-risk patient for DVT, but not necessarily for PE (arguably a more serious complication of VTE). One trauma study[61] identified four injury patterns that accounted for 92% of PEs: spinal cord injury with paraplegia or quadriplegia; severe closed head injury with a GCS score ≤ 8 for > than 48 hours; age > 55 years with isolated long bone fractures; and complex pelvic fractures associated with long bone fractures. This single-institution study may seem at conflict with what was presented in the first section of this review, which showed that on meta-analysis, head injury was not a high-risk factor. It must be noted, however, the meta-analysis dealt only with DVT. Furthermore, this study found those patients who had a GCS score > 8 for greater than 48 hours at greater risk for PE, whereas the meta-analysis did not make such a distinction. This may explain the apparent conflict in head injury as a risk factor after injury. Another retrospective review including 9,721 patients[59] 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 had used a prophylactic filter in these 2% of patients, a very dramatic reduction in PE would have been seen. They suggested that patients with an estimated risk of PE of 2% to 5%, despite prophylaxis, are reasonable candidates for prophylactic VCF 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%.[79] These complication rates were reasonable, but multiplied over the lifetime of a young patient, these rates could become important. One study indicated a significant amount of chronic venous insufficiency in long-term follow-up of prophylactic filter patients.[62] However, with no nonfilter group to compare with, whether the filter was the cause of this chronic venous insufficiency in this very-high-risk group is not clear.

The more recent literature on this subject of VCFs discusses the bedside placement of filters[68][75][80] and the use of ultrasound as an imaging modality in the placement of filters.68][75][78] These studies showed that filters could be placed safely at the bedside, resulting in a decrease in operating room use and cost. Ashley et al.[78] compared intravascular ultrasonography to contrast venography in 21 trauma patients who had prophylactic VCF placement. The authors noted that contrast venography overestimated the size of the vena cava in all cases (average vena cava diameter was 26.4 ± 3.3 mm by venography vs. 20.6 ± 3.1 mm by intravascular ultrasound). The use of contrast venography presents a significant concern when one notes that a vena cava of greater than 28 mm is a contraindication to the placement of a Greenfield VCF.

More recently, interest and experience have been increasing for the many types of retrievable filters. Much of this early work has been performed in Europe.[81][82] The use of retrievable filters is particularly appealing to trauma surgeons whose patients are at high risk for PE for a relatively short period. Technical problems with the retrievable 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 potential removability of filters would significantly increase (p < 0.01) prophylactic filter placement from 29% to 53%.

Summary

No Class I studies exist to support insertion of a VCF in a trauma patient without an established DVT or PE. A fair amount of Class II and III data that may support VCF use has been accumulated 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 be anticoagulated.

Future Investigation

Important unresolved issues with regard to filter use in trauma patients include the following:

  • Do VCFs 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 of VCF insertion used as primary prophylaxis in trauma patients?
  • Is VCF insertion cost-effective?
  • Do temporary VCFs have a role in trauma patients whose risk of PE may be high for only a short time?

Acknowledgment

We thank Jody Ciano for her help in the preparation of this article.

References

  1. Pasquale M, Fabian TC, and the EAST Ad Hoc Committee on Guidelines Development. Practice management guidelines for trauma from the Eastern Association for the Surgery of Trauma. J Trauma. 1998; 44: 941-957.
  2. Interim Manual for Clinical Practice Guideline Development. Rockville, MD: Agency for Health Care Policy and Research; May 1991.
  3. Knudson MM, Lewis FR, Clinton A, et al. Prevention of venous thromboembolism in trauma patients. J Trauma. 1994; 37: 480-487.
  4. Kudsk KA, Fabian T, Baum S, et al. Silent deep venous thrombosis in immobilized multiple trauma patients. Am J Surg. 1989; 158: 515-519.
  5. Velmahos GC, Nigro J, Tatevossian R, et al. Inability of an aggressive policy of thromboprophylaxis to prevent deep venous thrombosis (DVT) in critically injured patients: are current methods of DVT prophylaxis insufficient? J Am Coll Surg. 1998; 187: 529-533.
  6. Spain DA, Richardson JD, Polk JR, et al. Venous thromboembolism in the high-risk trauma patient: do risks justify aggressive screening and prophylaxis? J Trauma. 1997; 42: 463-469.
  7. Dennis JW, Menawat S, Von Thron J, et al. Efficacy of deep venous thrombosis prophylaxis in trauma patients and identification of high-risk groups. J Trauma. 1993; 35: 132-139.
  8. Meyer CS, Blebea J, Davis K Jr, Fowl R, Kempsczinski RF. Surveillance venous scans for deep venous thrombosis in multiple trauma patients. Ann Vasc Surg. 1995; 9: 109-114.
  9. Piotrowski JJ, Alexander JJ, Brandt CP, et al. Is deep vein thrombosis surveillance warranted in high-risk patients? Am J Surg. 1996; 172: 210-213.
  10. Napolitano LM, Garlapati VS, Heard SO, et al. Asymptomatic deep venous thrombosis in the trauma patient: is an aggressive screening protocol justified? J Trauma. 1995; 39: 651-659.
  11. Geerts WH, Code KJ, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994; 331: 1601-1606.
  12. Knudson MM, Morabito D, Paiement GD, et al. Use of low molecular weight heparin in preventing thromboembolism in trauma patients. J Trauma. 1996; 41: 446-459.
  13. Abelseth G, Buckley RE, Pineo GE, et al. Incidence of deep vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop Trauma. 1996; 10: 230-235.
  14. Upchurch GR Jr, Demling RH, Davies J, et al. Efficacy of subcutaneous heparin in prevention of venous thromboembolic events in trauma patients. Am Surg. 1995; 61: 749-755.
  15. Knudson MM, Collins JA, Goodman SB, et al. Thromboembolism following multiple trauma. J Trauma. 1992; 32: 2-11.
  16. Hill SL, Berry RE, Ruiz AJ. Deep venous thrombosis in the trauma patient. Am Surg. 1994; 60: 405-408.
  17. Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med. 1996; 335: 701-707.
  18. Waring WP, Karunas RS. Acute spinal cord injury and the incidence of clinically occurring thromboembolic disease. Paraplegia. 1991; 29: 8-16.
  19. Spannagel U, Kujath P. Low molecular weight heparin for the prevention of thromboembolism in outpatients immobilized by plaster cast. Semin Thromb Hemost. 1993; 19 (suppl 1): 131-141.
  20. Shackford SR, Davis JW, Hollingsworth-Fridlund P, et al. Venous thromboembolism in patients with major trauma. Am J Surg. 1990; 159: 365-369.
  21. Ruiz AJ, Hill SL, Berry RE. Heparin, deep venous thrombosis, and trauma patients. Am J Surg. 1991; 162: 159-162.
  22. Velmahos GC, Kern J, Chan L, et al. Prevention of venous thromboembolism after injury: an evidence-based report-part I: analysis of risk factors and evaluation of the role of vena cava filters. J Trauma. 2000; 49: 132-139.
  23. Gardner AMN, Fox RH. The venous pump of the human foot: preliminary report. Bristol Med Chir J. 1983; 98: 109-112.
  24. Laverick MD, McGivern RC, Crone MD, Mollan RAB. A comparison of the effects of electrical calf muscle stimulation and the venous foot pump on venous blood flow in the lower leg. Phlebology. 1990; 5: 285-290.
  25. Spain DA, Bergamini, Hoffman JF, et al. Comparison of sequential compression devices and foot pumps for prophylaxis of deep venous thrombosis in high-risk trauma patients.Am Surg. 1998;64:522-526.
  26. Anglen JO, Bagby C, George R. A randomized comparison of sequential-gradient calf compression with intermittent plantar compression for prevention of venous thrombosis in orthopedic trauma patients: preliminary results. Am J Orthop. 1998; 33: 53-57.
  27. Gardner AM, Fox RH, Lawrence C, et al. Reduction of post-traumatic swelling and compartment pressure by impulse compression of the foot. J Bone Joint Surg Br. 1990; 72: 810-815.
  28. Morgan RH, Carolan G, Psaila JV, et al. Arterial flow enhancement by impulse compression. Vasc Surg. 1991; 25: 8-15.
  29. Abu-Own A, Cheatle T, Scurr JH, et al. Effects of intermittent pneumatic compression of the foot on microcirculatory function in arterial disease. Eur J Vasc Surg. 1993; 7: 488-492.
  30. Anglen JO, Goss K, Edwards J, Heickfeldt RE. Foot pump prophylaxis for deep venous thrombosis: the rate of effective usage in trauma patients. Am J Orthop. 1998; 27: 580-582.
  31. Comerota AJ, Katz ML, White JV. Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail? Am J Surg. 1992; 164: 265-268.
  32. Caprini JA, Arcelus JI, Hoffman K, et al. Prevention of venous thromboembolism in North America: results of a survey among general surgeons. J Vasc Surg. 1994; 20: 751-758.
  33. Pidala MJ, Donovan DL, Kepley RF. A prospective study on intermittent pneumatic compression in the prevention of deep vein thrombosis in patients undergoing total hip or total knee replacement. Surg Gynecol Obstet. 1992; 175: 47-51.
  34. Woolson ST, Watt JM. Intermittent pneumatic compression to prevent proximal deep venous thrombosis during and after total hip replacement: a prospective, randomized study of compression alone, compression and aspirin, and compression and low-dose warfarin. J Bone Joint Surg Am. 1991; 73: 507-512.
  35. Gersin K, Grindlinger GA, Lee V, et al. The efficacy of sequential compression devices in multiple trauma patients with severe head injury. J Trauma. 1994; 37: 205-208.
  36. Fisher CG, Blachut PA, Salvian AJ, et al. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma. 1995; 9: 1-7.
  37. Keith SL, McLaughlin DJ, Anderson FA Jr, et al. Do graduated compression stockings and pneumatic boots have an additive effect on the peak velocity of venous blood flow? Arch Surg. 1992; 127: 727-730.
  38. Inada K, Koike S, Shirai N, et al. Effects of intermittent pneumatic leg compression for prevention of postoperative deep venous thrombosis with special reference to fibrinolytic activity. Am J Surg. 1988; 155: 602-605.
  39. Jacobs DG, Piotrowski JJ, Hoppensteadt DA, et al. Hemodynamic and fibrinolytic consequences of intermittent pneumatic compression: preliminary results. J Trauma. 1996; 40: 710-717.
  40. Bradley JG, Krugener GH, Jager HJ. The effectiveness of intermittent plantar venous compression in prevention of deep venous thrombosis after total hip arthroplasty. J Arthroplasty. 1993; 8: 57-61.
  41. Davidson JE, Willms DC, Hoffman MS. Effect of intermittent pneumatic leg compression on intracranial pressure in brain-injured patients. Crit Care Med. 1993; 21: 224-227.
  42. Parra RO, Farber R, Feigl A. Pressure necrosis from intermittent-pneumatic-compression stockings [letter]. N Engl J Med. 1989; 321: 1615.
  43. Lachmann EA, Rook JL, Tunkel R, et al. Complications associated with intermittent pneumatic compression. Arch Phys Med Rehabil. 1992; 73: 482-485.
  44. Greenfield LJ, Proctor MC, Rodriguez JL, et al. Posttrauma thromboembolism prophylaxis. J Trauma. 1997; 42: 100-103.
  45. Monreal M, Lafoz E, Navarro A, et al. A prospective double-blind trial of a low molecular weight heparin once daily compared with conventional low-dose heparin three times daily to prevent pulmonary embolism and venous thrombosis in patients with hip fracture. J Trauma. 1989; 29: 873-875.
  46. Green D, Lee MY, Lim AC, et al. Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin. Ann Intern Med. 1990; 113: 571-574.
  47. Litz RJ, Hubler M, Koch T, Albrecht DM. Spinal-epidural hematoma following epidural anesthesia in the presence of antiplatelet and heparin therapy. Anesthesiology. 2000; 95: 1031-1033.
  48. Hirsh J, Warkentin TE, Shaughnessy SG, et al. Heparin and low molecular weight heparin: mechanism of action, pharmacokinetics, dosing, monitoring, safety. Chest. 2001; 119: 64S-94S.
  49. Osler TM, Rogers FB. Prophylaxis against venous thromboembolism after major trauma. N Engl J Med. 1997; 336: 586.
  50. Turpie AGG, Gallus AS, Hoek JA. A synthetic pentasaccharide for the prevention of deep-vein thrombosis after total hip replacement. N Engl J Med. 2001; 344: 619-625.
  51. Bauer KA, Eriksson BI, Lassen MR, et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med. 2001; 345: 1305-1310.
  52. Webb LX, Rush PT, Fuller SB, et al. Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture. J Orthop Trauma. 1992; 6: 139-145.
  53. Jarrell BE, Posuniak E, Roberts J, et al. 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. 1983; 157: 316-320.
  54. Cipolle M, Marcinczyk M, Pasquale M, et al. Prophylactic vena caval filters reduce pulmonary embolism in trauma patients [abstract]. Crit Care Med. 1995; 23: A93.
  55. Rodriguez JL, Lopez JM, Proctor MC, et al. Early placement of prophylactic vena caval filters in injured patients at high-risk for pulmonary embolism. J Trauma. 1996; 40: 797-804.
  56. Rogers FB, Shackford SR, Ricci MA, et al. Routine prophylactic vena cava filter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism. J Am Coll Surg. 1995; 180: 641-647.
  57. Rosenthal D, McKinsey JF, Levy AM, et al. Use of the Greenfield filter in patients with major trauma. Cardiovasc Surg. 1994; 2: 52-55.
  58. Wilson JT, Rogers FB, Wald SL, et al. Prophylactic vena cava filter insertion in patients with traumatic spinal cord injury: preliminary results. Neurosurgery. 1994; 35: 234-239.
  59. Winchell RJ, Hoyt DB, Walsh JC, et al. Risk factors associated with pulmonary embolism despite routine prophylaxis: implications for improved protection. J Trauma. 1994; 37: 600-606.
  60. Zolfaghari D, Johnson B, Weireter LJ, et al. Expanded use of inferior vena cava filters in the trauma population. Surg Annu. 1995; 27: 99-105.
  61. Rogers FB, Shackford SR, Wilson J, et al. Prophylactic vena cava filter insertion in severely injured trauma patients: indications and preliminary results. J Trauma. 1993; 35: 637-642.
  62. Patton JH Jr, Fabian TC, Croce MA, et al. Prophylactic Greenfield filter: acute complications and long-term follow up. J Trauma. 1996; 41: 231-237.
  63. Leach TA, Pastena JA, Swan KG. Surgical prophylaxis for pulmonary embolism. Am Surg. 1994; 60: 292-295.
  64. Khansarinia S, Dennis JW, Veldenz HC, Butcher JL, Hartland L. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J Vasc Surg. 1995; 22: 235-236.
  65. Gosin JS, Graham AM, Ciocca RG, Hammond JS. Efficacy of prophylactic vena cava filters in high-risk trauma patients. Ann Vasc Surg. 1997; 11: 100-105.
  66. Sekharan J, Dennis JW, Miranda FE, et al. Long-term follow-up of prophylactic Greenfield filters in multisystem trauma patients. J Trauma. 2001; 51: 1087-1091.
  67. Greenfield LJ, Proctor MC, Michaels AJ, Taheri PA. Prophylactic vena cava filters in trauma: the rest of the story. J Vasc Surg. 2000; 32: 490-495.
  68. Van Natta TL, Morris JA Jr, Eddy VA, et al. Elective bedside surgery in critically injured patients is safe and cost effective. Ann Surg. 1998; 227: 618-624.
  69. Langan EM III, Miller RS, Casey WJ, et al. Prophylactic inferior vena cava filters in trauma patients at high-risk: follow-up examination and risk/benefit assessment. J Vasc Surg. 1999; 30: 484-488.
  70. Velmahos GC, Kern J, Chan L, et al. Prevention of venous thromboembolism after trauma: an evidence-based report-part II: analysis of risk factors and evaluation of the role of vena cava filters. J Trauma. 2000; 49: 140-144.
  71. Greenfield LJ, Proctor MC. Recurrent thromboembolism in patients with vena cava filters. J Vasc Surg. 2001; 33: 510-514.
  72. Golueke PJ, Garrett WV, Thompson JE, et al. Interruption of the vena cava by means of the Greenfield filter: expanding the indications. Surgery. 1988; 103: 111-117.
  73. Rohrer MJ, Scheidler MG, Wheeler HB, et al. Extended indications for placement of inferior vena cava filter. J Vasc Surg. 1989; 10: 44-50.
  74. Ferris EJ, McCowan TC, Carver DK, et al. Percutaneous inferior vena cava filters: follow-up of seven designs in 320 patients. Radiology. 1993; 188: 851-856.
  75. Nunn CR, Neuzil D, Naslund T, et al. Cost-effective method for bedside insertion of vena cava filters in trauma patients. J Trauma. 1997; 45: 752-758.
  76. Headrick JR, Barker DE, Pate LM, Horne K, Russell WL, Burns RP. The role of ultrasonography and inferior vena cava filter placement in high-risk trauma patients. Am Surg. 1997; 63: 1-8.
  77. McMurtry AL, Owings JT, Anderson JT, Battistella FD, Gosselin R. Increase use of prophylactic vena cava filters in trauma patients failed to decrease overall incidence of pulmonary embolism. J Am Coll Surg. 1999; 189: 314-320.
  78. Ashley DW, Gamblin TC, Burch ST, Solis MM. Accurate deployment of vena cava filters: comparison of intravascular ultrasound and contrast venography. J Trauma. 2001; 50: 975-981.
  79. Greenfield LJ. Post trauma thromboembolism prophylaxis. Paper presented at: Eighth Annual Meeting of the American Venous Forum, February 1996; San Diego, CA.
  80. Tola JC, Hotzman R, Lottenberg L. Bedside placement of inferior vena cava filters in the intensive care unit. Am Surg. 1999; 65: 833-837.
  81. Lorch H, Welger D, Wagner V, et al. Current practice of temporary vena cava filter insertion: a multicenter registry. J Vasc Intervent Radiol. 2000; 11: 83-88.
  82. Neuerburg JM, Gunther RW, Vorwerk D, et al. Results of a multicenter study of the retrievable tulip vena cava filter: early clinical experience. Cardiovasc Intervent Radiol. 1997; 20: 10-16.
  83. Wheeler HB, Anderson FA Jr. Diagnostic methods for deep vein thrombosis. Haemostasis. 1995; 25: 6-26.
  84. Wheeler HB, Anderson FA Jr. Use of noninvasive tests as the basis for treatment of deep vein thrombosis. In: Bernstein EF, ed. Vascular Diagnosis. 4th ed. St. Louis: Mosby; 1993: 1894-1912.
  85. Burns GA, Cohn SM, Frumento RJ, et al. Prospective ultrasound evaluation of venous thrombosis in high-risk trauma patients. J Trauma. 1993; 35: 405-408.
  86. Napolitano LM, Garlapati VS, Heard SO, et al. Asymptomatic deep venous thrombosis in the trauma patient: is an aggressive screening protocol justified? J Trauma. 1995; 39: 651-659.
  87. Meythaler JM, DeVivo MJ, Hayne JB. Cost-effectiveness of routine screening for proximal deep venous thrombosis in acquired brain injury patients admitted to rehabilitation. Arch Phys Med Rehabil. 1996; 77: 1-5.
  88. White RH, Goulet JA, Bray TJ, et al. Deep-vein thrombosis after fracture of the pelvis: assessment with serial duplex-ultrasound screening. J Bone Joint Surg Am. 1990; 72: 495-500.
  89. Meredith JW, Young JS, O'Neil EA, et al. Femoral catheters and deep venous thrombosis: a prospective evaluation of venous duplex sonography. J Trauma. 1993; 35: 187-191.
  90. Brasel KJ, Borgstrom DC, Weigelt JA. Cost effective prevention of pulmonary embolus in high-risk trauma patients. J Trauma. 1997; 42: 456-463.
  91. Agnelli G, Radicchia S, Nenci GG. Diagnosis of deep vein thrombosis in asymptomatic high-risk patients. Haemostasis. 1995; 25: 40-48.
  92. Wells PS, Lensing AW, Davidson BL, et al. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery: a meta-analysis. Ann Intern Med. 1995; 122: 47-54.
  93. Prandoni P, Bernardi E. Upper extremity deep vein thrombosis. Curr Opin Pulm Med. 1999; 5: 222-226.
  94. Chu DA, Ahn JH, Ragnarson KT, et al. Deep venous thrombosis: diagnosis in spinal cord injured patients. Arch Phys Med Rehabil. 1985; 66: L365-L368.
  95. Myllynen P, Kammonen M, Rokkanen P, et al. Deep venous thrombosis and pulmonary embolism in patients with acute spinal cord injury: a comparison with nonparalyzed patients immobilized due to spinal fractures. J Trauma. 1985; 25: 541-543.
  96. Brach BB, Moser KM, Cedar L, et al. Venous thrombosis in acute spinal cord paralysis. J Trauma. 1977; 17: 289-292.
  97. Satiani B, Falcone R, Shook L, Price J. Screening for major deep venous thrombosis in seriously injured patients: a prospective study. Ann Vasc Surg. 1997; 11: 626-629.
  98. Sandler DA, Martin JF, Duncan JS, et al. Diagnosis of deep-vein thrombosis: comparison of clinical evaluation, ultrasound, plethysmography and venoscan with x-ray venogram. Lancet. 1984; 2: 716-719.
  99. Burke B, Sostman HD, Carroll BA, Witty LA. The diagnostic approach to deep venous thrombosis. Clin Chest Med. 1995; 16: 253-268.
  100. Freeark RJ, Boswick J, Fardin R. Posttraumatic venous thrombosis. Arch Surg. 1967; 95: 567-575.
  101. Montgomery KD, Potter HG, Helfet DL. Magnetic resonance venography to evaluate the deep venous system of the pelvis in patients who have an acetabular fracture. J Bone Joint Surg Am. 1995; 77: 1639-1649.
  102. Rabinov K, Paulin S. Roentgen diagnosis of venous thrombosis in the leg. Arch Surg. 1972; 104: 134-144.
  103. Bettmann MA, Robbins A, Braun SD, et al. Contrast venography of the leg: diagnostic efficacy, tolerance, and complication rates with ionic and nonionic contrast media. Radiology. 1987; 165: 113-116.
  104. Kakkar VV, Howe CT, Nicolaides AN, et al. Deep vein thrombosis of the leg: is there a high-risk group? Am J Surg. 1970; 120: 527-530.
  105. Brathwaite CE, Mure AJ, O'Malley K, et al. Complications of anticoagulation for pulmonary embolism in low risk trauma patients. Chest. 1993; 104: 718-720.

Table

Title

First Author

Year

Reference Title

Class

Conclusion 

Webb LX

1992

Greenfield filter prophylaxis of pulmonary embolism in  patients undergoing surgery for acetabular fracture.  J Orthop Trauma. 6:139–145

II

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 preoperative filter; 2 PEs in this group, 1 fatal. All patients  had SQ heparin and aspirin.

 

Jarrell BE

1983

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. 157:316–320

III

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  population 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.

 

Cipolle M

1995

Prophylactic vena caval filters reduce pulmonary  embolism in trauma patients [abstract]. Crit Care  Med. 23:A93.

III

Review of 43 high-risk trauma patients who had VCFs placed, 16 for  traditional indications and 27 for prophylaxis. 0 PEs in prophylactic  group and 5 PEs in traditional indications group. Overall PE rate  was 11.6%.

 

Rodriguez JL

1996

Early placement of prophylactic vena cava filters in  injured patients at high-risk for pulmonary embolism.  J Trauma. 40:797–804

II

40 VCFs placed in consecutive 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.

 

Rogers FB

1995

Routine prophylactic vena cava filter insertion in  severely injured trauma patients decreases the  incidence of pulmonary embolism. J Am Coll Surg.  180:641–647

II

Continued follow-up from J Trauma 1993. 63 prophylactic VCFs  placed in high-risk patients as previously outlined. DVT rate: 30%,  1 PE (fatal). No insertion complications, 3.5% insertion-related  thromboses. 30-day patency, 100% (n = 36); 1 year, 96% (n =  34); 2 year, 96% (n = 16).

 

Rosenthal D

1994

Use of the Greenfield filter in patients with major  trauma. Cardiovasc Surg. 2:52–55

II

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.

 

Wilson JT

1994

Prophylactic vena cava filter insertion in patients with  traumatic spinal cord injury: preliminary results.  Neurosurgery. 35:234–239

II

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 (9–5,993). 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

1994

Risk factors associated with pulmonary embolism  despite routine prophylaxis: implications for  improved protection. J Trauma. 37:600–606

III

8-year retrospective registry review at Level I trauma center (9,721  patients). Overall PE rate, 37%. 29 prophylactic VCFs 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 +  long bone fracture (12%); multiple long bone fractures (10%).  Patients with estimated risk of PE, despite prophylaxis of > 2–5%,  are reasonable candidates for prophylactic VCF placement,  especially if conventional measures cannot be used.

 

Zolfaghari D

1995

Expanded use of inferior vena cava filters in the trauma  population. Surg Annu. 27:99–105

III

Retrospective analysis of 45 filters placed in 3,005 patients. 38/45  had extended 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.

 

Rogers FB

1993

Prophylactic vena cava filter insertion in severely  injured trauma patients: indications and preliminary  results. J Trauma. 35:637–642

II

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).

 

Patton JH Jr

1996

Prophylactic Greenfield filter: acute complications and  long-term follow-up. J Trauma. 41:231–237

II

Follow-up of prophylactic filters placed between 1991 and 1994. 69  filters with 9% insertion rate. 15 patients died. 30 patients were  located and 19 returned for follow-up evaluation (35%). Average  follow-up was 770 days (246–1,255). No caval thrombosis. 14  patients had chronic DVT. 11/14 had chronic venous insufficiency.  No long-term caval thromboses. Not clear, however, whether filter  caused chronic venous insufficiency because there was no nonfilter  group.

 

Leach TA

1994

Surgical prophylaxis for pulmonary embolism. Am  Surg. 16:292–295

II

205 VCFs placed for indications that were outlined prospectively,  although many were inserted for “traditional” indications. No PEs in  these filters, patients, and minimal insertion complications.

Khansarinia S

1995

Prophylactic Greenfield filter placement in selected  high-risk trauma patients. J Vasc Surg. 22:235–236

I

108 filters placed in high-risk trauma patients over a 2-year period  with injury-matched controls who did not receive a filter. PEs 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

1997

Efficacy of prophylactic vena cava filters in high-risk  trauma patients. Ann Vasc Surg. 11:100–105

II

99 prophylactic filters placed in high-risk trauma population over 2- year period. This decreased PEs in trauma populatin to 1.6% from  4.8% in historical controls (p � 0.045 Fisher’s exact).

Sekharan J

2001

Long term follow up prophylactic Greenfield filters in  multisystem trauma patients. J Trauma. 51:1087–  1091

III

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

Greenfield LJ

2000

Prophylactic vena cava filters in trauma: the rest of the  story. J Vasc Surg. 32:490–495

II

249 patients had prophylactic filters and prospectively followed. Caval  occlusion rate was 3.5% and new PE was 1.5%. Authors  concluded that prophylactic VCF was associated with low adverse  outcome rate while protecting from fatal PE.

Van Natta TL

1998

Elective bedside surgery in critically injured patients is  safe and cost effective. Ann Surg. 227:618–624

III

71 ICU filters placed at bedside in the ICU in trauma patients under  ultrasound guidance. No complications associated with IVC filter  placement. Decreased cost and OR use.

Langan EM 3rd

1999

Prophylactic inferior vena cava filters in trauma patients  at high-risk: follow-up examination and risk/benefit  assessment. J Vasc Surg. 30:484–488

III

160 prophylactic filters inserted: 75 (45%) returned for follow-up, a  mean of 19.4 mo (range, 7–60 mo) after insertion. 93% patiency of  vena cava on follow-up ultrasound; 13.3% had DVT with one  nonfatal PE. Filter insertion complications occurred in 3 (1.6%)  patients including one groin hematoma, one A-V fistula, and one  misplacement in common iliac vein.

Velmahos GC

2000

Prevention of venous thromboembolism after trauma:  an evidence-based report—part II: analysis of risk  factors and evaluation of the role of vena cava  filters. J Trauma. 49:140–144

I

Meta-analysis of literature on prophylactic vena cava filters. Patients  with prophylactic vena cava filters had a lower incidence of PE  (0.2%) compared with those without filters (1.5%) vs. historical  controls (5.8%).

Greenfield LJ

1988

Twelve-year clinical experience with the Greenfield  vena cava filter. Surgery. 104:706–712

III

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.

Golueke PJ

1988

Interruption of the vena cava by means of the  Greenfield filter: expanding the indications. Surgery.  103:111–117

III

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 mo (range 1–60 mo) in 65  patients. Complications: 3% recurrent PE, 9% leg edema, 7.5%  caval occlusion 92.5% patency. No PEs in prophylactic group that  received antiplatelet and pneumatic compression therapy.  Indications should be extended for VCFs to help reduce  preventable deaths secondary to PE.

Rohrer MJ

1989

Extended indications for placement of inferior vena  cava filters. J Vasc Surg. 10:44–50

III

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 because of 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.

Ferris EJ

1993

Percutaneous inferior vena cava filters: follow-up of  seven designs in 320 patients. Radiology. 188:851–  856

III

324 filters placed over 7 yr. No placement-related mortality or  morbidity. Average follow-up, 404 days (1–2,392). 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.

Nunn CR

1997

Cost-effective method for bedside insertion of vena  cava filters in trauma patients. J Trauma. 45:752–758

III

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

Headrick JR

1997

The role of ultrasonography and inferior vena cava filter  placement in high-risk trauma patients. Am Surg.  63:1–8

II

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 with historical controls.

McMurtry AL

1999

Increase use of prophylactic vena cava filters in trauma  patients failed to decrease overall incidence of  pulmonary embolism. J Am Coll Surg. 189:314–320

III

Review of 299 patients with prophylactic filters over an 8-yr period,  yielded no demonstrable decrease in PE incidence compared with  historical controls.

Ashley DW

2001

Accurate deployment of vena cava filters: comparison  of intravascular ultrasound and contrast venography.  J Trauma. 50:975–981

III

21 patients had VCF placed via intravascular ultrasound in the OR,  followed by contrast venography. In four cases, contrast  venography missed “best location” by 3 mm or more. Contrast  venography overestimated vena cava diameter on average (24.4 :  3.3 mm venography vs. 20.6 : 3.1 mm intravascular ultrasound; < 0.0001).

 

Greenfield LJ

1996

Posttrauma thromboembolism prophylaxis. 8th Annual  American Venous Forum

I

Pilot study for large, multicenter trial. 53 patients randomized to  receive PCD, LMWH, or unfractionated heparin and 1/2  randomized to receive VCF. 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 group. 12 DVTs in nonfilter  patients and 11 DVTs in filter patients.

 

Tola JC

1999

Bedside placement of inferior vena cava filters in the  intensive care unit. Am Surg. 65:833–837

III

25 patients underwent prophylactic IVC filters in the ICU with digital  C-arm with no postoperative or intraoperative complications.  Average saving of $1,844 when filters were placed in ICU vs. OR.

 

Lorch H

2000

Current practice of temporary vena cava filter insertion:  a multicenter registry. J Vasc Interv Radiol. 11:83–88

III

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

 

Neuerburg JM

1997

Results of a multicenter study of the retrievable tulip  vena cava filter: early clinical experience. Cardiovasc  Intervent Radiol. 20:10–16

III

83 patients implanted with retrievable Tulip filter; 3 filter insertion  problems, 1 fatal recurrent PE; 2 nonfatal PEs; 8 caval occlusions.

 

« Back to guidelines

Eastern Association for the Surgery of Trauma

Contact
633 N. Saint Clair Street, Suite 2600 Chicago, Illinois 60611 (312) 202-5508 phone (312) 202-5064 fax managementoffice@east.org
Stay connected to EAST
Support EAST
  • AmazonSmiel