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Wed Jan 17 15:01:58 GMT 2007

Part of the problem is a misinterpretation by some health care providers about what an IVC filter accomplishes. Commonly I've seen cases in which practioners withdrew anticoagulation subsequent to filter placement due to the misperception that the presence of the filter abolishes the need for anticoagulation.

  In the presence of venous thrombosis, anticoagulation is prophylaxis against embolic phenomenon, and an infrarenal IVC filter provides protection from pulmonary emboli from lower body sites. Other benefits of anticoagulation, however, include prevention of propagation of existing clot and reduction of post thrombotic syndrome sequelae of chronic limb swelling, skin breakdown and ulceration.

  I'm aware of one successful litigation against a team of providers who placed a filter for indication of recurrent thromboembolism in the context of hypercoaguable disorder. The patient dropped anticoagulation and went on to develop extensive bilateral LE DVTs with caval extension and severe, irreversible chronic sequelae.

  So, placement of a filter doesn't change indications for anticoagulation which exist prior to or subsequent to placement. If no contraindications exist, or transient contraindications resolve, then initiation of anticoagulation is prudent.

  In the absence of other indications for anticoagulation, however, most vascular specialists do not consider the mere presence of an IVC filter to dictate ongoing coagulation. However, most of these cases would be addressed with temporary filter placement and subsequent removal.

KMATTOX at aol.com wrote:
  To the wise and informed trauma surgeons, nurses, and others on this List 
Server. I posted similar letters to ccmL and Surginet in an attempt to 
determine if anyone else besides me has not learned of a new alledged "Standard 
of Practice"? It seems to me that this is shot gun therapy and is 
DANGEROUS. How can such an urban legend get started??

HELP. I try to remain well informed, but today I encountered something I 
have not read in journals or text books, and have not heard at any national 
meeting. I was so dumbfounded from what was told to me by a "senior" 
surgeon and interventional cardiologist, that I just said, "really, can you tell me 
more or give me the source of the "standard."

Here it is........

Today I was informed that in TWO major hospitals in Houston (NOT THE BEN 
TAUB General Hospital), that it is a "Standard of Practice" to put all patients 
in whom an IVC filter has been inserted on LIVELONG Coumadin. The same 
senior surgeon also indicated that Aspirin and Plavix (LIFELONG) are also added 
in high risk patients. I discovered that it is not unusual to also receive 
Fragmin or Lovenox in these same hospitals for patients with IVC filters. 

This "practice" seems totally illogical to me. 

HELP

1. I have always thought that one indication for an IVC filter was to use 
them in patients with contraindications to anticoagulation

2. What effect (if any) has Plavix had in preventing or treating DVT in 
any location

3. I cannot find the aforementioned "standard" in the package insert or 
PDR of any of these drugs (ASA, Coumadin, Fragmin, Lovenox), NOR any of the 
IVC filters

4. I was told that this logic is supported by vascular surgeons, 
cardiologists, and intensivists, on the same logic as using Plavix and Coumadin in 
patients with coronary stents (including drug eluding stents. --Weird

5. Is there really really support for life long Coumadin ASA Fragmin, or 
Lovenox in patients with coronary stents.

6. What are the complications of this combined Rx (IVC filter and drugs) 
across the board, and not just in selected patients. 

I live in this city. I abide by evidence based medicine, but am subject to 
a local standard of practice. Perhaps I just misunderstood one of the 
senior surgeons, who is relative recent addition to the TMC. Perhaps this is 
just a shot gun therapy which was passed around in the coffee room. I 
checked with a nurse I know that Coumadin (LIfe LONG) is commonly ordered by these 
senior physicians in patients in whom an IVC filter has been inserted. 

Please either educate me or support my more traditional views on this 
subject. 

Kenneth L Mattox, MD
Houston

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IVC Filters, Coumadin, Plavix,ASA, Fragmin