One significant risk following blunt force trauma is the development of Pulmonary Embolism (PE). This comes from a blockage of the pulmonary artery or one of its branches by a blood clot, traveling from another part of the body. PE most commonly results from deep vein thrombosis (DVT) where a blood clot breaks off and migrates to the lung, in a process called venous thromboembolism (VTE). PE and DVT are common complications following major trauma, occurring in over 50% of trauma patients.[1] Death resulting from PE approaches 50% according to research[2] and is the third most common known cause of death in patients who survive the first 24 hours following trauma.[3]
The occurrence rate for fatal PE following major trauma ranges between 0.4% and 4.2%. In a 2010 study, the rate of fatal PE following major trauma was relatively low (1.6%), but it accounted for approximately 12% of all deaths.[4] Researchers estimated that approximately 50% of these fatalities were preventable. Factors which pose increased risk for PE include injury severity, and other co-morbid conditions, such as hypertension, obesity, cardiac disease, and vascular disease.
Typical symptoms of PE include shortness of breath (dyspnea), rapid breathing (tachypnea), chest pain worsening with breathing, and coughing up blood (hemoptysis). Severe cases may also involve blue discoloration of the lips and fingers (cyanosis), circulatory instability, or collapse. Symptom onset is usually sudden.
Therapeutic anticoagulation medication is most commonly used to treat DVT and PE following trauma. However, the use of pneumatic lower extremity compression devices and low-dose anticoagulant therapy are not entirely effective in preventing venous thromboembolism.[5] Vena cava filter placement is a widely accepted approach to preventing PE in the event anticoagulation therapy is unsuccessful or contraindicated. Filters may be of the permanent or removable type, and are most commonly placed in the inferior vena cava (IVC), though superior vena cava placement may be considered in select situations.[6]
Use of vena cava filters can fluctuate greatly for a variety of reasons. According to a study of 263 hospitals surveying over 130,000 patients admitted with acute venous thromboembolism, vena cava filter placement occurred in 15% of the cases with variability ranging from 0% to 39%.[7] Clinical indicators for vane cava filter placement included acute bleeding on admission, major operation after admission, presence of metastatic cancer or other severe illnesses. Lower vena cava placement rates were more common in hospitals with a small number of beds and in rural locations. Vena cava filter use also varied greatly depending on insurance and payor status; almost twice as many patients with insurance received the vena cava filter as compared to patients without insurance.[8]
IVC filer placement is typically achieved using either a jugular or femoral venous approach. Regardless of the chosen vessel, a right-sided approach is preferred, given the more direct route to the IVC. A guidewire is used to access the vena cava with fluoroscopy and intravenous contrast to guide the final position of the filter. Alternatively, the use of bedside ultrasound has had increasing success, and is more advantageous in patients with significant abdominal wounds, patients with turning precautions, or who are morbidly obese.[9] The filter is placed in a location that will reduce the risk of VTE passing into all likely venous pathways, most commonly just below the renal veins.[10]
Complications related to the placement of the IVC filter include entrapment of the guidewire within the filter; post-procedure complications associated with the access site, such as hematoma, and acute venous thrombosis. Acute vein thrombosis at the insertion site occurred in up to 40% of patients, most commonly in procedures using a femoral vein approach.[11] Long term complications can include filter migration, erosion, embolization, chronic thrombosis, and recurrent thromboembolism.[12] [13] Filter migration can occur during after the placement procedure. Most of the complications involving filter migration, erosion, perforation through the IVC wall and filter embolization are reported in individual case studies, therefore little data is available.[14]
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[1] Ho KM, Burrell M, Rao S, Baker R: Incidence and risk factors for fatal pulmonary embolism after major trauma: a nested cohort study. Br J Anaesth 2010; 105:596-602.
[2] Rogers FB, Cipolle MD, Velmahos G, et al. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma 2002; 53:142-64.
[3] Ho KM, et al. The rate of symptomatic PE following trauma varies widely and is dependent on how the diagnosis is confirmed, likely resulting in fewer reported cases of sudden death, in the absence of an autopsy.
[4] Id.
[5] Rosenthal D, McKinsey JF, Levy AM, et al. Use of the Greenfield filer in patients with major trauma. Cardiovasc Surg 1994; 2:52-5
[6] Fedullo P, et al. Placement of inferior vena cava filters and their complications. UptoDate.Article revision date Oct 2013.
[7] White RH, Geraghty EM, Brunson A, et al. High variation between hospitals in vena cava filter use for venous thromboembolism. JAMA Intern Med 2013; 173:506.
[8] Pickham DM, Callcut RA, Maggio PM, et al. Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients. Surgery 2012; 152:232.
[9] Fedullo P, et al. Placement of inferior vena cava filters and their complications.
[10] Fang AS, Morita S, Gill GS, et al. Clinical outcomes of inferior vena cava filter placement in patients with renal vein anomalies. Ann Vasc Surg 2014; 28:318.
[11] Fedullo P, et al. Placement of inferior vena cava filters and their complications.
[12] Sarosiek S, Crowther M, Sloan JM. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients an academic hospital with a level I trauma center. JAMA Intern Med 2013; 173:513.
[13] Joels CS, Sing, RF, Heniford BT. Complications of inferior vena cava filters. Am Surg 2003; 69:654.
[14] Fedullo P, et al. Placement of inferior vena cava filters and their complications.
