RIPT Feasibility Trial (RIPT)

February 25, 2021 updated by: Lawson Health Research Institute

Retrievable Inferior Vena Cava Filter for Primary Pulmonary Embolism Prophylaxis in At-Risk Trauma Patients: RIPT Feasibility Trial

The risk of venous thromboembolism (VTE) is very high in trauma patients, secondary to tissue injury, venous status from immobilization, and thrombophilia. As such, early initiation of VTE prophylaxis is essential in this population. The competing risks of life threatening hemorrhage and VTE need to be considered very carefully. Potential approaches to VTE prophylaxis include pharmacologic means, and mechanical devices. For patients unable to receive pharmacologic VTE prophylaxis, retrievable inferior vena cava filters (rIVCFs) may be placed until low molecular weight heparin (LMWH) can be initiated, as per guidelines such as Eastern Association for the Surgery of Trauma

The investigators propose a feasibility study to determine whether or not our center can insert rIVCFs in at-risk trauma patients expeditiously enough to cause a meaningful reduction in the time they are left unprotected to PE.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

The risk of venous thromboembolism (VTE) is very high in trauma patients, secondary to tissue injury, venous status from immobilization, and thrombophilia. As such, early initiation of VTE prophylaxis is essential in this population. The competing risks of life threatening hemorrhage and VTE need to be considered very carefully. Potential approaches to VTE prophylaxis include pharmacologic means, and mechanical devices. For patients unable to receive pharmacologic VTE prophylaxis, retrievable inferior vena cava filters (rIVCFs) may be placed until low molecular weight heparin (LMWH) can be initiated.

The need for mechanical VTE prophylaxis in patients unable to receive pharmacologic therapy is underscored by Geerts and colleagues' prospective study of trauma patients who did not receive anticoagulation. In their study, 58% of their 349 trauma patients sustained deep venous thromboses (DVT). [Geerts et a., 1994] Furthermore, a confirmed or clinically suspected pulmonary embolus (PE) was identified in an additional 5% of patients. Importantly, this study excluded patients who died during the first 5 days of admission. However, the highest risk of VTE occurs in the first 4 days after admission and many advocate early insertion of rIVCF [Owings et al. 1997, O'Malley et al. 1990, Carlin et al. 2002, Haut et al. 2014]. Coincidentally, VTE prophylaxis is often withheld pending repeat neurologic imaging and / or surgical intervention.

Current guidelines on the use of rIVCFs are contradictory. The Eastern Association for the Surgery of Trauma's (EAST) practice management guideline suggests the use of rIVCFs are advisable in the "very-high-risk trauma patients". Such patients are defined as the those who cannot receive anticoagulation because of increased bleeding risk and have sustained injuries preventing mobilization such as: i) severe closed head injury (GCS < 8) ii) incomplete spinal cord injury with paraplegia or quadriplegia iii) complex pelvic fracture with associated long bone fractures iv) multiple long bone fractures [Rogers et al 2002]. Contrasting this, the American College of Chest Physicians sated in their 2012 Guideline, that there is no role for rIVCFs in primary VTE prevention. [Gould et al. 2012]

Reflecting this lack of consensus in guidelines, there is practice variability among major trauma centres. In an American based survey study of 131 Trauma Directors, LMWH was the preferred method for VTE prophylaxis in over half (51%) of the responders, followed by intermittent pneumatic compression devices (IPCD, 42%), Foot pump (8%) Low Dose Heparin (LDH, 7%) and rIVCFs (1%). In patients with contraindications to pharmacologic prophylaxis, the favoured approach for VTE Prophylaxis is IPCD (80%) followed by rIVCF (16%) and foot pump (9%). [Knudson et al. 2004] More work is needed to improve our understanding of the optimal role for rIVCFs, particularly considering recent advances in, and physician experience with rIVCF technology.

One of the most cited concerns with the use of rIVCF in trauma patients is the low reported retrieval rates ranging from 21-35% of patients. [Kirilcuk et al. 2005, Antevil et al. 2006, Karmy-Jones et al., 2007] The need for VTE prophylaxis in trauma patients is usually temporary, and long term filter use is associated with an increased VTE risk, which was demonstrated in the PREPIC-1 trial and the 8-year follow up study examining the use of permanent IVCF in non-trauma patients with DVT for PE prevention [Decousus et al. 1998, PREPIC Study Group, 2005]. Of note, these trials were examining the role of rIVCF in patients for secondary prophylaxis in at risk patients with known VTE disease. The low retrieval rates of rIVCFs that have been reported in the Unites States are not a problem in our Canadian Lead Trauma Centre. We recently demonstrated a 97% retrieval rate in trauma patients surviving to discharge. [Leeper et al. 2015] We advocate a trial of early rIVCF use followed by prompt removal once medical prophylaxis is safe.

There is a paucity of data regarding the use of rIVCFs in the Canadian setting, and our group is currently surveying Canadian trauma directors to improve our understanding of current practice. Despite the current deficiency of evidence, many Level 1 North American Trauma centres use rIVCF for primary VTE prophylaxis in their at risk trauma patients, as per EAST guidelines. In a recent meta-analysis by Haut et al. that reviewed 8 studies, they identified a reduction in PE incidence with rIVCF use, but concluded that further studies are required. [Haut et al. 2014]

The investigators propose a feasibility study to determine whether or not our center can insert rIVCFs in at-risk trauma patients expeditiously enough to cause a meaningful reduction in the time they are left unprotected to PE.

Study Type

Interventional

Enrollment (Actual)

42

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Canada
    • Ontario
      • London, Ontario, Canada, N6A 5W9
        • Victoria Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (ADULT, OLDER_ADULT)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • consecutive age adult trauma patients who are:

    1. Deemed unable to receive medial VTE prophylaxis within 72 hours post injury based on traumatologists' suspicion of increased bleeding risk, peri-spinal cord bleeding risk, or need for multiple surgical interventions.

      AND

    2. have at-least on of the following high risk VTE injuries as per EAST Guidelines:

      1. severe closed head injury (GCS 8 or less upon presentation)
      2. incomplete spinal cord injury with paraplegia or quadriplegia
      3. complex pelvic fracture with associated long bone fracture(s)
      4. multiple long bone fractures

Exclusion Criteria:

  1. Patients not expected to survive for at least 72 hours post trauma
  2. Patients with known uncorrectable coagulopathy
  3. Patients known to be unable to receive a rIVC filter as part of this trial (for anatomical reasons or standard contraindication for device insertion)
  4. Known active venous thromboembolic disease
  5. Pregnancy

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: TREATMENT
  • Allocation: RANDOMIZED
  • Interventional Model: PARALLEL
  • Masking: NONE

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
EXPERIMENTAL: rIVCF
Randomized to receive insertion of retrievable inferior vena cava filter until chemical anticoagulation can be safely administered.
Device: Cook 'Celect' retrievable inferior vena cava filter
Cook 'Celect' device will be deployed If randomized to rIVCF insertion
NO_INTERVENTION: Standard Care
Randomized to not receive insertion of retrievable inferior vena cava filter.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Time left unprotected to venous thromboembolism
Time Frame: two weeks post trauma
time left unprotected to pulmonary embolism two weeks post arrival to hospital defined as: time point from arrival to LHSC to two weeks after, measured in hours where-in patient either has no rIVCF in situ, or has no regular low molecular weight heparin (LMWH) on board. missed doses of LMWH > 2 hours within planned administration time will count toward primary outcome. If LMWH is held for operative intervention, time left held > 24 hours post previous dose will count toward the primary outcome.
two weeks post trauma

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Venous Thromboembolism
Time Frame: in hospital (up to one year)
1. Incidence of symptomatic/clinically impactful pulmonary embolism (as defined by result of computed tomography pulmonary angiogram, autopsy, or ventilation perfusion scan, reported by a radiologist and ordered at the discretion of the MRP on clinical grounds.
in hospital (up to one year)
Mortality
Time Frame: In Hospital (up to one year)
in hospital death
In Hospital (up to one year)
Filter Feasibility Outcome: Time to filter insertion
Time Frame: hours to weeks, up to one year
a) time to filter insertion (defined as time from arrival to London Health Sciences Cente, to time of insertion of rIVCF as documented on the procedure note) b) time to filter removal (defined as time from rIVCF insertion, to removal) c) filter retrieval rate (percentage of patients who receive rIVCF who have rIVCF extraction, will track all patients through follow-up in Trauma Clinic upon discharge if they still have their devices in-situ)
hours to weeks, up to one year
Filter Feasibility Outcome: Time to filter removal
Time Frame: hours to weeks, up to one year
b) time to filter removal (defined as time from rIVCF insertion, to removal)
hours to weeks, up to one year
Filter Feasibility Outcome: Filter retrieval rate
Time Frame: hours to weeks, up to one year
c) filter retrieval rate (percentage of patients who receive rIVCF who have rIVCF extraction, will track all patients through follow-up in Trauma Clinic upon discharge if they still have their devices in-situ)
hours to weeks, up to one year
Rates of worsening intracranial bleed
Time Frame: up to 2 weeks
5) rates of worsening intracranial haemorrhage within patients: Defined as the change in cubic volume of the documented hematoma found in serial computed tomography investigations (if done so as part of routine care)
up to 2 weeks

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Lawson Health Research Institute

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (ACTUAL)

July 1, 2017

Primary Completion (ACTUAL)

February 16, 2020

Study Completion (ACTUAL)

February 28, 2020

Study Registration Dates

First Submitted

February 17, 2017

First Submitted That Met QC Criteria

February 28, 2017

First Posted (ACTUAL)

March 6, 2017

Study Record Updates

Last Update Posted (ACTUAL)

March 1, 2021

Last Update Submitted That Met QC Criteria

February 25, 2021

Last Verified

February 1, 2020

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 108169

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

Yes

product manufactured in and exported from the U.S.

Yes

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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