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Does an indication exist to place IVC filters in patients with cancer who can receive anticoagulation?
Click here to read the Cover Story, “‘Disconnect’ blamed for potential overuse of inferior vena cava filters.”
Yes.
In most patients for whom anticoagulation is indicated and can be administered safely, the placement of an IVC filter is unnecessary and usually ill-advised. However, as with most of patient care, there are few certainties and it is incorrect to say there is never a reason to place a filter in a patient with cancer who can receive anticoagulation.
Even well-managed anticoagulation can fail; this risk may be three times greater among patients with cancer. Some patients have such poor cardiopulmonary reserve or performance status — because of chemotherapy, comorbidities or malnutrition — that any additional PE burden could be life threatening. These patients may benefit from the additional protection of an IVC filter, or the “belt-and-suspenders” strategy. Occasionally, patients develop thrombi that pose such lethal potential — such as a massive, free-floating IVC clot, the so-called widow-maker thrombus — that an extra layer of protection with caval filtration may be warranted despite the ability to anticoagulate. Although I do not routinely place filters during thrombectomy or thrombolysis, encountering such a clot may compel me to do so.
Finally, let us keep in mind that patients with cancer often require interruption of anticoagulation because of surgeries or interventional procedures. Placement of an IVC filter may be prudent in the perioperative or periprocedural setting among patients at very high risk for complications from VTE. Here, retrievable IVC filters — which are approved for permanent use, but designed to allow their removal — likely are a more appropriate option.
The landmark PREPIC trial showed that IVC filters confer no mortality benefit to patients who are concomitantly anticoagulated. So, uncommon and judicious — rather than routine — use of cava filters should be the rule for patients with cancer.
A critical point is that IVC filters are often only ephemerally indicated. It is incumbent upon the implanting physician to collaborate with the oncologist to monitor the patient and consider removing the retrievable filter once the indication for IVC filtration has been lost. Although no immutable rules exist in the care of patients with cancer, with careful consideration of the risks and benefits of IVC filters, the physician caring for the oncology patient can strike an optimal balance to prevent unnecessary procedural complications while protecting the patient from potentially lethal thromboembolic events.
References:
Prandoni P, et al. Blood. 2002;doi:10.1182/blood-2002-01-0108.
PREPIC Study Group. Circulation. 2005;doi:10.1161/Circulationaha.104.512834.
Mark L. Lessne, MD, is a vascular and interventional specialist at Charlotte Radiology. He can be reached at mark.lessne@charlotteradiology.com. Disclosure: Lessne reports he has no relevant financial disclosures.
No.
There is no doubt that this is a controversial topic. IVC filters are to be inserted if a patient has an acute venous thromboembolic event and there is an absolute contraindication to anticoagulation.
Unfortunately — especially for patients with cancer — they tend to be inserted all the time, even with just a diagnosis. Data from a California database showed 20% of patients with cancer who have a VTE and are admitted to a hospital get an IVC filter, and there really is no difference in the risk for DVT, PE and overall mortality among those patients. To push it further, when researchers looked at patients who might have had a contraindication — either they need to have a surgery soon or are experiencing bleeding — results showed no difference in OS in that specific subgroup.
The advantages of IVC filters are certainly not clear. There have never been any data, even from patients who do not have cancer, to support that putting a temporary or permanent IVC filter in patients who are receiving anticoagulation is of any benefit. The PREPIC and PREPIC 2 trials are very clear on that, and we know the filters can cause harm.
In the absence of data showing they are helpful, there are now data showing that if the filters are left in long term — which they often are because, unfortunately, there is no reimbursement for taking them out — they often are associated with complications, which include misplacement and changing position of the IVC filter. More importantly, you are introducing a foreign body that disturbs the flow and is directly associated with an increased risk for DVT in patients with cancer, which may already have associated symptoms and comorbidities.
IVC filters should be avoided unless there is an absolute contraindication to anticoagulation in a setting of VTE. There also are no data on prevention in any setting for IVC filter insertion. The only indication is for a patient with an acute clot who cannot receive blood thinners. In that case, use an IVC filter, but only for as short a time as possible. Once the patient is back on anticoagulation, remove the filter to avoid complications.
References:
Brunson A, et al. Thromb Res. 2016;doi:10.1016/20049-3848(16)30112-8.
Mismetti P, et al. JAMA. 2015;doi:10.1001/jama.2015.3780.
PREPIC Study Group. Circulation. 2005;doi:10.1161/Circulationaha.104.512834.
Marc Carrier, MD, MSc, FRCPC, is associate professor in the faculty of medicine in the clinical epidemiology program at Ottawa Hospital Research Institute. He can be reached at mcarrier@toh.on.ca. Disclosure: Carrier reports he has no relevant financial disclosures.