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Venous Thromboembolism (Rehab Phase)

Internal Methods

Inferior Vena Cava Filtration

Vena Cava Filters are an invasive form of thromboembolic prophylaxis that primarily function to prevent clots from travelling to the heart and lungs while still allowing venous blood flow to flow. Earlier, these cone-shaped filters were placed surgically through the femoral vein; currently, less invasive techniques exist, allowing for filter placement through femoral, internal jugular, or small peripheral veins under fluoroscopic or ultrasound guidance (Jundt, Liem, & Moneta 2014; Tai et al. 2013).

While pharmacological and mechanical methods remain the primary forms of thromboprophylaxis used in acute SCI, the use of vena cava filters is indicated in trauma individuals who are considered to be at high risk for developing DVT, specifically when there are contraindications to using anticoagulation (e.g., bleeding risk) or mechanical prophylaxis (e.g., external fixators or immobilizers are present). The ability to retrieve IVC filters offers the benefit of the filter during periods when PE risk is high, without long-term complications associated with their use (Lo et al. 2013; Rogers et al. 1993; Shackford et al. 2007). Routine implementation of IVC filters is not recommended as prophylaxis in SCI individuals (Maxwell et al. 2002).

Author Year; Country
PEDro Score
Research Design
Sample Size

Methods Outcome

Roberts & Young, 2010; USA
Case Series
N = 15

Population: Mean age=39.7 yr; Gender: males=37, females=8; Level of injury: cervical; Severity of injury: injury severity score (ISS)>20 (mean score=34.2).
Chronicity: Filters were placed in all individuals within 72 hr of admission.
Intervention: Placement of a prophylactic inferior vena cava (IVC) filter. Individuals were placed on prophylactic anticoagulant therapy 1 week after injury (Lovenox or Heparin).
Outcome Measures: Incidence of pulmonary embolism (PE) and complications related to insertion.
Method of Diagnosis: Not indicated.
Timing of DVT onset: Not indicated.
Incidence of PE:

  1. No individuals sustained a PE.
  2. No complications related to IVC filter insertion were observed.
  3. IVC filters are suggested as safe and perhaps add preventative value against thrombotic complications.

Gorman et al. 2009; USA
Case Control
N = 112

Population: Mean age=37.1 yr (inferior vena cava (IVC) filter), Mean age=48.1 yr (no filter); Gender: males=96% (IVC filter), males=69% (no filter); Level of injury: C3-L3; Severity of injury: not specified.
Chronicity: Individuals either received or did not receive an IVC filter during their acute hospitalization before admission to the rehabilitation centres. No other information was provided.
Intervention: Retrospective review of SCI individuals who had received a prophylactic IVC filter, compared to those that had not. All individuals were also treated with another form of prophylaxis, “usually low molecular unfractionated heparin (LMWH) and compression stockings.”
Outcome Measures: Incidence of deep vein thrombosis (DVT).
Method of Diagnosis: Clinical examination and duplex ultrasonography.
Timing of DVT onset: Average length of stay for individuals was 39 days (IVC filter) and 27 days (no filter) after acute hospitalization. No information was provided specifying when screening was performed.
Incidence of DVT:

  1. Individuals without IVC filter had fewer DVTs than those with an IVC filter (5.2% and 20.4% respectively, p=0.021).
  2. IVC filter placement resulted in significantly increased risk of DVT development.

Kinney et al. 1996; USA
Case Control
N = 11

Population: Mean age=33.8 yr; Gender: males=100% (SCI group); Level of injury: cervical; Severity of injury: not specified.
Chronicity: The mean acute hospitalization after injury was 27.5 days (SCI group). Timing of filter insertion was not described.
Intervention: Retrospective review of SCI individuals who received prophylactic inferior vena cava (IVC) filters, compared to non-SCI individuals (historical controls) who received the filter.
Outcome Measures: Incidence of pulmonary embolism (PE).
Method of Diagnosis: Computed tomography and ventilation-perfusion lung scanning.
Timing of PE onset: No information was provided specifying when screening was performed.
Incidence of PE: The SCI population had an 18.2% incidence rate of PE, which was higher compared to rates in historical controls.

Rogers et al. 1995; USA
Pre-Post
N = 63

Population: Mean age=38.9 yr; Gender: males=73%, females=27%; Level of injury: not specified; Severity of injury: not specified.
Chronicity: The mean time from admission to filter insertion was 4.3 days.
Intervention: A subset of high-risk trauma individuals (SCI=25) received prophylactic vena cava filter (VCF) insertion. Forms of standard prophylaxis were contraindicated.
Outcome Measures: Incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE).
Method of Diagnosis: Impedance plethysmography, venous duplex ultrasonography, ventilation-perfusion scanning, and pulmonary angiography.
Timing of DVT onset: Screening was done within 48 hr of filter insertion and on a weekly basis afterwards until death/discharge. No other information specifying timing of DVT onset was described.
Incidence of DVT:

  1. 3 individuals developed DVT.
  2. No individuals developed PE.

Wilson et al. 1994; USA
Pre-Post
N = 15

Population: Mean age=31.4 yr; Gender: males=12, females=3; Level of injury: cervical-lumbar; Severity of injury: injury severity score (ISS)>20.
Chronicity: Individuals were hospitalized for a median of 22 days. Timing of filter insertion was done “as soon as clinically feasible.”
Intervention: Prophylactic inferior vena cava (IVC) filter insertion. All individuals also received either low-dose subcutaneous heparin or venous compression devices while hospitalized. These individuals were compared to historic controls who did not receive filters.
Outcome Measures: Incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE).
Method of Diagnosis: Impedance plethysmography and venous duplex ultrasonography.
Timing of DVT/PE onset: No PE was observed in up to 24 mo of follow-up.

Incidence of DVT:

  1. No individuals developed DVT during acute hospitalization.
  2. No individuals developed PE after filter insertion.
Balshi et al. 1989; USA
Case Series
N = 13
Population: Age range=17-48yr; Gender: males=11, females=2; Severity of Injury: quadriplegia.
Chronicity: 2 weeks-4 yr post SCI.
Intervention: Prophylactic Greenfield inferior vena cava (IVC) filter insertion.
Outcome Measures: Incidence of deep venous thrombosis (DVT) or pulmonary embolism (PE).
  1. Twelve individuals experienced a DVT while one had a PE.
  2. Two individuals experienced recurrent DVT.
  3. Distal migration of the filter occurred in two individuals.

Jarrell et al. 1983; USA
Case Series
N = 21

Population: Not clear.
Chronicity: Acute.
Intervention: Prophylactic Greenfield inferior vena cava (IVC) filter insertion.
Outcome Measures: Incidence of pulmonary embolism (PE).
  1. There was one PE-related fatality.
  2. There was no other instance of suspected or proved PE after insertion of the filter.
  3. Follow-up revealed two instances of thrombosis.

Discussion

Several studies have examined the prophylactic effect of IVC filter insertion on the incidence of DVT and/or PE after acute SCI. Roberts and Young (2010) conducted a case series study of individuals who received IVC filters within 72 hours of admission. The authors observed no occurrences of PE or other complications. These findings were supported by two pre-post studies by Wilson et al. (1994) and Rogers et al. (1995). In the latter studies, the authors observed that inferior vena cava filter insertion “as soon as clinically feasible” and on average 4.3 days after admission, respectively, did not result in any occurrences of PE. However, it should be noted that, in the latter study, individuals were not on any other forms of prophylaxis concurrently and as a result, three individuals developed DVT.

Interestingly, a retrospective case control study by Gorman et al. (2009) compared SCI individuals who had received IVC filters during acute hospitalization with SCI individuals who had not received filters. The authors found that the incidence of DVT was significantly higher in individuals with implanted filters (p=0.021).

Three studies have specifically studied the insertion of Greenfield IVC filters. Jarrell et al. (1983) studied 21 individuals with acute SCI who had received a Greenfield filter and reported that one individual developed a PE. On follow-up, no other PEs were noted although two individuals developed thrombosis of the inferior vena cava. Balshi et al. (1989) reported on individuals with SCI who received this filter and found that 12 of the 13 individuals had a DVT; distal migration of the filter was a common complication. Kinney et al. (1996) also studied Greenfield filter placement among 27 individuals with SCI and noted that filters migrated frequently in individuals with cervical injuries (45.5%). The mean migration distance was significantly higher than individuals with non-cervical injuries (p<0.05). Overall, there was a greater number of PEs sustained in the SCI population compared to the non-SCI control group.

The literature has shown that IVC filters significantly reduce PE in individuals with SCI; however, this form of prophylaxis is invasive and therefore, should only be considered for high-risk individuals. According to the Consortium for Spinal Cord Injury (2008) clinical practise guidelines, it is recommended that health care providers should “consider placing a vena cava filter only in those individuals with active bleeding anticipated to persist for more than 72 hours and begin anticoagulants as soon as feasible” (p. 38).

Conclusion

There is conflicting level 3 evidence (from two case control studies, two case series studies, and one pre-post study: Gorman et al. 2009; Jarrell et al. 1983; Kinney et al. 1996; Roberts & Young 2010; Wilson et al. 1994) that inferior vena cava filters significantly reduce the risk of pulmonary emboli in high-risk individuals with SCI.

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