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Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.

We present a case of acute pulmonary embolism in a patient with myelofibrosis and thrombocytopenia. The patient had a history of portal vein thrombosis and had taken warfarin for the past six years. At the time of his pulmonary embolism diagnosis, his INR was 1.5 and platelet count 58 × 109/L. This article discusses how to balance the risk of thrombosis against the risk of bleeding, and reviews the options for pulmonary embolism treatment including transition to low-molecular-weight heparin, direct oral anticoagulants and/or inferior vena cava filters.

Haemoptysis is a potentially life-threatening symptom, which require immediate management. Haemoptysis is a challenging situation because the potential numerous causes lead to strongly different therapeutic options (medical, surgical, systematic embolization). When haemoptysis occurred at the acute phase of pulmonary embolism, anticoagulation should be stopped and inferior vena cava filter is justified. Based on a case report of massive haemoptysis related to pulmonary infarction (i.e., no other causes) in a patient with a unprovoked intermediate high-risk pulmonary embolism, we describe the dilemma set in the paradox between the need for stopping anticoagulation and the need to treat the cause of haemoptysis which is also anticoagulation. If anticoagulation should be stopped, however, the optimal management regarding the use of specific reversal agents or prothrombotic plasma concentrates remains uncertain and weakly documented. After haemoptysis has been resolved, there is also uncertainty on restarting anticoagulation modalities. Regarding long-term management, the decision to stop at three months or to prolong indefinitely based on international recommendation is also challenging in the case of unprovoked severe pulmonary embolism. In this particularly high risk situation, multidisciplinary expertise is essential.

Introduction Inferior vena cava filters are used to prevent embolization of a lower extremity deep vein thrombosis when the risk of pulmonary embolism is thought to be high. However, evidence is lacking for their benefit and guidelines differ on the recommended indications for filter insertion. The study aim was to determine the reasons for inferior vena cava filter placement and subsequent complication rate. Materials and methods A retrospective cohort of patients receiving inferior vena cava filters in Edmonton, Alberta, Canada from 2007 to 2011. Main outcome was the indication of inferior vena cava filter insertion. Other measures include baseline demographic and medical history of patients, clinical outcomes and filter retrieval rates. Results 464 patients received inferior vena cava filters. An acute deep vein thrombosis with a contraindication to anticoagulation was the indication for 206 (44.4%) filter insertions. No contraindication to anticoagulation could be identified in 20.7% of filter placements. 30.6% were placed in those with active cancer, in which mortality was significantly higher. Only 38.9% of retrievable filters were successfully retrieved. Conclusions Inferior vena cava filters were placed frequently in patients with weak or no guideline-supported indications for filter placement and in up to 20% of patients with no contraindication to anticoagulation. The high rates of cancer and the high mortality rate of the cohort raise the possibility that some filters are placed inappropriately in end of life settings.

© 2016 Elsevier Ltd. All rights reserved. Background Few studies have evaluated the use and outcomes of inferior vena cava filters (IVCF) insertion in cancer patients with deep venous thrombosis (DVT) or pulmonary embolism (PE). Methods Hospital records of patients with a principal diagnosis of lower extremity DVT and/or PE and cancer in California between January 1, 2005 and December 31, 2009 were analyzed. Multivariable logistic regression analysis was used to identify variables associated with IVCF use and propensity matched methodology was used to determine the effect of IVCF insertion on clinical outcomes. Results An IVCF was placed in 19.6% of 14,000 cancer patients and VTE. This varied widely across hospitals, from 0% to 52%, and by cancer type. The strongest predictors of IVCF use were a diagnosis of brain cancer (OR = 4.6, CI: 3.7-5.6), undergoing major surgery (OR = 4.9, CI: 3.9-6.1), and bleeding (OR = 2.7, CI: 2.0-3.5). Only 21% of patients with IVCF had a strong contraindication to anticoagulation (bleeding or major surgery). There was no benefit for 30-day mortality and no reduction in subsequent PE (+/- DVT). Additionally, there was 60% increased risk of recurrent DVT and 20% increased risk of subsequent bleeding when an IVCF was placed. Conclusions An IVCF was placed in approximately 20% of acute VTE patients with cancer and use varied widely between hospitals and cancer types. Most patients did not have a contraindication for anticoagulation. There was no benefit in short-term mortality or risk of PE; there was increased risk of DVT and subsequent bleeding.

Background Mortality rates due to pulmonary embolism (PE) are difficult to estimate often due to the presence of comorbid disease. Objectives To determine the accuracy of hospital records in identifying PE cases, PE-related mortality, and the number of PE-related deaths which are potentially preventable. Methods Retrospective chart review of PE cases hospitalized at The Ottawa Hospital over an 8 year period. Cases were reviewed to determine accuracy of coding, as well as the certainty with which PE was the cause of death. In PE-related deaths, a determination was made as to whether any interventions may have been life-saving. Results 498 cases of 612 (81%) cases coded as PE were correctly coded. 111 (22%) died during hospitalization, 63% of deaths were attributed to PE. The presence of a cardiorespiratory comorbidity or cancer was independently associated with an increased rate of death due to PE. 54% of PE-related deaths were determined to be potentially preventable, most commonly by appropriate DVT prophylaxis. A significantly higher number of cancer patients as compared to non-cancer patients may have potentially had their death due to PE prevented by an inferior vena cava filter (IVCF). Systemic thrombolysis was deemed to be potentially life-saving in 1/38 PE-related deaths. Conclusion Hospital mortality due to clinically recognized PE can be determined by chart review of PE cases identified using the ICD coding system. Death due to PE is often potentially preventable; in the subgroup with cancer and DVT/PE, an IVCF may be a potentially useful intervention to prevent death due to PE. Prospective studies are needed to confirm these results.

Retrievable filters are a new generation of inferior vena cava (IVC) filters and represent an attractive option because they may be either left in place permanently or safely retrieved after a quite long period when they become unnecessary. In this review the currently available literature regarding retrievable IVC filters is summarized and their efficacy and safety is discussed. Moreover, the appropriate indications for their use are reviewed. Retrievable filters are becoming safer and easier to use; in fact the bioengineering research has optimized the technical characteristics of these devices, in order to reduce the incidence of possible complications. However, there are important unresolved issues, including the appropriate maximum implantation time, the possibility to safely and efficaciously remove the filters without being compromised by entrapped clots, and the use of anticoagulation during the implantation and periremoval periods. Large prospective cohort studies or randomized trials are strongly warranted to definitely clarify the beneficial role of these devices.

Although various methods of preventing venous thromboembolism (VTE) have proven effective in many patient populations [1], neither low-dose heparin (LDH) nor mechanical prophylaxis using sequential compression devices (SCD) has proven better than no prophylaxis in patients who are at high risk for VTE due tomajor trauma [2]. Additionally, low-molecular-weight heparin (LMWH) may be no better than LDH in the prevention of pulmonary embolism (PE) [2]. In response to the limited effectiveness of standard preventive measures, more and more hospitals have adopted the practice of placing prophylactic inferior vena cava (IVC) filters to prevent PE in high risk trauma patients [2]. Athanasoulis et al. [3] reported the indications for placement of 1753 IVC filters from 1973 to 1998 at the Massachusetts General Hospital. Prophylaxis was not an indication until 1982. From that time until 1998, a total of 83 filters (4.7%) were placed for prophylaxis. In 1998, the percentage of prophylactic filters surpassed 15%. Greenfield et al. [4] reported a similar experience at the University of Michigan. Is there evidence to support the safety and efficacy of prophylactic IVC filter placement in patients at high risk of PE after major trauma? To address this question, we conducted a systematic review of the literature that describes the use of IVC filters in this clinical setting.

The treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) in pregnant patients is challenging for several reasons. Coumarins can cause embryopathy and other adverse effects in the fetus. Although unfractionated heparin and low-molecular-weight heparins, the cornerstones of initial therapy, are safe for the fetus, they can have significant maternal side effects, including osteoporosis and thrombocytopenia. Because they must be given parenterally, long-term administration is inconvenient. Further, although low-molecular-weight heparins probably cause less maternal osteoporosis and thrombocytopenia than unfractionated heparin, the appropriate dosing regimens for prevention and treatment of thrombosis during pregnancy have not been established. In addition, there is a paucity of reliable information on the incidence of venous thromboembolism and the risk of recurrent thrombosis during pregnancy. This paper briefly reviews the areas of controversy and provides recommendations for the treatment and prophylaxis of acute deep vein thrombosis and pulmonary embolism in pregnant patients.

Background Venous thromboembolism (VTE) is a frequent complication of patients who experienced major trauma. Prevention of VTE is usually by thrombophylaxis and or by the use of a retrievable filter. Lately, the use of a retrievable filter in trauma patients has increased despite evidence cautioning against its use. Aims To evaluate complications related to a single type of filter prophylactically used in a tertiary trauma center and search for risk factors that may preclude filter retrieval Methods 142 patients aged 16 through 60 who experienced a major trauma and were treated with a prophylactic IVC filter of type optease were evaluated. Results The median time from trauma to filter insertion was 2 days and low molecular weight heparin at prophylactic dose was initiated in 92% once the filter was inserted. Nine patients developed IVC thrombosis and one of them died despite the use of thrombolytic therapy. Another 8 patients developed lower extremities deep vein thrombosis. The filter was left in place in 13 more patients after attempted filter removal was unsuccessful. Among patients with successful removal, the median dwelling time was 30 days. There was no relationship between successful removal and age, sex, BMI, Glasgow coma scale, or injury severity score of patients when first evaluated. Conclusions Of concern is the persistent complications related to IVC filter even with the prophylactic use of anticoagulants and the dose of radiation trauma patients were exposed during insertion and retrieval of filter. Thus, the routine use of IVC filter in trauma patients may not be desirable.

Objective The effectiveness, safety, and patient outcomes after Vena Tech LP caval filter placement were evaluated retrospectively in China. Methods and Results From January 2002 to January 2013, 1,200 patients received Tech LP caval filters to prevent PE at three Beijing University medical centers. The patients’ general condition, reasons for DVT formation, filter placement method, indication for filter placement, complications, safety of the filter, treatment post-filter, and follow-up were recorded. The patients’ mean age was 65 (range, 19–87) years, and 840 were males. Before filter placement, all had ultrasonic-diagnosed DVT, 84% (1008/1200) were assessed for PE, and 73% (736/1008) had PE. Filters were placed via the femoral or jugular vein, with 62 placements at the SVC and 1,138 at the IVC. Filter placement via various venous access routes was 100% successful. Anticoagulation therapy was continued in 88% patients (n = 1056) for ≥ 6 months after filter placement. Follow-up was accomplished in 80% (n = 960) of patients for an average of 6 years (range, 3 months to 10 years). The patency rate of the vena cava was 90% at 5 years. The morbidity was 2% and the mortality was 0.5% during 30 days post-filter placement. After 30 days, the mortality rate was 2.4%, no PE reoccurred, and there were no other clinical adverse events. Conclusion Vena Tech LP caval filter placement was effective and safe, with demonstrated stability and a good long-term patency rate at the IVC and SVC in China.

Retrieval rates of optional recovery inferior vena cava (IVC) filters in US hospitals range from 11 - 70%. We conducted a retrospective study in a Canadian tertiary care centre to determine retrieval rates and predictors of filter removal.Consecutive patients who had a retrievable IVC filter inserted or removed between January 2007 and December 2010 were identified. Data collected included baseline demographics, indications for filter insertion and removal, documentation of an IVC filter management plan, reasons for non-retrieval, complications, and death.275 patients with a median age of 60years were followed in hospital for a median of 17 patient-days (range 1-876). Indications for filter placement were acute or prior VTE with contraindication to anticoagulation (72.4%), high risk of PE (11.3%) and primary prophylaxis (13.8%). Retrieval was attempted in 165 patients (60%) and was successful in 146 patients (53.1%). The most common reason for failed retrieval was filter thrombus. Predictors of attempted retrieval included documentation of filter plan (odds ratio [OR] 16.7; p0.001), surgical indication for IVC filter insertion (OR 4.8; p=0.002), age ≤70years (OR 3.8; p=0.001), Hematology service involvement (OR 3.0; p=0.006), and presence of metastatic cancer (OR 0.2; p=0.001). Thrombotic complications occurred in 48 patients, including 3 patients who died of fatal PE.Our filter retrieval rate is suboptimal. Improvements in follow-up documentation or a dedicated clinical service may help increase retrieval rates.

Rationale The use of inferior vena cava (IVC) filters is associated with various complications. We aimed to elucidate the clinical course and predictive factors for complications of IVC filters, especially IVC penetration Methods A retrospective observational study was performed in 45 adult patients with retrievable IVC filters and follow-up computed tomography (CT) between January 2003 and December 2012. Primary outcomes were the prevalence and predictive factors of IVC penetration. Secondary outcome was other complications of IVC filters. Results IVC penetration following filter placement occurred in 87.6% of patients, and 57.8% of those involved significant penetration. Embedding of filter tips, suggestive of lateral tilting, was observed in 51.1%. Both Vertebral body erosions and aortic penetrations were seen in 4.4%, but they were asymptomatic. Longer indwelling duration of the IVC filter was significantly associated with a higher grade of IVC penetration, and the risk of significant IVC penetration increased in patients with the filter indwelling time of more than 20 days and an IVC diameter of less than 24.2 mm. Conclusions In patients with a retrievable IVC filter, IVC penetration on CT was common, and significant IVC penetration was associated with a longer indwelling time of the IVC filter and a lesser IVC diameter.

To evaluate the role of filter implantation in reducing the incidence of fatal pulmonary embolism during the endovascular treatment of thrombosis in the major tributary of the superior vena cava (SVC).From October 2004 to October 2008, we conducted a cohort study of 40 patients with thrombosis of the central veins who were preparing for endovascular interventions and received or did not receive filter. The symptom scores were measured, the incidence of pulmonary embolism (PE) was observed, and patient follow-up studies were conducted for three years.One week after therapy, the symptom score improved in both groups compared with before therapy (P0.001), but no significant difference was found between the scores of the two groups (P0.05). Four patients in the control group died from PEs after therapy, but no patients in the filter group presented evidence of PE. The survival rates at 1, 2, and 3 years (72.9%, 50%, and 27.1%, respectively) for the filter group were higher than those for the control group (47.6%, 19.0% and 14.3%, respectively; P =0.015). The survival time of patients in the filter group with bronchogenic carcinoma (18 ± 2 months) was longer than that of the patients in the control group (12 ± 2 months) after the endovascular treatment (P0.001).Prophylactic filter placement could be a safe and effective method for preventing PE in pre- or post-endovascular-treated patients with thrombi in their central veins.

The purpose of this study is to assess the retrieval rate and the predictors of successful retrieval of Retrievable Inferior Vena Cava (RIVC) filters.We retrospectively reviewed the medical records of adult patients who had RIVC filter placements from 2004-2008. We excluded patients who died or were lost to follow-up and those who refused or had unsuccessful retrieval. We collected demographic and clinical data including indications for placement and follow-up. Successful retrieval was defined as objective evidence of retrieval by medical records.Over a 4 year period, we identified 351 patients who had RIVC filter placements. We excluded 99 patients (65 died, 24 decided to leave filter in place, 7 had unsuccessful retrieval and 3 lost follow-up). Majority of the filters were placed for surgical patients (161, 63.9%). Of 252 eligible patients for retrieval, only 47 filters were successfully retrieved yielding a retrieval rate of 18.7%. We identified three predictors for successful retrieval: Male gender, home discharge and follow up with procedural service.In this large cohort we found that the retrieval rate of retrievable IVCF is extremely low consistent with national statistics. Male patients, patients who were discharged home and patients who were followed by the procedural service had higher chance of successful retrieval. We recommend that procedural service placing the filter should ascertain adequate follow-up. We are not certain why more males had successful retrieval than females. Further studies are necessary to investigate this finding.

Introduction CT Pulmonary Angiography has been shown to be equivalent to Ventilation/ Perfusion scanning in 3-month outcome studies, but it detects more pulmonary emboli. Isolated subsegmental pulmonary emboli are thought to account for some of the increase in diagnosis, but it is not known whether these emboli represent a harbinger for future thromboembolic events. The objective of this study was to determine the 3-month clinical outcomes of a cohort of patients diagnosed with isolated subsegmental pulmonary emboli. Materials and Methods Review of 10,453 consecutive CTPA radiology reports over 74-month period since the implementation of Multidetector CT Pulmonary Angiography identified a cohort of 93 patients found to have acute pulmonary embolism isolated to subsegmental pulmonary arteries without other evidence of deep venous thrombosis at one institution. The study measured 3-month clinical outcomes (anticoagulation use, recurrence, death, hemorrhage) determined by review of records and telephone interviews with physicians. Results Seventy-one patients (76%) were treated with anticoagulation and/or IVC filter, while 22 (24%) were observed without therapy. One patient (1/93, 1.05%; 95% CI: 0-6.6%) who was treated with anticoagulants and a vena caval filter had a recurrent subsegmental pulmonary embolus. No patients died of pulmonary embolism. There were 8 hemorrhages, including 5 (5.3%) major hemorrhages without any hemorrhage-related mortality. Conclusions Patients diagnosed with isolated subsegmental pulmonary emboli have favorable 3-month outcomes. Short-term prognosis for recurrent thromboembolism may be lower than the risk of adverse events with anticoagulation in patients at high risk of hemorrhage.