- Department of Neuroscience, Winthrop University Hospital, Mineola, New York, USA
Nancy E. Epstein
Department of Neuroscience, Winthrop University Hospital, Mineola, New York, USA
DOI:10.4103/2152-7806.166877Copyright: © 2015 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Epstein NE. Prophylactic inferior vena cava filter placement prior to lumbar surgery in morbidly obese patients: Two-case study and literature review. Surg Neurol Int 08-Oct-2015;6:
How to cite this URL: Epstein NE. Prophylactic inferior vena cava filter placement prior to lumbar surgery in morbidly obese patients: Two-case study and literature review. Surg Neurol Int 08-Oct-2015;6:. Available from: http://surgicalneurologyint.com/surgicalint_articles/prophylactic-inferior-vena-cava-filter-placement-prior-to-lumbar/
Background:Preoperative “prophylactic” placement of inferior vena cava (IVC) filters in morbidly obese patients (e.g., body mass index [BMI] >40 or BMI over 35 with hypertension/diabetes) undergoing multilevel decompressive lumbar laminectomies may reduce the risk of postoperative pulmonary embolism (PE), and death.
Methods:Two patients, ages 69 and 68, with morbid obesity (BMI's of 40.4 and 37.5 both with hypertension and diabetes), received prophylactic IVC filters prior to L1–S1 laminectomies. Intraoperatively and postoperatively, both received alternating compression stocking prophylaxis, and received subcutaneous heparin 5000 U q12 h 48 h after surgery until discharge; none developed deep venous thrombosis (DVT) or PE, and both filters were uneventfully removed within 3 postoperative months.
Results:The spinal surgical literature largely supports the placement of IVC filters for major risk factors; obesity (BMI >40), a history of DVT/PE, cancer, fusions, hypercoagulation syndromes, pulmonary/circulatory disorders, preoperative/postoperative immobility, staged procedures (five spinal levels), combined anterior-posterior surgery, iliocaval manipulation, age >80, and prolonged surgery (e.g., >261 min vs. >8 h). Although the safety and efficacy of prophylactic IVC filters for spine surgery in patients with morbidly obesity are well substantiated, those for bariatric patients are less clear.
Conclusions:Prophylactic IVC filters were successfully placed/retrieved in 2 morbidly obese patients, ages 68 and 69, undergoing L1–S1 lumbar decompressions. Although the spine surgery literature documents the safety/efficacy of prophylactic IVC filters in patients with morbid obesity, the bariatric literature still has major concerns.
Keywords: Bariatric surgery, deep venous thrombosis, efficacy, inferior vena cava filter, morbidly obese patients, mortality, prophylaxis, pulmonary embolism, safety, spine surgery
To reduce the frequency of significant postoperative pulmonary embolism (PE), and death, the spine literature largely supports the use of prophylactic inferior vena cava (IVC) filters prior to extensive spine surgery for patients who meet high-risk criteria. These include obesity with a body mass index (BMI) >40, a history of deep venous thrombosis (DVT) or PE, cancer, hypercoagulation syndromes, >2 weeks of preoperative immobility, anticipated long-term postoperative immobility, fusions, staged procedures (five spinal levels), combined anterior-posterior surgery, iliocaval manipulation, and prolonged surgery among other factors [
Prior to L1–S1 lumbar laminectomies without fusions, 2 morbidly obese patients, ages, 68 and 69, (BMI's of 37.5 and 40.4, both with hypertension and diabetes) underwent prophylactic IVC filter placement. Both patients were ambulated the day of surgery, and received alternating compression stocking (CS) prophylaxis intraoperatively and postoperatively/throughout the hospital course. They were also started on subcutaneous Mini Heparin 5000 U q12 h on the 2nd postoperative day (continued through discharge). Both patients had negative screening Doppler's performed on postoperative day 2 and were discharged home after 2- and 3-night hospital stays. Postoperatively, neither developed DVT or PE, and both underwent uneventful elective IVC filter removal within 3 postoperative months.
Risk factors and rates of deep venous thrombosis, pulmonary embolism, and mortality for lumbar spine surgery
Risk factors and rates of DVT, PE, and mortality were asssessed in large databases and smaller series of patients undergoing lumbar spine surgery [Tables
Utility of pneumatic compression stockings (CS) as prophylaxis for lumbar surgery
Pneumatic CS alone reduce the incidence of DVT/PE in patients undergoing spinal surgery.[
Sequential compression devices and chemoprophylaxis reduce deep venous thrombosis/pulmonary embolism without risking spinal epidural hematomas
Two authors determined the safety/efficacy of SCD and chemoprophylaxis in complex spine surgery.[
Prophylactic inferior vena cava filters in spine surgery
Several authors effectively used prophylactic IVC filters to avoid PE/death in complex spine surgery.[
Orthopedic surgery (joints/fractures/spine) use inferior vena cava filters with/without prophylaxis
Bass et al. evaluated how IVC filters were utilized in orthopedic surgery at one institution.[
Inferior vena cava filters used in mixed populations at tertiary care centers
At a large Level I trauma center, Rottenstreich et al. observed that 405 retrievable filters were inserted from 2009 to 2013; 52 patients (12.8%) developed a minimum of one filter-related complication, the most common being DVT (6.9%).[
Inferior vena cava filters in bariatric patients
In bariatric surgery, the safety and efficacy of prophylactic IVC filters remains controversial.[
Mixed population receiving inferior vena cava filters including bariatric patients
Patel et al. evaluated 180 medical records (International Classification of Diseases, Ninth Revision-9) for patients receiving IVC filters over a 5 year period utilizing different guidelines from the American College of Chest Physicians and the Society of Interventional Radiologists.[
Complications of inferior vena cava filters
Various complications of IVC filters have been reported.[
To reduce the risk of fatal PE, various regimens of DVT/PE prophylaxis have been offered for morbidly obese patients undergoing complex spinal surgery; CS, CS with LDH/LMWH, and the latter with prophylactic IVC filters. The 2 morbidly patients in this series were successfully treated with CS/LDH and prophylactic IVC filter placement; neither DVT or PE occurred, and filters were uneventfully removed. Although the literature substantiates the safety/efficacy of prophylactic IVC filter placement in morbidly obese patients undergoing spine surgery, the data for bariatric procedures remains uncertain.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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