Is anticoagulation with Eliquis (apixaban) necessary in a patient with a history of Pulmonary Embolism (PE) and a Superior Vena Cava (SVC) filter in place?

Anticoagulation with Eliquis in Patients with History of PE and SVC Filter

Long-term anticoagulation with Eliquis (apixaban) should be continued in patients with a history of PE who have an SVC filter in place, unless there is an absolute contraindication to anticoagulation. 1, 2

Rationale for Continued Anticoagulation

The presence of a vena cava filter alone is not sufficient protection against recurrent venous thromboembolism (VTE) and does not eliminate the need for anticoagulation therapy. Guidelines strongly support this approach for several important reasons:

• Increased DVT risk with filters: Vena cava filters are associated with a significantly increased risk of recurrent deep vein thrombosis (21% vs 12% at 2 years) 1
• Filter thrombosis risk: Without anticoagulation, the occlusion rate of vena cava filters can be as high as 15%, compared to only 8% with anticoagulation 1
• Long-term outcomes: After 6 years of follow-up, 59% of patients with filters had clinical evidence of venous insufficiency 1
• Mortality benefit: While filters may reduce PE-related mortality in the acute phase, this comes at the cost of increased risk of recurrent VTE 1

Evidence-Based Recommendations

The European Society of Cardiology and American Heart Association guidelines clearly state:

1. Anticoagulation should be resumed in patients with an IVC/SVC filter once contraindications to anticoagulation or active bleeding complications have resolved (Class I; Level of Evidence B) 1

2. Long-term anticoagulant treatment with an INR in the range of 2.0 to 3.0 (if using warfarin) or appropriate DOAC dosing (such as Eliquis) should be recommended with vena cava filters 1

3. Standard duration of anticoagulation for VTE is at least 6 months, with the minimum being 3 months 2

4. For patients with recurrent PE or persistent risk factors, extended treatment (>3 months) or indefinite anticoagulation is recommended 2

Specific Considerations for SVC Filters

SVC filters present unique challenges compared to IVC filters:

• SVC filters are less commonly placed but are increasingly used as UEDVT frequency rises 3
• Placement in the SVC carries specific risks including potential pericardial tamponade 1
• Data on SVC filters are more limited than for IVC filters, but the same principles of anticoagulation apply 3

Important Caveats and Pitfalls

• Do not rely on the filter alone: The PREPIC trial showed that vena cava filters without anticoagulation are insufficient for preventing recurrent VTE 1

• Monitor for filter complications: Regular assessment for filter-related complications such as thrombosis, migration, or perforation is essential 1

• Consider filter retrieval: If the filter is retrievable and the period of high PE risk has passed, retrieval should be considered to reduce long-term complications 1

• Avoid unnecessary filter placement: The PREPIC2 trial showed that in patients who can receive anticoagulation, adding a retrievable filter did not reduce the risk of recurrent PE at 3 months 4

Special Circumstances

The only situations where anticoagulation might be withheld in a patient with PE history and SVC filter would be:

• Absolute contraindication to anticoagulation: Such as active major bleeding, recent intracranial hemorrhage, or severe thrombocytopenia 5

• Recurrent life-threatening bleeding on anticoagulation: In such cases, the filter alone may be the only option until bleeding risk decreases 6

In summary, unless there is an absolute contraindication to anticoagulation, patients with a history of PE and an SVC filter should continue anticoagulation therapy with Eliquis (apixaban) to prevent recurrent VTE, filter thrombosis, and post-thrombotic syndrome.