The effectiveness of prophylactic inferior vena cava filters in trauma patients: A systematic review and meta-analysis

Elliott Haut, Luis J. Garcia, Hasan M. Shihab, Daniel Brotman, Kent A Stevens, Ritu Sharma, Yohalakshmi Chelladurai, Tokunbo O. Akande, Kenneth M Shermock, Sosena Kebede, Jodi Segal, Sonal Singh

Research output: Contribution to journalArticle

Abstract

IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012).We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori.We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks.We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95%CI, 0.06-0.70]; I2 = 0%) and fatal PE (0.09 [0.01-0.81]; I2 = 0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95%CI, 0.50-6.19]; P = .38; I2 = 56.8%) or mortality (0.70 [0.40-1.23]; I2 = 6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95%CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studiesmay be informative.

Original languageEnglish (US)
Pages (from-to)194-202
Number of pages9
JournalJAMA Surgery
Volume149
Issue number2
DOIs
StatePublished - Feb 2014

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Vena Cava Filters
Pulmonary Embolism
Meta-Analysis
Wounds and Injuries
Venous Thrombosis
Mortality
Medical Subject Headings
Databases
Numbers Needed To Treat
Health Services Research
Low Molecular Weight Heparin
Incidence
Venous Thromboembolism
MEDLINE
Libraries

ASJC Scopus subject areas

  • Surgery

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The effectiveness of prophylactic inferior vena cava filters in trauma patients : A systematic review and meta-analysis. / Haut, Elliott; Garcia, Luis J.; Shihab, Hasan M.; Brotman, Daniel; Stevens, Kent A; Sharma, Ritu; Chelladurai, Yohalakshmi; Akande, Tokunbo O.; Shermock, Kenneth M; Kebede, Sosena; Segal, Jodi; Singh, Sonal.

In: JAMA Surgery, Vol. 149, No. 2, 02.2014, p. 194-202.

Research output: Contribution to journalArticle

Haut, Elliott ; Garcia, Luis J. ; Shihab, Hasan M. ; Brotman, Daniel ; Stevens, Kent A ; Sharma, Ritu ; Chelladurai, Yohalakshmi ; Akande, Tokunbo O. ; Shermock, Kenneth M ; Kebede, Sosena ; Segal, Jodi ; Singh, Sonal. / The effectiveness of prophylactic inferior vena cava filters in trauma patients : A systematic review and meta-analysis. In: JAMA Surgery. 2014 ; Vol. 149, No. 2. pp. 194-202.
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abstract = "IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012).We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori.We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks.We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95{\%}CI, 0.06-0.70]; I2 = 0{\%}) and fatal PE (0.09 [0.01-0.81]; I2 = 0{\%}) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95{\%}CI, 0.50-6.19]; P = .38; I2 = 56.8{\%}) or mortality (0.70 [0.40-1.23]; I2 = 6.7{\%}). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95{\%}CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studiesmay be informative.",
author = "Elliott Haut and Garcia, {Luis J.} and Shihab, {Hasan M.} and Daniel Brotman and Stevens, {Kent A} and Ritu Sharma and Yohalakshmi Chelladurai and Akande, {Tokunbo O.} and Shermock, {Kenneth M} and Sosena Kebede and Jodi Segal and Sonal Singh",
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T1 - The effectiveness of prophylactic inferior vena cava filters in trauma patients

T2 - A systematic review and meta-analysis

AU - Haut, Elliott

AU - Garcia, Luis J.

AU - Shihab, Hasan M.

AU - Brotman, Daniel

AU - Stevens, Kent A

AU - Sharma, Ritu

AU - Chelladurai, Yohalakshmi

AU - Akande, Tokunbo O.

AU - Shermock, Kenneth M

AU - Kebede, Sosena

AU - Segal, Jodi

AU - Singh, Sonal

PY - 2014/2

Y1 - 2014/2

N2 - IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012).We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori.We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks.We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95%CI, 0.06-0.70]; I2 = 0%) and fatal PE (0.09 [0.01-0.81]; I2 = 0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95%CI, 0.50-6.19]; P = .38; I2 = 56.8%) or mortality (0.70 [0.40-1.23]; I2 = 6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95%CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studiesmay be informative.

AB - IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012).We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori.We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks.We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95%CI, 0.06-0.70]; I2 = 0%) and fatal PE (0.09 [0.01-0.81]; I2 = 0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95%CI, 0.50-6.19]; P = .38; I2 = 56.8%) or mortality (0.70 [0.40-1.23]; I2 = 6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95%CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studiesmay be informative.

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