Inferior Vena Cava Filter Retrieval Trends: A Single Center Experience

Background: Inferior vena cava (IVC) filters are indicated in patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) who either have contraindications to or have failed anticoagulation (AC). Given rising concerns about their safety and efficacy, the FDA has issued a communication urging clinicians to remove filters (optimally, within 90 days post-implantation). According to national data retrieval rates remain low. Our study aimed to assess IVC filter retrieval rates and factors that influence retrieval. Methods: This is a single center, retrospective cohort study of patients who had IVC filter placement between December 2015 and December 2018. Subjects were identified using procedural codes for IVC filter insertion; data regarding demographics, comorbidities, retrieval, IVC filter-related complications and subsequent thromboembolic events were obtained by direct chart review. Survival analyses and a Cox regression model were performed using JMP statistical software. Results: Over 3 years, 494 patients with IVC filters were identified; 305 (62%) were retrievable. The average age at placement was 69±16 years; 249 (50%) were men and 332 (67%) were Caucasian. After excluding patients who died or were lost to follow-up within 30 days of placement or were discharged to hospice from the index admission, 258 patients with retrievable filters remained (54 retrieved). Indications for IVC filter placement were PE ± DVT 90 (35%), proximal DVT 159 (62%) and prophylactic 9 (3%). Forty two percent of patients (109) were restarted on AC at discharge, while an additional 18% (total 155) received AC at some point thereafter. The rate of retrieval was 8% at 90 days, 23% at 1 year and 28% at 2 years (Figure A). The proportional hazards model identified resumption of AC at any time (HR 3.11, 95%CI 1.6-6.8, p=0.0006) as the strongest predictor of retrieval; AC at discharge was not predictive. Advanced age at placement (HR 0.97 per unit change, 0.96-0.99, p=0.004) and active malignancy (HR 0.5, 95%CI 0.24-0.98, p=0.04) were associated with a lower likelihood of retrieval. The initial thrombotic event, the reversibility of the contraindication to AC, the placing service, sex, ethnicity and other comorbid conditions did not have an impact on retrieval. Kaplan-Meier analysis revealed that subjects who ever resumed AC had significantly higher rates of retrieval at 90 days (11% vs 3.4%) and at 1 year (33% vs 9.7%, log-rank p=0.0003, Figure B) when compared to those who did not. Only four patients experienced IVC filter-related complications (2 filter thrombosis, 1 IVC penetration, 1 device tilting); all occurred 2 or more years after placement. Recurrent thromboembolic events occurred in 50 patients (5 PE, 48 proximal DVT) with no significant difference in frequency between subjects with retrieved and non-retrieved filters; one PE and one DVT occurred at 1 month and 1 week respectively after retrieval. Conclusion: Despite efforts to increase awareness of IVC filter-associated complications, the unweighted retrieval rate remained below the nationally reported average of 30%. Persistent risk factors for thrombosis such as active malignancy or increasing age and poor prognosis may play a role in the decision to defer retrieval. In our study, resumption of AC proved a powerful predictor of retrieval, with rates approaching expected values in this population. Active surveillance for resolution of contraindications to AC post-IVC filter placement is crucial in increasing retrieval rates. Figure Disclosures No relevant conflicts of interest to declare.

Adoption Breakdown in Spain: A Survival and Age-Related Analysis

Purpose: The two goals of this article are the analysis of the duration of adoptive placements ending in breakdown and the role of age at placement in the breakdown experience. Method: All known cases of adoption breakdown during a whole decade in Andalusia, a Spanish region, were studied. Preadoption and formalized adoptions, domestic and intercountry adoptions were included. Data were analyzed using survival analysis, Cox regression, χ2, and rate ratio analyses. Results: The duration of adoptive placements ending in breakdown, significantly shorter in intercountry adoptions, is associated with a configuration of characteristics in the child, the adoptive parents and adoptive family life, and professional intervention. Among child-related factors, age at placement is of special relevance for the breakdown experience. Conclusions: Placements involving older children last less and break down more frequently, but are not condemned to failure. They need to be better supported with protective factors compensating the risks.

Beyond the Child’s Age at Placement: Risk and Protective Factors in Preadoption Breakdown in Portugal

Purpose: The main goals were to determine the incidence of preadoption breakdown in Portugal, describe preadoptive parents’ reasons for ending placement, compare intact/disrupted placements, and identify adoption disruption risk and protective factors. Method: A matched design involving a case file analysis of 71 disrupted and 71 intact preadoptive placements was used. Results: The accumulated incidence of preadoption disruption was 5.8%. Adoptive parents’ motives for requesting removal included the child’s behavior, their own parenting limitations, and dissatisfaction with professional interventions. These three domains were present in the group comparisons and explained 54% of the variance, predicting group membership for 80.8% cases. Conclusion: Besides age at placement, other risk factors related to the child, the adopters, and the professional practices help to gain a more complete understanding of adoption disruption.

Family Placements from a Chinese Institution

In this article Chris Beckett and June Thoburn look at an innovative fostering project in Shanghai, which places children from a large children's institution. They consider placement outcomes for 220 children placed over a two-year period. A number of variables are discussed which might impact on placement outcomes, including age, gender, level of disability, length of time spent in the institution and age at time of placement. The length of time spent in institutional care and age at placement were found to be predictors of the placements breaking down during the first few years after placement. Younger children moved quickly into foster homes were most likely to settle there successfully. This finding is in accord with other studies that have found that early institutional care can have adverse long-term consequences for development. This pattern, it is suggested, does not necessarily reflect poor physical care within the institution. It may simply be a consequence of the fact that an environment of this kind cannot provide the kinds of relationships which are necessary for optimal development. The authors believe that looking at placement outcomes for projects of this kind provides a valuable opportunity to learn more about children's vulnerabilities and about the kinds of post-placement support which are needed.

The Adjustment of Black Children Adopted by White Families

A study has found that, initially, transracially placed children are more maladjusted than their inracially adopted peers. Yet, when age at placement is taken into account, the differences disappear. Thus, transracial adoption may continue to be a viable option for the many nonwhite children awaiting placement.