American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Venous Thromboembolism-Inferior Vena Cava Filters

Variant 1: Acute venous thromboembolism (proximal deep vein thrombosis of the leg or pulmonary embolism) with no contraindication to anticoagulation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Moderate N/A N/A 9 9 0 0 0 0 0 0 0 2 12
References Study Quality
1 (24549552) 4
3 (26867832) 4
4 (18322285) 4
22 (19717844) 1
Retrievable IVC filter May be appropriate Strong N/A N/A 4 4 0 3 2 4 4 1 0 0 0
References Study Quality
18 (16567669) 4
25 (25446296) 3
26 (24269095) 3
27 (22310013) 3
28 (24280176) 3
29 (17625093) 4
30 (9040297) 4
31 (15784297) 4
32 (22643565) 4
33 (23968903) 2
34 (24997415) 4
35 (22421738) 1
36 (17261856) 4
37 (23467701) 3
38 (17329532) 4
39 (16215350) 4
40 (9674471) 2
Permanent IVC filter Usually not appropriate Moderate N/A N/A 2 2 7 4 2 0 1 0 0 0 0
References Study Quality
3 (26867832) 4
23 (9459643) 1
24 (28935036) Good
Variant 2: Acute venous thromboembolism (proximal deep vein thrombosis of the leg or pulmonary embolism) with contraindication to anticoagulation, major complication of anticoagulation, or failure of anticoagulation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Retrievable IVC filter Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 2 7 5
References Study Quality
9 (22173108) 4
14 (24928649) 3
51 (25919526) 1
52 (17916166) 4
53 (23180324) 4
54 (24980424) 3
55 (10693718) 4
56 (24630748) 2
57 (20696949) 4
58 (-3123667) 4
Permanent IVC filter May be appropriate Strong N/A N/A 6 6 0 1 0 0 5 3 2 3 0
References Study Quality
12 (22024114) 4
23 (9459643) 1
43 (24576432) 1
44 (16009794) 1
45 (24500085) 3
46 (23622035) 2
47 (10887228) 4
48 (12953821) 4
49 (15252766) 4
50 (16604959) 4
Observation Usually not appropriate Strong TBD TBD 2 2 6 5 2 1 0 0 0 0 0
References Study Quality
31 (15784297) 4
42 (21530308) 2
43 (24576432) 1
Variant 3: Isolated acute distal deep vein thrombosis of the leg.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Observation with serial imaging Usually appropriate Limited N/A N/A 7 7 0 0 0 0 1 3 5 3 2
References Study Quality
3 (26867832) 4
Anticoagulation May be appropriate Limited N/A N/A 6 6 0 0 0 0 1 7 1 2 3
References Study Quality
3 (26867832) 4
Retrievable IVC filter Usually not appropriate Expert Consensus N/A N/A 3 3 5 1 3 3 0 2 0 0 0
Permanent IVC filter Usually not appropriate Expert Consensus N/A N/A 2 2 7 5 2 0 0 0 0 0 0
Variant 4: Chronic venous thromboembolism (eg, chronic thromboembolic pulmonary hypertension).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Moderate N/A N/A 9 9 0 0 0 0 1 0 1 3 9
References Study Quality
3 (26867832) 4
59 (23883377) 1
Pulmonary thromboendarterectomy Usually appropriate Limited N/A N/A 7 7 0 0 0 1 1 5 4 3 0
References Study Quality
60 (15163775) 4
61 (27571005) 4
Permanent IVC filter May be appropriate Limited N/A N/A 5 5 0 0 0 2 9 2 0 0 0
References Study Quality
62 (21330453) 4
Balloon pulmonary angioplasty May be appropriate Limited N/A N/A 5 5 0 0 1 3 8 1 0 0 0
References Study Quality
63 (29636403) 4
Retrievable IVC filter May be appropriate Limited N/A N/A 4 4 0 1 3 4 3 3 0 0 0
References Study Quality
62 (21330453) 4
Variant 5: Venous thromboembolism prophylaxis in high-risk patient (eg, major trauma, traumatic brain injury, etc).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Intermittent pneumatic compression devices Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 4 2 3 5
References Study Quality
78 (14598411) 1
Prophylactic anticoagulation Usually appropriate Limited N/A N/A 7 7 0 0 0 0 1 1 5 5 1
References Study Quality
64 (8703169) 1
Retrievable IVC filter May be appropriate Strong N/A N/A 6 6 0 0 1 2 2 7 1 1 0
References Study Quality
15 (22698970) 4
19 (17070525) 4
20 (22047757) 2
21 (20345723) 4
66 (16859222) 4
67 (16310701) 4
68 (17124100) 4
69 (15041267) 4
70 (26366537) 2
71 (27682367) 2
72 (21825934) 1
73 (24195920) Good
74 (10759199) 4
75 (23754086) 4
76 (22360915) 3
77 (25599325) 4
Surveillance US May be appropriate Limited N/A N/A 5 5 0 1 1 1 8 2 0 0 0
References Study Quality
79 (26032827) 4
Permanent IVC filter Usually not appropriate Limited N/A N/A 3 3 6 1 4 1 1 1 0 0 0
References Study Quality
65 (21990806) 3
Variant 6: Proximal deep vein thrombosis of the leg undergoing catheter-directed thrombolysis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Expert Consensus N/A N/A 9 9 0 1 0 1 2 1 0 2 7
Retrievable IVC filter May be appropriate Limited N/A N/A 5 5 0 0 1 3 8 1 0 0 0
References Study Quality
31 (15784297) 4
80 (22271078) 1
Permanent IVC filter Usually not appropriate Limited N/A N/A 2 2 5 3 3 2 0 1 0 0 0
References Study Quality
31 (15784297) 4
80 (22271078) 1
Variant 7: Indwelling prophylactic retrievable inferior vena cava filter, resolution of risk factors for venous thromboembolism.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Venography at time of retrieval procedure Usually appropriate Limited N/A N/A 9 9 0 0 0 0 0 0 0 4 10
References Study Quality
18 (16567669) 4
US duplex Doppler lower extremities prior to retrieval May be appropriate Limited N/A N/A 6 6 0 0 1 4 1 1 5 1 0
References Study Quality
18 (16567669) 4
CT venography prior to retrieval Usually not appropriate Limited N/A N/A 3 3 0 0 10 2 1 0 0 0 0
References Study Quality
18 (16567669) 4
Variant 8: Indwelling retrievable inferior vena cava filter for venous thromboembolism, now tolerating or completed therapeutic anticoagulation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Venography at time of retrieval procedure Usually appropriate Limited N/A N/A 9 9 0 0 0 0 0 0 0 4 10
References Study Quality
18 (16567669) 4
US duplex Doppler lower extremities prior to retrieval May be appropriate (Disagreement) Expert Opinion N/A N/A 5 4 0 1 4 2 0 2 4 0 0
References Study Quality
18 (16567669) 4
CT venography prior to retrieval Usually not appropriate Limited N/A N/A 3 3 0 0 9 4 0 0 0 0 0
References Study Quality
18 (16567669) 4
Variant 9: Indwelling retrievable inferior vena cava filter with failed first retrieval attempt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Re-attempt retrieval with advanced techniques Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 1 2 9 2
References Study Quality
56 (24630748) 2
88 (21530309) 4
89 (21050774) 4
Convert to permanent device May be appropriate Limited N/A N/A 4 4 0 2 2 5 3 0 1 0 0
References Study Quality
56 (24630748) 2
Refer for surgical evaluation for retrieval Usually not appropriate Limited N/A N/A 3 3 0 5 4 1 2 2 0 0 0
References Study Quality
90 (21674279) 4
91 (26993841) 4
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.