Bottom line
There is no evidence-based guideline as to whether IVC filters should be placed adjunctively in patients with submassive or massive PE; however, based on expert consensus, it may be appropriate to place an IVC filter as an adjunct to anticoagulation in patients with severe PE. The decision should be individualized based on each patient’s characteristics, preferences, and institutional expertise.
In our case, in hope of preventing further embolic burden, the patient received an IVC filter the day after presentation. Despite the initiation of anticoagulation with heparin, she remained tachycardic and tachypneic, prompting referral for CDT. The interventional radiology team did not feel that she was a good candidate, given her persistent vaginal bleeding and widely metastatic uterine carcinoma. She was switched to therapeutic enoxaparin after no further invasive intervention was deemed appropriate. Her respiratory status did not improve and bilevel positive airway pressure was initiated. Taking into consideration the terminal nature of her cancer, she ultimately elected to pursue comfort care and died shortly afterward.
Acknowledgements
The authors would like to thank Benjamin A. Hohmuth, MD, A. Joseph Layon, MD, and Luis L. Nadal, MD, for their review of the article and invaluable feedback.
Dr. Wenqian Wang, Dr. Vedamurthy, and Dr. Wang are based in the department of hospital medicine at The Medicine Institute, Geisinger Health System, Danville, Penn. Contact Dr. Wenqian Wang at [email protected].
Key Points
• Use pulmonary angiographic data, clinical stability, and analysis of other comorbid conditions to decide the best treatment modality.
• Our team prefers ultrasound-enhanced thrombolysis (EKOS) for submassive PE patients, massive PE patients, and as a rescue procedure for patients who fail systemic thrombolysis.
• Establishing multidisciplinary teams composed of interventional radiologists, intensivists, cardiologists, and vascular surgeons is prudent to make individualized decisions.
• It may be appropriate to place an IVC filter as an adjunct to anticoagulation in patients with severe PE.
References
1. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123:1788-1830.
2. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386-9.
3. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149:315-52.
4. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002;347:1143-50.
5. Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M, “MOPETT” Investigators. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol. 2013;111:273-7.
6. Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370:1402-11.
7. Kuo WT. Endovascular therapy for acute pulmonary embolism. J Vasc Interv Radiol 2012;23:167-79. e164
8. Kucher N, Boekstegers P, Muller OJ, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014;129:479-86.
9. Kuo WT, Banerjee A, Kim PS, et al. Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis (PERFECT): Initial Results From a Prospective Multicenter Registry. Chest. 2015;148:667-73.
10. Piazza G, Hohlfelder B, Jaff MR, et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv. 2015;8:1382-92.
11. Sharifi M. Systemic Full Dose, Half Dose, and Catheter Directed Thrombolysis for Pulmonary Embolism. When to Use and How to Choose? Curr Treat Options Cardiovasc Med. 2016;18:31.
12. Wang C, Zhai Z, Yang Y, et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest. 2010;137:254-62.
13. Sharifi M, Vajo Z, Freeman W, Bay C, Sharifi M, Schwartz F. Transforming and simplifying the treatment of pulmonary embolism: “safe dose” thrombolysis plus new oral anticoagulants. Lung. 2015;193:369-74.
14. Kabrhel C, Rosovsky R, Channick R, et al. A Multidisciplinary Pulmonary Embolism Response Team: Initial 30-Month Experience With a Novel Approach to Delivery of Care to Patients With Submassive and Massive Pulmonary Embolism. Chest. 2016;150:384-93.
15. Lessne ML, Sing RF. Counterpoint: Do the Benefits Outweigh the Risks for Most Patients Under Consideration for inferior vena cava filters? No. Chest. 2016; 150(6):1182-4.
16. The PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005;112(3):416-22.
17. Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs. anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015. 313(16):1627-35.
18. Deshpande KS, Hatem C, Karwa M, et al. The use of inferior vena cava filter as a treatment modality for massive pulmonary embolism. A case series and review of pathophysiology. Respir Med. 2002.96(12):984-9.
19. Kucher N, Rossi E, De Rosa M, et al. Massive Pulmonary embolism. Circulation. 2006;113(4):577-82.
20. Stein P, Matta F. Case Fatality Rate with Pulmonary Embolectomy for Acute Pulmonary Embolism. Am J Med. 2012;125:471-7.
