The high-risk polytrauma patient and inferior vena cava filter use
Introduction
The high-risk trauma patient cohort poses many medical challenges, one of which is the increased risk of venous thrombo-embolism (VTE). The quoted incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in this patient group is 11.8% for deep vein thrombosis and 1.5% for pulmonary emboli [1]. Chemical and mechanical prophylactic approaches to prevent VTE are well established [2], [3].
These modalities however are contraindicated in a small proportion of trauma patients. Owing typically to an increased bleeding risk from injuries preventing administration of chemical prophylaxis or lower extremity fractures preventing mechanical prophylaxis.
The use of inferior vena cava (IVC) filters has a role in such patients. Debate in the literature on the efficacy of IVC filters in this cohort is ongoing. Several guidelines exist with conflicting recommendations. The Eastern Association for the Surgery of Trauma Practice management guideline promotes IVC filters in certain patients [2]. However, guidelines from the American College of Chest Physicians (ACCP) advise against the use of IVC filters for primary prevention in patients even despite contraindication to both chemical and mechanical thromboprophylaxis [3]. In addition to the above consensus statements, there are several other society guidelines available including the ‘Society of Interventional Radiology Standards of Practice Committee’ [4], the ‘Cardiovascular and Interventional Radiological Society of Europe’ [5], the ‘Inflammation and the Host Response to Injury Collaborative Research Project Investigators’ [6], the ‘Society of Interventional Radiology Multidisciplinary Consensus Conference’ [7], all supporting filter placement in trauma patients. Finally, several well conducted reviews such as from Giannoudis et al. [8], and meta-analyses by Velmahos et al. [1] and Haut et al. [9] provide support for the use of IVC filters.
The aim of this study was to assess the theoretical impact of international IVC filter insertion guidelines on PE rates in high-risk trauma patients. A further aim was to determine the local PE and DVT rates in this cohort of trauma patients.
Section snippets
Patients and methods
The patients under investigation were trauma patients presenting to the emergency department of a level 1 trauma centre in the London region. Cases for this study were obtained from the ‘Trauma Audit and Research Network’ (TARN) database.
The inclusion criteria in this study were designed to capture all high-risk polytrauma patients and were based on the EAST Practice management guidelines [2]. These suggest insertion of a prophylactic IVC filter in trauma patients who cannot receive
Results
The TARN data request produced 1138 cases for the study period January 2007 till December 2013. The demographics for the cohort of patients are shown in Table 2. The sustained mechanism of injury is illustrated in Table 3.
The overall pulmonary embolism rate in this cohort of patients was 1.8% (20 patients). A pulmonary embolism was diagnosed on average 7.7 (range: 0–23) days after the injury. The deep vein thrombosis rate was 2.6%. An IVC filter was inserted in 42 cases. Filter insertion was
Discussion
The observed pulmonary embolus rate in this patient cohort of 1.8% is similar to previously quoted rates from other studies summarised in a meta-analysis by Velmahos et al. [1]. Although, a more recent quotation is a range of 0–9.1% determined through systematic review by Kidane et al. [1], [12]. There is an upward trend of IVC filter insertion in North America [13], [14]. This may in part be due to the introduction of retrievable IVC filters. In our institution, 42 IVC filters were inserted
Conflict of interest
None.
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