Percutaneous placement of a filter in the inferior vena cava prevents pulmonary embolism from a deep venous thrombosis (DVT) in a lower extremity. Similarly, a filter in the superior vena cava may prevent pulmonary embolism from an upper extremity thrombus. However, placement of a filter into the superior vena cava is more challenging than insertion into the inferior vena cava because of the relatively small area for filter deployment. Theoretically, the technical demands of placing a filter in the superior vena cava could contribute to an increased complication rate. Spence and associates evaluated the safety and effectiveness of superior vena caval filters for the prevention of pulmonary embolism in 41 patients with upper extremity DVT.
Vena caval filters were required in these patients because of complications from or contraindications to anticoagulation. The patients were seen during a nine-year period. In no patient was the upper extremity DVT the reason for hospital admission. Rather, DVT developed in all of them following hospital admission for other conditions, including carcinoma (15 patients), congestive heart failure or recent myocardial infarction (11 patients), intracranial hemorrhage (seven patients), pancreatitis (two patients), elective surgery for arteriovenous malformation (two patients), gastrointestinal hemorrhage (one patient) and Henoch-Schöenlein purpura (one patient).
The extent of the upper extremity DVT was determined by venogram, duplex ultrasound examination, or both. The filters were placed, whenever possible, by way of the right common femoral vein to avoid inadvertent dislodgement of a central thrombus during internal jugular venous insertion.
In 22 of the patients, the thrombus was present at the site of a central venous catheter. In 14 of the patients, the thrombus was located where a central venous cathether had been located within the previous two weeks. Nine patients had hypercoagulable states. Sixteen of the patients had upper and lower extremity DVT simultaneously; 15 of these 16 patients underwent insertion of filters into both the superior and the inferior vena cavas.
No patient had immediate or delayed complications directly related to the procedure. At a median follow-up of 12 weeks (range: one day to 221 weeks), no evidence of migration, fracture or dislodgement of the filter was found in any patient, despite placement of central or Swan-Ganz catheters in 23 patients. No patient showed clinical evidence of superior vena cava occlusion, venous gangrene or exacerbation of upper extremity symptoms during a median follow-up of 15 weeks. One patient subsequently had a pulmonary embolism 44 months after placement of the superior vena caval filter. The clot was thought to have originated in the lower extremity. In 10 patients, anticoagulation was reinstituted while the filter was in place, and the filter likely provided additional protection against pulmonary embolism.
In the authors' experience, mechanical interruption of the superior vena cava was 100 percent effective in preventing symptomatic pulmonary embolism related to upper extremity DVT. Although the survival rate at six months was low (48 percent) in this study group, deaths were largely from cancer and cardiac disease.