Prophylactic Caval Filter Insertion In Trauma Patients

Patients with multiple trauma have been considered for prophylactic caval filters. The usual prophylactic measures that are useful in the prevention of thromboembolic disease in surgical or medical patients, often fail in multiple trauma patients. Prophylaxis is often started too late in these trauma patients and there is frequent venous stasis and/or associated venous injury along with hypercoagulable states. Venous compression devices and venous surveillance ultrasound cannot be applied in many of these patients due to external fixation devices, the extent of edema, or the application of casts.

Although several reports have advocated the use of caval filters in high-risk trauma patients, other reports caution against routine prophylactic caval filter placement. In one large series, prophylactic caval filters would not have benefited 95% of high-risk patients without a DVT and would not have prevented any deaths.31 These authors advised against prophylactic caval filters in high-risk trauma patients, with the exception of patients having major venous injuries. Most investigators have attempted to identify trauma patients at particularly high risk for thromboembolism and recommended prophylactic caval filter insertion.32,33 These high-risk patients (e.g., brain or spinal cord injury, pelvic, and multiple long bone fractures) have been demonstrated to have a 50-fold increase in thromboembolic complications compared to other trauma patients. Most studies have demonstrated favorable outcomes with caval filters in such patients, however others failed to show this benefit.23,32-35

Wojcik et al.36 reported on a series of 105 blunt trauma patients who were treated with permanent caval filters for treatment of DVT and prophylaxis, with a mean follow-up of 29 months. There was no PE in the patients in whom filters were placed, and no patients experienced any clinically significant complications related to caval filter insertions. They also reported minimal migration of only one filter and one caval occlusion (0.95%). However, 11 patients (10.4%) experienced symptoms of leg swelling after hospital discharge, and 28 of the 64 patients with prophylactically placed caval filters had a DVT after filter placement.

Rodriguez et al.24 also reported on their experience of Greenfield filter insertion in trauma patients within 48 hours, with a PE related mortality decrease from 17 to 2.5%, and only two of 40 patients developed significant venous stasis of the lower extremities.

Leon et al.37 reported on the prophylactic use of IVC filters in patients undergoing high-risk spinal surgery. Seventy-four spine surgery patients with contraindications to anticoagulation received prophylactic IVC filters with a mean age of 56 years. Criteria for usage were: 1) history of thromboembolism, 2) diagnosed thrombophilia, 3) malignancy, 4) bedridden for over two weeks prior to surgery, 5) staged procedures or multiple levels, 6) combined anterior/ posterior approaches, 7) expected need for significant ilio-caval manipulation during exposure, and 8) single-stage anesthetic time over eight-hour period. Seventy patients had at least two risk factors. All patients received caval filters prior to the first stage of spine reconstruction. Patients were evaluated for filter complications, DVT, and PE. Their lower extremity veins were also examined weekly until discharge using duplex ultrasound. One-third also underwent thoracic and pelvic computed tomography scans, and pelvic veins, IVC, and pulmonary vasculature were evaluated for venous thromboembolic events. At a mean follow-up of 11 months, one patient developed PE. Twenty-seven limbs in 23 patients developed DVT. Five limbs had isolated calf DVT, and 22 had proximal vein involvement. Insertion site DVT accounted for nearly one-third of the DVTs. Six patients died from unrelated complications. They concluded that despite the high incidence of DVT following high-risk spinal surgery, prophylactic caval filter placement appears to protect patients from PE.37

With the advances in the use of retrievable filters, the indication of prophylactic caval filters in trauma patients may be justified.

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