Are Open Reduction Internal Fixation (ORIF) patients considered for Inferior Vena Cava (IVC) filters?

IVC Filter Use in ORIF Patients

IVC filters should not be routinely used in ORIF patients and should be reserved only for specific cases where there are absolute contraindications to anticoagulation, major bleeding complications during anticoagulation, or recurrent VTE despite therapeutic anticoagulation. 1

Appropriate Indications for IVC Filter Placement

IVC filters should only be considered in ORIF patients under the following specific circumstances:

1. Absolute contraindications to anticoagulation 2, 1:

   • Active bleeding
   • Recent intracranial hemorrhage
   • Severe bleeding diathesis

2. Major bleeding complications during anticoagulation 2, 1

3. Failure of anticoagulation therapy 2, 1:

   • Recurrent or progressive VTE despite therapeutic anticoagulation

Evidence Against Routine Prophylactic Use in ORIF Patients

• The American College of Radiology (ACR) explicitly states there is no evidence to support prophylactic IVC filters in patients without established DVT or PE 1
• Widespread prophylactic use of IVC filters is not supported by evidence and should be discouraged 3
• Although orthopedic patients are at high risk for VTE, pharmacologic prophylaxis remains the preferred approach once the immediate risk of hemorrhage has passed 2

Important Considerations for IVC Filter Use

If an IVC filter is deemed necessary in an ORIF patient:

• Use retrievable filters whenever possible 2, 1
• Resume anticoagulation as soon as contraindications resolve 2
• Plan for filter retrieval once anticoagulation is established 1
• Monitor for complications associated with IVC filters 1:
  • Increased risk of recurrent DVT (20-21%)
  • Post-thrombotic syndrome (40%)
  • IVC occlusion (22% at 5 years)
  • Filter migration, fracture, or perforation

Special Considerations in Orthopedic Surgery

• In a study of orthopedic surgery cases, IVC filters were used in only 0.96% of inpatient orthopedic surgeries 4
• Among filters placed prophylactically in orthopedic patients, only 42% had a true contraindication to anticoagulation 4
• Despite intentions to remove retrievable filters, only 40% were actually removed, with 11% experiencing complications during removal attempts 4

Practical Algorithm for IVC Filter Decision-Making in ORIF Patients

1. First-line approach: Implement standard VTE prophylaxis with pharmacologic agents once hemostasis is achieved (typically within 36 hours)

2. If contraindication to anticoagulation exists:

   • Consider temporary IVC filter placement
   • Document clear plan for filter removal
   • Resume anticoagulation as soon as contraindication resolves
   • Schedule filter retrieval once anticoagulation is established

3. If patient develops VTE despite prophylaxis:

   • Begin therapeutic anticoagulation if no contraindications
   • Consider IVC filter only if anticoagulation is contraindicated or fails

4. Do not place IVC filters prophylactically in ORIF patients without established DVT/PE

Conclusion

The evidence strongly suggests that IVC filters should not be routinely used in ORIF patients for prophylaxis. Their use should be limited to specific scenarios where anticoagulation is absolutely contraindicated or has failed. When filters are placed, retrievable options should be selected with a clear plan for removal once anticoagulation can be safely initiated.