Chapters Transcript Video IVC Filters - Hager Back to Symposium Alright, um, thank you very much. um, my topics are much easier, more straightforward, so I can go through these relatively quickly. I get the privilege of talking about IVC filters which I think in general has been really well described the the studies that have been out. There from the early days really have have been uh really relevant throughout and I I think that it's it's an interesting thing to kind of look at where we were and more importantly where we are and not a lot has changed just kind of our understanding and and the way that we apply uh that knowledge to our patients so we'll talk about the IVC filters. And, oh, you know. So what is an IVC filter? I think most of us know what these things are. I mean, I always describe it as it's a shuttlecock in badminton that just catches clots, so it doesn't go to the lungs. It doesn't cause pulmonary embolism. It doesn't cause a paradoxical stroke. So the idea here, it was a pretty ingenious idea. We put this thing in. No one ever has a PE. The problem, like when the proof was in the pudding, as we kind of so said, um, what happened was we followed these things along and we started to see what the downside was over time. So we try to use filters and and really reserve them for the patients that need them the most. We were putting them in everybody, so you came in, you know, you had your knee hurt, you got a filter like I mean just everybody got these things, and the reality was is we were probably doing a lot more harm than good. And so I think that when you looked at this, there were 96,000 placed annually in the United States and this was at the peak so you really did see there's a lot of these patients coming in that the indications would be really what each hospital had recommended. Uh Looking back, so this was a great study in 1998, and this was really one of the first early studies that was published in the New England Journal that looked at what happens to these patients. So these were 400 patients with proximal DVT. They were randomized. They either received a filter with anticoagulation or anticoagulation known. Only and then they looked at the data of 12 days and 2 years and what they found was basically if you have a high risk patient with a proximal DVT, the IVC filter is beneficial to prevent pulmonary embolism early but later on you got a higher chance of having a DVT so it kind of. That if you can anticoagulate, you really wanna anticoagulate. If you don't, great, you can prevent pulmonary emboli up front, but the long term of not taking these things out was pretty significant and, and we saw a lot of these studies, a lot of talking about kind of uh post thrombotic syndrome which patients would, would really have to deal with. So the pre-PIC trial, uh, this was one of the original trials, this was in 2005 in circulation, um, this was again looking at 400 patients with proximal DVT randomized to receive a filter or not receive a filter in addition to anticoagulation. So they looked at pulmonary embolism at 8 years and at that time 6.2% had it with a filter, only 15% had it without a filter, so obviously a statistically higher difference, but again, DVT rates were much higher. There's no difference in overall survival so while it reduces the risk of pulmonary embolism, it does increase the risk of deep vein thrombosis. So this is kind of what a lot of the early litigation started to build on and and you'll start to see this theme and I think if there's any lawyers in the room, they enjoyed this theme while us as physicians and patients did not love that. So retrievable filters, the, the PRPIC 2 trial, uh, this was 2015 published in JAMA, and this was a randomized trial of severe acute PE patients eligible for anticoagulation, and basically they looked at recurrent pulmonary embolism at 3 months with filter versus an anticoagulation versus anticoagulation alone, and they actually found there's no statistical difference in the study, but they found that there was really no difference between filter and anticoagulation or anticoagulation alone, um. What was interesting too is the one of the the biggest things that came out of this was they had a really good and robust way of of retrieving these filters and ultimately what patients need is a filter that gets placed uh in a in a responsible way they need a follow up and that's what this really came out so I even underlined it, um, but patients who have anticoagulation do not need filters, but robust follow up is needed, uh, so anticoagulation became the mainstay of treatment for pulmonary embolism or DVT. So we talk about these patients and I still have colleagues of mine that are trauma surgeons that will say this patient had X, Y, or Z, uh, trauma, they need a filter and so this was a good study. This was done recently published in 2000 I should say recently seven years ago now, but in 2019, uh, multi-center randomized trial of severely injured trauma patients. These are the patients with contraindication to anticoagulation. And they had an IVC filter placed or they had no filter placed and they really kind of followed them with a duplex. What they found was the composite endpoint of pulmonary embolism death at 90 days there was no difference. There was a subgroup that was unable to receive anticoagulation for greater than or equal to 7 days did have a reduced pulmonary embolism. So this is that subgroup. So a patient that has a. Hemorrhagic stroke or or a major crush injury that cannot be anticoagulated for in a longer period of time they would actually benefit from an IVC filter but those who the initial trauma precludes them from anticoagulation really you can wait, make sure that they are getting their STDs and things like that, and then start them on anticoagulation when they can be monitored and it's feasible and again to routine prophylactic use was not supported. So clinical takeaway, so anticoagulation should be used whenever it's possible. So anybody that comes in with a blood clot that is in the deep system, and, and I will put an asterisk next to that because things like, uh, posterior tibial thrombi, um, maybe you can avoid it, and, and there's some extenuating circumstances with things like that. But large DVTs certainly, uh, pulmonary embolism certainly permanent filters to reduce pulmonary embolism, but they increase, so we, we try to avoid permanent filters. The only time I ever really put them in. Um, if I had one on the shelf and there was a terminal patient with cancer, um, I really, most of us don't even supply them. and my hospital system does not. Retrievable filters do not add a benefit when anticoagulation is, is feasible, and filters benefit from, uh, from it basically anybody who is high risk would benefit from a filter if the, the duration of not being able to be anticoagulated is over really 14 days. Um, and again structural follow up is incredibly important. So the economics again just to add on something that's slightly more boring to a relatively bland topic this is the economic impact of IVC filters. So the filter you can imagine depending inpatient outpatient it is. What we look at is the cost for things like placement we, and this is the physician fee, this is the, the, um, anesthesia fee, everything that goes into it. But you can see here that the economic it really depends on it's predicated on placement but also it's the retrieval, and that's what a lot of of the cost is incurred. The in general, and this is this was a relatively uh recent study 2023 that looked at the overall cost and so there's a lot, a huge standard deviations based on region based on reimbursement, things like that but inpatient cost is astronomically higher, 10 times the cost of outpatient. And the mean retrieval cost for a simple retrieval is relatively low, $2300. Again I say simple because as soon as you start adding things like forceps advanced techniques, it does get much more expensive. So why do we wanna do this? Why do we wanna treat these things and why, more importantly, why do we want to, um, really start talking about the retrieval? And I think this is the most important part of all of IVC filter implantation is how do you get them out, because we can all agree that we've all seen these pictures where there's, you know, you do an EGD and you see a strut within the duodenum or you see all of a sudden that they're starting to get a weird, you know, there is swelling. Now they have a fistula in the aorta. All of these things you can see the tines will penetrate. Uh, we see them into the psoas muscles. We see filter fractures. So the important thing and what drives cost here is the complications. So back in the old days we would put a filter in, we'd say, all right, go on your merry way. If you remember you have a filter, please let us know and we'll take it out. That no longer works. And and the reality is is because it does harm to the patient, but also doesn't incur quite a cost. So clinical outcomes and cost effectiveness, short term pulmonary embolism risk reduction in selected patients. So that's ultimately what we're talking about. You're talking about the patients that have clot in transit. You're talking about patients that have a history of a pul a large pulmonary embolism that maybe couldn't have a second hit to that system. These are the patients that we we know would do well with this, uh, but there's no consistent long term mortality benefit in many populations again, not all patients, but many populations, and the longer a filter is in dwelling, the less cost effective it is. So placement alone under uh the cost underestimate the true economic impact again too if a patient comes back in with GI bleeding because they have a strut in their duodenum, that's a big difference on how what the cost is incurred so again early retrieval, early retrieval, and that's I think the most important thing. Um, standard retrievals are very, very easy. Uh, I'm actually embarrassed to say that I don't do forceps. I think I'm just afraid of it. A lot of my IR colleagues, uh, they, they make it look very easy, and so I refer the, a lot of the complicated ones to them, uh, again with my, you know, kind of tail between my legs because it is always hard for a surgeon to be like, I don't know how to do this. Can you help me out? But nonetheless, I think if you're good at it, it's, that's who you refer to. And I love the standard ones, um, just a caveat, the one thing I can tell you, I think it's important to talk about all the things we did wrong. I had a patient that came in for a filter retrieval. I had got access. I went down to the abdomen and there was no filter. And so I looked back at the op note and somebody at another hospital had retrieved it the week before. So you could make the argument the patient should have probably known that, but ultimately that's my fault. So my one piece of advice is take a quick X-ray of the abdomen and make sure they have a filter before you take it out. So in retrieval increases short term costs but reduces health care spending over time. Again early robust follow up for these patients and you can imagine the the challenge if a patient comes in at my hospital system in Pittsburgh we have the we really cover 9 or 10 different hospitals and our catch-all is from the middle. Of Ohio all the way to the middle of the state down in the West Virginia and all the way up north in Erie, huge area so if somebody you know falls on a chainsaw and comes in and needs a filter, we may never see these patients again. So how do you follow the person that lives in the woods to let them know they need to have a follow up for this filter? So that's kind of one of the things that we see. So why do we need to retrieve filters again this is a great study. This is, and it's hard to probably see. I can't even see it, but I'm getting older. So if you look at these, these are the average retrieval rates, and this is a this is a study in 2024 looking at basically all. The Medicare beneficiaries in the best case scenario, Medicare patients are relatively easy to follow. 20%, 21% of these filters are retrieved, which means 78 to 80% are out there floating around with a filter in place, waiting to do the things that that filters do. And again, why time penetration, filter fracture, migration, cable thrombosis, all of these things are well described. This was a one of our patients, and I, I, this is the magic of PowerPoint that took me a long time. So that circle, when I blow it up and there's a little arrow, it's probably hard to see there's a tine in this patient's lung, they're having hemoptysis, and so that was one of those, hey, I don't think the tine belongs there kind of moments. And so this is again just reiterating the fact why do we take these things out. So that brings me to the BD Reach program. So I, uh, was giving a talk at VI two years ago and I was introduced to the BD Reach program. This is a wonderful, uh, of all the things that I kinda advocate and get behind, I think this is one of those things that is one of the most effective. The reason is this is a program that BD runs. You can enroll patients into it, and it's free. It's free for the patients. It has great longitudinal follow up. They actually will call the patients if you look at this and look how happy this lady is. She's super excited. But it they will you enroll the patient there's a primary contact secondary contact and then eventually you get a consult and it doesn't have to be with you. So one of the big barriers that I have found is that a patient coming from Saint elsewhere you know in a car accident or whatever doesn't wanna necessarily go back to. Hospital where everything happened, but they will help connect with an interventional radiologist, a vascular surgeon, whomever to remove this filter, and the success rates have been much, much better. I mean as high as 60, 70, and 80% depending on where it is. So that's pretty much the basics of IVC filters why we use them and how much they cost. Published Created by
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