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continuing to be placed, the view that an IVC filter prevents
blood clots is highly prevalent in many different classes of
physicians. The IVC filter is often equated with an anticoagulant in the management of venous thromboembolism (VTE),
so placement of the filter allows the patient to be discharged
early – thus providing extra revenue for hospitals (i.e., the filter
placement procedure, X-ray machine usage, and earlier discharge) and radiologists (i.e., placing and retrieving the filter).
Those who place IVC filters also argue that it will prevent
a lawsuit in the event of a subsequent complication. When a
patient is seen in the emergency room and an ultrasound for a
blood clot is positive, the IVC filter is sometimes placed because
the patient is routed from the ER to the interventional radiology department– before any legitimate hematology consult is
obtained. Though this is done in the interest of saving time (and
reducing length of stay), one really needs a hematologist with
a focus on hemostasis to address this issue – not an oncologist
who also doubles as a hematologist, as is common practice in
some settings.
The most dangerous situation is one where the patient is
in an intense hypercoagulable state, comprising a combination of inherited and acquired disorders. This is particularly true
of heparin-induced thrombocytopenia and thrombosis (HITT),
where the added insult of a foreign body is especially harmful.
I have seen instances of patients who present with extensive
thromboses and, after the IVC filter is placed, HITT accelerates,
leading to venous gangrene of the lower extremity. HITT is still a
frequently missed diagnosis, as is the development of thrombi
proximal to the filter (an obvious source for PE).
I believe clot extension occurs due to the common practice of
inadequate anticoagulation and a false feeling of security on the
part of physicians placing these devices. The critical importance
of and primacy of anticoagulation gets lost in this transaction.
There needs to be an aggressive campaign to educate
individuals about the fundamentals of thrombosis care. The
ever-rapid admission and discharge scenario currently in place
does not allow much room for an informed debate that must, of
necessity, involve a well-informed patient.
Finally, many interventional radiology physicians refuse to
write a consult note – as they ought to – and simply feel they
are doing a procedure ordered by a physician. They are often
offended when I insist that they write a consult and obtain
informed consent (including perforation, floating into the right
atrium, perforation through the duodenum, and the fact that
the filter does not obviate the need for proper anticoagulation)
for a procedure that they perform.
—Rajalaxmi McKenna, MD
Southwest Medical Consultants
Willowbrook, IL
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