Controversial indications for VCF insertion that we consider inappropriate indications for VCF insertion
| Indication . | Comments . |
|---|---|
| Pulmonary embolism with an absolute contraindication to therapeutic anticoagulation but without concurrent proximal DVT | If there is no proximal DVT, patients with PE generally do not require immediate therapeutic anticoagulation. They can often be given prophylactic anticoagulation to prevent recurrent proximal DVT (and, therefore, to prevent recurrent PE) until therapeutic anticoagulation can be initiated when the contraindication resolves. |
| Patients with VTE who are receiving therapeutic anticoagulation | VCF insertion does not significantly benefit patients who are therapeutically anticoagulated.22,23 |
| Symptomatic PE within a few days of starting therapeutic anticoagulation | This uncommon situation most commonly represents mechanical dislodgement of part of a DVT during the early treatment period. For most such patients, therapeutic anticoagulation should continue without a VCF. |
| Recurrent VTE or progressive DVT despite therapeutic anticoagulation (generally seen only in patients with active cancer) | This may represent failure of the current anticoagulant regimen. However, we believe this is a contraindication to a VCF. Such patients should be managed by switching to another anticoagulant (such as low-molecular-weight heparin) or increasing the intensity of anticoagulation.2,29 A VCF will not control the recurrent or progressing thrombosis and, in this very hypercoagulable state, may make the situation worse by adding another thrombogenic stimulus. |
| Major PE in patients with poor cardiopulmonary reserve (massive PE, right ventricular dysfunction, sepsis, etc) and concern that recurrent PE could be life-threatening | Recurrent PE is very uncommon when appropriate therapeutic anticoagulation is initiated. |
| Extensive DVT (involving the vena cava or iliac veins) or DVT with a free-floating proximal end | Extensive DVT is adequately treated with therapeutic anticoagulation. A VCF does not significantly benefit patients who receive therapeutic anticoagulation.22,23 There is no increase in PE with conventional anticoagulation alone if DVT is free-floating.30 |
| Proximal DVT in a patient undergoing a catheter-directed thrombus reduction procedure or PE managed with thrombolysis or surgical embolectomy | VCFs may reduce PE in such patients, but few experience hemodynamically significant PE, and VCF insertion increases the length and cost of the procedure. However, in this situation, a VCF may be considered selectively in patients thought to be at particularly high risk of PE.31 |
| Trauma or major surgery patients (general, orthopedic, neurosurgical, gynecologic, bariatric) with presumed high PE risk who are felt to have a contraindication to anticoagulant thromboprophylaxis due to risk of bleeding, or with such a presumed high VTE risk that a VCF is considered in addition to anticoagulant thromboprophylaxis | There is no direct evidence to support a benefit of VCF in these groups.32-34 Filter insertion may also lead to a delay in effective thromboprophylaxis. Calculations suggest the major complication rates of VCFs are at least as high as the risk of major PE in patients given the best available thromboprophylaxis. |
| Patients having surgery and requiring interruption of anticoagulation for VTE >1 month ago | Patients with VTE >1 month ago can safely interrupt anticoagulation briefly for surgery with the objective to hold periprocedure anticoagulant for as short a time as is safe. |
| Patients undergoing pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension | There is no evidence that vena caval interruption is required in such patients in addition to perioperative prophylactic anticoagulation followed by therapeutic anticoagulation. |
| Indication . | Comments . |
|---|---|
| Pulmonary embolism with an absolute contraindication to therapeutic anticoagulation but without concurrent proximal DVT | If there is no proximal DVT, patients with PE generally do not require immediate therapeutic anticoagulation. They can often be given prophylactic anticoagulation to prevent recurrent proximal DVT (and, therefore, to prevent recurrent PE) until therapeutic anticoagulation can be initiated when the contraindication resolves. |
| Patients with VTE who are receiving therapeutic anticoagulation | VCF insertion does not significantly benefit patients who are therapeutically anticoagulated.22,23 |
| Symptomatic PE within a few days of starting therapeutic anticoagulation | This uncommon situation most commonly represents mechanical dislodgement of part of a DVT during the early treatment period. For most such patients, therapeutic anticoagulation should continue without a VCF. |
| Recurrent VTE or progressive DVT despite therapeutic anticoagulation (generally seen only in patients with active cancer) | This may represent failure of the current anticoagulant regimen. However, we believe this is a contraindication to a VCF. Such patients should be managed by switching to another anticoagulant (such as low-molecular-weight heparin) or increasing the intensity of anticoagulation.2,29 A VCF will not control the recurrent or progressing thrombosis and, in this very hypercoagulable state, may make the situation worse by adding another thrombogenic stimulus. |
| Major PE in patients with poor cardiopulmonary reserve (massive PE, right ventricular dysfunction, sepsis, etc) and concern that recurrent PE could be life-threatening | Recurrent PE is very uncommon when appropriate therapeutic anticoagulation is initiated. |
| Extensive DVT (involving the vena cava or iliac veins) or DVT with a free-floating proximal end | Extensive DVT is adequately treated with therapeutic anticoagulation. A VCF does not significantly benefit patients who receive therapeutic anticoagulation.22,23 There is no increase in PE with conventional anticoagulation alone if DVT is free-floating.30 |
| Proximal DVT in a patient undergoing a catheter-directed thrombus reduction procedure or PE managed with thrombolysis or surgical embolectomy | VCFs may reduce PE in such patients, but few experience hemodynamically significant PE, and VCF insertion increases the length and cost of the procedure. However, in this situation, a VCF may be considered selectively in patients thought to be at particularly high risk of PE.31 |
| Trauma or major surgery patients (general, orthopedic, neurosurgical, gynecologic, bariatric) with presumed high PE risk who are felt to have a contraindication to anticoagulant thromboprophylaxis due to risk of bleeding, or with such a presumed high VTE risk that a VCF is considered in addition to anticoagulant thromboprophylaxis | There is no direct evidence to support a benefit of VCF in these groups.32-34 Filter insertion may also lead to a delay in effective thromboprophylaxis. Calculations suggest the major complication rates of VCFs are at least as high as the risk of major PE in patients given the best available thromboprophylaxis. |
| Patients having surgery and requiring interruption of anticoagulation for VTE >1 month ago | Patients with VTE >1 month ago can safely interrupt anticoagulation briefly for surgery with the objective to hold periprocedure anticoagulant for as short a time as is safe. |
| Patients undergoing pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension | There is no evidence that vena caval interruption is required in such patients in addition to perioperative prophylactic anticoagulation followed by therapeutic anticoagulation. |