Prospective implementation of an algorithm for bedside intravascular ultrasound-guided filter placement in critically ill patients.
BACKGROUND
Although contrast venography is the standard imaging method for inferior vena cava (IVC) filter insertion, intravascular ultrasound (IVUS) imaging is a safe and effective option that allows for bedside filter placement and is especially advantageous for immobilized critically ill patients by limiting resource use, risk of transportation, and cost. This study reviewed the effectiveness of a prospectively implemented algorithm for IVUS-guided IVC filter placement in this high-risk population.


METHODS
Current evidence-based guidelines were used to create a clinical decision algorithm for IVUS-guided IVC filter placement in critically ill patients. After a defined lead-in phase to allow dissemination of techniques, the algorithm was prospectively implemented on January 1, 2008. Data were collected for 1 year using accepted reporting standards and a quality assurance review performed based on intent-to-treat at 6, 12, and 18 months.


RESULTS
As defined in the prospectively implemented algorithm, 109 patients met criteria for IVUS-directed bedside IVC filter placement. Technical feasibility was 98.1%. Only 2 patients had inadequate IVUS visualization for bedside filter placement and required subsequent placement in the endovascular suite. Technical success, defined as proper deployment in an infrarenal position, was achieved in 104 of the remaining 107 patients (97.2%). The filter was permanent in 21 (19.6%) and retrievable in 86 (80.3%). The single-puncture technique was used in 101 (94.4%), with additional dual access required in 6 (5.6%). Periprocedural complications were rare but included malpositioning requiring retrieval and repositioning in three patients, filter tilt >/=15 degrees in two, and arteriovenous fistula in one. The 30-day mortality rate for the bedside group was 5.5%, with no filter-related deaths.


CONCLUSIONS
Successful placement of IVC filters using IVUS-guided imaging at the bedside in critically ill patients can be established through an evidence-based prospectively implemented algorithm, thereby limiting the need for transport in this high-risk population.
Killingsworth
Christopher D
CD
Division of General Surgery, University of Alabama at Birmingham, Birmingham, Ala, USA.
Taylor
Steven M
SM
Patterson
Mark A
MA
Weinberg
Jordan A
JA
McGwin
Gerald
G
Melton
Sherry M
SM
Reiff
Donald A
DA
Kerby
Jeffrey D
JD
Rue
Loring W
LW
Jordan
William D
WD
Passman
Marc A
MA
D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D003422:Critical Care / Q000379:methods / Q000592:standards; D016638:Critical Illness / Q000628:therapy; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography / Q000379:methods; D019095:Point-of-Care Systems; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000401:mortality / Q000517:prevention & control; D018570:Risk Assessment; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods*; D016306:Vena Cava Filters; D054556:Venous Thromboembolism / Q000401:mortality* / Q000517:prevention & control*; D055815:Young Adult