Prophylactic Insertion of Inferior vena cava filters in Trauma Patients - Guideline for the

Publication: 21/07/2016  --
Last review: 05/04/2019  
Next review: 05/04/2022  
Clinical Guideline
CURRENT 
ID: 4696 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the prophylactic insertion of inferior vena cava filters in trauma patients

Rationale

The incidence of symptomatic deep venous thrombosis [DVT] in the population of patients with polytrauma is approximately 5-12%. The incidence of pulmonary embolism [PE] in this population is 1%.
IVC filters reduce the risk of large PE in patients with known DVT. Their use in patients considered at high risk of PE who cannot be anticoagulated (eg. Polytrauma patients) is unproven.

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Indications

Consider Inferior Vena Cava [IVC] Filter insertion in polytrauma patients where the risks of DVT / PE are considered to be high and mechanical or pharmacological interventions to prevent DVT are contraindicated or impossible.

ie:

Risk of DVT / PE considered to be high: Severely polytraumatised patient with injury severity score [ISS] >15 likely to be immobile / bedbound for prolonged period (6 days or more)

AND

High risk injury pattern for lower limb DVT (pelvic fracture, pelvic surgery, lower limb long bone fracture, diplegia, hemiplegia, obesity [with body mass index >30])

AND

Unable to have bilateral lower limb mechanical DVT prophylaxis (flowtron boots and graduated compression hosiery) - commonest reason being presence of long bone or other soft tissue injuries of one or other of the lower limbs

AND

Unable to have prophylactic Low Molecular Weight Herparin [LMWH] prophylaxis due to severe intracranial injury (Glasgow Coma Score [GCS] <8 at 24hrs, severe contusions [>2cm] or >1 contusion per lobe, extradural or subdural haematoma >8mm, cranial surgery or intracranial pressure [ICP] monitoring), spinal injury (intra- or extra-axial spinal haematoma), ongoing active haemorrhage, allergy to heparins (eg. Heparin induced thrombocytopenia [HIT]), progression of intracranial injury on repeat imaging.

AND

The contraindication to LMWH is considered (by the treating consultant neurosurgeon or spinal surgeon) likely to be persistent for 6 days or more

THEN

Referral should be made (consultant to consultant) to vascular radiology for insertion of an IVC filter (ext. 23311 or secretaries 23504)

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Timing

A request for filter insertion should be made as soon as the above described conditions are identified.

The referral should be consultant trauma-, neuro- or vascular- surgeon to consultant vascular interventional radiologist

The filter should be then inserted as soon as practically possible: on admission (consider at time of pelvic angiography or embolization) if possible, but within 72 hrs if not practical before that.

Patients undergoing procedures in angio suite as part of their trauma care (usually for haemorrhage control or aortic injury) should ideally be assessed for indications for IVC filter insertion at the same time, though IVC filter insertion should not delay other priorities in their care.

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Removal

ALL PATIENTS IN WHOM PROPHYLACTIC FILTERS ARE PLACED SHOULD HAVE THE FILTER REMOVED BEFORE LEAVING THE MAJOR TRAUMA CENTRE [MTC].
THIS INCLUDES PATIENTS BEING TRANSFERRED BACK TO LOCAL TRAUMA CENTRES [TCs] FOR REHABILITATION.

The vascular radiology department will make an appointment for IVC filter retrieval at the time of insertion. This will usually be six weeks from the date of insertion, or sooner where the patient can be anticoagulated sooner (see below)

Referring consultant (trauma, neurosurgery or spinal surgery) to ensure, if the patient is to be discharged or repatriated before 6 weeks, that they make arrangements with the vascular radiology department (23311) for earlier retrieval prior to the patient leaving the MTC.

Removal may occur anytime prior to six weeks if anticoagulation can be started (prophylactic or therapeutic).

A pre-removal Doppler Ultrasounf [dUS] of IVC, iliac and femoral veins should be requested at the same time as request to remove the filter to ensure there is no DVT (in which case formal anticoagulation will be required, or if contraindicated, the filter should remain in situ until anticoagulation can be undertaken).

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Conventional indications for IVC filter insertion

The above recommendations apply to patients in whom there is considered to be a high risk of DVT / PE but in whom no DVT / PE has been identified. The conventional indications for IVC filter placement should not be overlooked….

  • Known (proven) DVT / PE with contraindication to therapeutic anticoagulation.
  • Proven PE despite therapeutic anticoagulation
  • Proven DVT / PE with minimal physiological reserve
  • Proven DVT / PE with likely poor compliance with anticoagulation (discuss)

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Anticoagulation

There is no need for anticoagulation to be commenced solely because of the presence of an IVC filter.

Indications for anticoagulation (therapeutic or prophylactic) should be made based on the patients other comorbidity, bleeding risk and / or the development of DVT / PE. If the risks of anticoagulation have reduced sufficiently to allow this therapy, administration of LMWH should commence immediately and should not be delayed pending filter retrieval.

Prophylactic dose LMWH need not be stopped for an IVC filter retrieval. If a patient is on treatment dose LMWH the dose the evening before the procedure should be omitted. For patients at high risk of recurrent DVT in whom omitting a dose is considered too high risk (usually on the advice of a haematologist), the filter can be retrieved at nadir LMWH levels (just before the next dose). This may need adjustment of dosing times to coordinate with angio suite logistics. Please liaise with angio suite to arrange (23311).

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Contraindications to filter insertion

  • Allergy to nitinol.
  • IVC diameter > 30 mm or < 15 mm
  • Lack of suitable access vessel.
  • Known infected thrombus or sepsis.

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Contraindications to filter retrieval

  • Lack of adequate venous access in neck (relative, please discuss)
  • Progressive thrombus formation on anticoagulation.
  • Remaining high risk of pulmonary embolus and ongoing contraindication to anticoagulation
  • Thrombus in filter on imaging.

Provenance

Record: 4696
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Adapted from:

Evidence base

Retrievable inferior vena cava filter use in major trauma (Review) A Vasireddy, M Phillips, D Lewis Ann R Coll Surg Engl 2012; 94: 157
The Parkland protocol’s modified Berne-Norwood criteria predict two tiers of risk from traumatic brain injury progression. Pastorek RA, Cripps MW, Bernstein IH et al. Journal of Neurotrauma 2014; 31: 1737
Routine prophylactic vena cava filtration is not indicated after acute spinal cord injury. Maxwell RA, Chavarria-Aguilar M, Cockerham WT et al. J Trauma. 2002; 52: 902

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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