Recurrent Pulmonary Embolism Despite Inferior Vena Cava Filter Placement in Patients With the Antiphospholipid Syndrome

Abstract

In patients at risk for pulmonary emboli, consideration is often given to placement of an inferior vena cava (IVC) filter to prevent propagation of a distal thrombus. However, long-term benefits remain controversial, and deep venous thrombosis and IVC thrombosis may result from the procedure itself. Whether a filter if beneficial or even detrimental in patients with the antiphospholipid syndrome (APS) is unclear. We reviewed clinical outcomes in 2 patients who had IVC filter placement years before the diagnosis of the APS and 1 who had a contraindication to anticoagulation. Recurrent pulmonary emboli were seen despite the presence of the filter. IVC pathology sometimes revealed thrombus both proximal and distal to the IVC filter. Pulmonary emboli in the APS may be secondary to deep venous thrombosis (DVT). They may also occur secondary to a cardiac source or in situ thrombosis in the pulmonary vessels. An IVC filter will not be of benefit if the heart or the lungs are the primary source for the emboli. It may also not protect against propagation of a more distal thrombus if collateral vessels develop around the filter or a thrombus is present on the proximal side of the filter. Recurrence of pulmonary emboli after a filter placement should alert the clinician to the possibility of a hypercoagulable state such as APS. Clinicians need to assess risks and benefits carefully before placing a permanent IVC filter in patients with APS. Whether a temporary or retrievable filter is safer in APS and more effective is unknown at the present time.

Recurrent venous thromboembolism during coumarin therapy. Data from the computerised registry of patients with venous thromboembolism

“…However, there is a substantial percentage of non‐cancer patients for whom no specific therapy has proved to be superior. Some patients were found to have antiphospholipid antibodies, and would probably benefit from AVK therapy with a higher target of INR (Cherian & Gertner, 2005). Finally, for those who had a sub‐therapeutical INR at recurrence the best therapeutical approach would probably consist of a more accurate dose of AVK (Hull et al , 1982).…”

Safety of retrievable inferior vena cava filters in patients with the antiphospholipid syndrome

“…In clinical situations where anticoagulation is not possible or not advisable, consideration is often given for the placement of an IVC filter to prevent propagation of clots. Limited case reports on the use of permanent filters suggested that clot formation can still occur proximal and distal to the filter and recurrent pulmonary emboli may still be seen (6,11). Cherian et al found clots on the proximal side of the filter (6).…”

“…However long-term benefits of filters remain controversial. In particular, in APS, recurrent pulmonary emboli and thrombus proximal and distal to the IVC filter have been described in patients with permanent filters (6). Experts recommend avoiding IVC filters in the acute APS setting, as these devices can be associated with a variety of adverse events, including IVC thrombosis and pulmonary embolus (PE) (7).…”

“…Given the potentially devastating effect of lack of anticoagulation in patients with APS, and the complications and concerns about lack of efficacy with permanent filters, we evaluated the safety of retrievable IVC filters (placement and removal) in a small case series of patients with APS requiring cessation of anticoagulation because of massive gastrointestinal bleeding, those requiring surgical procedures or other clinical situations where placement of a filter is considered while the patient is anticoagulated (6).…”

Endovascular recanalisation of a chronic occlusion of the retrohepatic IVC associated to a filter in a patient with antiphospholipid syndrome

“…Pulmonary embolism (PE) may be fatal in as many as 25% of patients1; IVC filter placement should be considered in such clinical situation. Despite their widespread use, long-term benefits of this intraluminal device remain controversial, particularly in complex cases such as patients with prothrombotic disorders as antiphospholipid antibody syndrome (APS) 2. We herein present the case of a young man with known history of APS and IVC filter placement in a retrohepatic position, who developed a chronic occlusion in the IVC and progressed to Budd-Chiari and post-thrombotic syndromes.…”