Indications for inferior vena cava filter placement: do physicians comply with guidelines?

PURPOSE: Inferior vena cava (IVC) filter placement has increased significantly over the past few decades, but indications for filter placement vary widely depending on which professional society recommendations are followed, and it is uncertain how compliant physicians are in adhering to guidelines. This study assessed documented indications for IVC filter placement and evaluated compliance with standards set by the American College of Chest Physicians (ACCP) and the Society of Interventional Radiology (SIR). MATERIALS AND METHODS: A single-center, retrospective medical record review in a metropolitan, 652-bed, acute care, teaching hospital. Inpatient filter placement over a 26-month period was reviewed. The study measured compliance with established guidelines, relationship of medical specialty to filter placement, and evaluation of self-referral patterns among physicians. RESULTS: Compliance with established ACCP guidelines was poor regardless of whether the IVC filter insertion was performed by interventional radiology (IR; 43.5%), vascular surgery (VS; 39.9%), or interventional cardiology (IC; 33.3%) staff. Compliance with the less restrictive SIR guidelines was better (77.5%, 77.1%, and 80% for IR, VS, and IC, respectively). There was a greater degree of guideline compliance when filter placement was recommended by internal medicine (IM)-trained physicians than by non-IM-trained physicians: 46.3% of IR-placed filters requested by IM physicians met ACCP criteria whereas only 24.0% of filters recommended by non-IM specialties were compliant with criteria (P = .03). In the VS group, these compliance rates were 45.8% and 31.5%, respectively (P = .03). Among IR-placed filters, 84.0% of IM-recommended filter placements were compliant with SIR guidelines, versus only 48.0% of non-IM-recommended placements (P ≤ .001). In the VS group, these compliance rates were 87.8% and 69.6%, respectively (P ≤ .001). CONCLUSIONS: There is poor physician compliance with guidelines for IVC filter placement. Most filter indications meeting SIR guidelines are for patients classified as "falls risks," failures of anticoagulation, patients with limited cardiopulmonary reserve and patients non compliant with anticoagulation medications. This single-center study suggests a need for harmonization of current guidelines espoused by professional societies.

Thrombin injection of a pancreaticoduodenal artery pseudoaneurysm after failed attempts at transcatheter embolization.

We describe a case of a pseudoaneurysm of the pancreaticoduodenal artery in a patient with history of cholecystectomy and chronic pancreatitis. Attempts at transcatheter coil embolotherapy failed because of vessel tortuosity. The lesion was then successfully treated by computed tomography-guided direct percutaneous injection of thrombin into the pseudoaneurysm. This technique may be a first line of treatment or a useful adjunct to transcatheter embolization technique.