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Original Investigation |

The Effectiveness of Prophylactic Inferior Vena Cava Filters in Trauma Patients:  A Systematic Review and Meta-analysis

Elliott R. Haut, MD1,2,3,4; Luis J. Garcia, MD1; Hasan M. Shihab, MBChB, MPH5; Daniel J. Brotman, MD6; Kent A. Stevens, MD, MPH1; Ritu Sharma, BSc5; Yohalakshmi Chelladurai, MBBS, MPH5; Tokunbo O. Akande, MBBS, MPH5; Kenneth M. Shermock, PharmD, PhD4,7; Sosena Kebede, MD, MPH6; Jodi B. Segal, MD, MPH5,6; Sonal Singh, MD, MPH5,6
[+] Author Affiliations
1Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
2Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
3Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
4Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
5The Johns Hopkins Evidence-Based Practice Center, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
6Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
7Center for Pharmaceutical Outcomes, The Johns Hopkins Hospital, Baltimore, Maryland
JAMA Surg. 2014;149(2):194-202. doi:10.1001/jamasurg.2013.3970.
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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 studies may be informative.

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Figure 1.
Flow Diagram of Included and Excluded Studies

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist13 to refine the search for eligible studies, resulting in 8 controlled studies for analysis. HIT indicates heparin-induced thrombocytopenia; IVC, inferior vena cava; VTE, venous thromboembolism.aTotal exceeds the number excluded because reviewers were allowed to mark more than 1 reason for exclusion.

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Figure 2.
Forest Plot of Relative Risk (RR) of Pulmonary Embolism (PE) With Use of Inferior Vena Cava (IVC) Filters vs No IVC Filters in Trauma Patients

Weights are calculated from random-effects analysis. Dashed line indicates the overall weighted point estimate (0.20); diamond, same overall weighted point estimate (95% CI). Shadow size varies relative to weight assigned to each study. Overall I2 = 0% (P = .48). Test of RR = 1 (z = 2.52; P = .01).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Forest Plot of Relative Risk (RR) of Fatal Pulmonary Embolism (PE) With Use of Inferior Vena Cava (IVC) Filters vs No IVC Filters in Trauma Patients

Weights are calculated from random-effects analysis. Dashed line indicates the overall weighted point estimate (0.20); diamond, same overall weighted point estimate (95% CI). Shadow size varies relative to weight assigned to each study. Overall I2 = 0% (P = .94). Test of RR = 1 (z = 2.14; P = .03).

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