Theoretically, resolving the underlying obstructive iliac vein lesion by a stent may eliminate the main trigger for recurrence, the post-thrombotic syndrome (PTS), and the need for extended-duration AT. Until these data are available, it is reasonable to place patients undergoing venous stent placement for thrombotic disease on anticoagulation in the 3–12 months post-stent placement, along with concomitant single-agent antiplatelet therapy (low-dose aspirin or clopidogrel). Many current management practices are derived from previous literature regarding arterial stent placement, and while some consensus is present among interventionalists, few data are available to inform practice. However, no consensus was reached regarding antithrombotic therapy following stenting in NIVL patients. However, as previously discussed, the pathophysiology underlying venous stent stenosis is distinct from arterial stenosis, as there are marked differences in vessel characteristics and flow haemodynamics. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. Martufi G, Forneris A, Appoo JJ, Di Martino ES. Oral anticoagulation was routinely used for coronary stent thrombosis prevention during the first era of stents.1 It has since been replaced by the combination of aspirin and a thienopyridine because studies have shown a definite advantage of the antiplatelet combination on coronary events2–4 and on reducing the risk of access-site bleeding complications. Anticoagulation guidelines are not very helpful as they do not stipulate the anticoagulation treatment prescription after a venous stent placement. Copyright® 2021 Radcliffe Medical Media. For a contained leak, I still treat with uncovered stents because a low-pressure system (venous) tends to thrombose as soon as anticoagulation has been stopped. Venous stent patency is likely influenced by a number of factors including those associated with the patient, their operation (and underlying problem), and the type of postoperative anticoagulation used. With the advent of several new venous-specific devices and rapid advancements in techniques, ongoing studies will be needed to understand optimal post-procedural management in these patients. If patients presented with a first episode of deep vein thrombosis (DVT) and underwent thrombolysis prior to stenting, thrombophilia screening should be performed. Arterial thrombosis is typically a result of high shear stress and rupture of atherosclerotic plaques leading to endothelial dysfunction and platelet aggregation. IV. Recently, endovascular intervention with percutaneous transluminal angioplasty and venous stent placement has become a mainstay treatment for this disease entity, and has been shown to have high rates of technical and clinical success (Figure 2). Premium Drupal Theme by Adaptivethemes.com. All patients post stenting should have low molecular weight heparin for two to six weeks, followed by anticoagulation therapy for 6 to 12 months. Login failed. Traditional treatment involved prolonged repeat compression therapy or major open surgical venous bypass reconstruction procedures. Despite adequate conservative treatment involving early anticoagulation, early compression therapy, and early mobilization, PTS will develop in 25%‐50% of patients with an acute iliofemoral DVT. Several other factors are also essential for stent failure prevention, such as elimination of thrombus when treating acute DVT, appropriate stent landing and positioning into disease-free segments of the vein, and ensuring that inflow and outflow of the stent is optimised and sufficient. When warfarin therapy is initiated for venous thromboembolism, it should be given the first day, along with a heparin product or fondaparinux. Members of _ can log in with their society credentials below, Phlebology: The Journal of Venous Disease, Hao Y Yap, Jacky Loa, Patrik J Tosenovsky, Shaun QW Lee, Tze T Chong, and Tjun Y Tang. Long-term anticoagulation is used in the management of many medical conditions including deep vein thrombosis, hypercoagulable conditions, … A major surprise from our iliac stenting experiences was the unexpectedly high long-term patency in a vascular bed prone to thrombosis with low-pressure, slow flow. Levine GN, Bates ER, Bittl JA, et al. 27 A 51-year-old man presented with May-Thurner syndrome. Combination of factor Xa inhibition and antiplatelet therapy after stenting in patients with iliofemoral post-thrombotic venous obstruction. Currently, there are no large prospective randomised controlled trials that clearly establish a superior efficacy of a particular anticoagulation regimen following endovenous stent placement. Antiplatelet therapy is associated with stent patency after iliocaval venous stenting. May-Thurner syndrome and thrombosis: a systematic review of antithrombotic use after endovascular stent placement. After iliocaval venous stenting, stent patency was best predicted by concomitant antiplatelet and anticoagulation therapy rather than anticoagulation alone. A systemic review done in 20147 evaluating anticoagulation after deep venous stenting for PTS showed that anticoagulation did not seem to affect stent patency. Primary and secondary patency rates with these protocols were 96% and 99% for non-thrombotics, 87% and 89% for acute thrombosis and 79% and 94% for post-thrombotics, respectively. However, the use of oral anticoagulation is recommended in addition to DAPT if patients suffer from some other comorbidity after stenting, such as AF with a CHA 2 DS 2-VASc score ≥2, recent venous thromboembolism, LV thrombus or mechanical valve prosthesis, and this is called triple therapy by ESC and ACC/AHA guidelines. Stenting Blocked Veins. 8,9 Much of the practice in the realm of venous stents are based off these data. Gordon BM, Fishbein MC, Levi DS. Sebastian T, Engelberger RP, Spirk D, et al. These are possibly the predominant factors leading to the formation of fibrin-rich clots and stent occlusions, and hence the belief in the use of anticoagulation therapy for venous disease. A systematic review by Padrnos et al. More research is needed to establish the optimal anticoagulation regimen following thrombotic and non-thrombotic venous stent placement, especially with the advent of venous-specific stents. Most published studies are plagued with data heterogeneity and incomplete reporting. Vascular & Endovascular Review 2020;3:e10. Cilostazol reduces angiographic restenosis after endovascular therapy for femoropopliteal lesions in the Sufficient Treatment of Peripheral Intervention by Cilostazol study. Anticoagulation postoperatively was with warfarin and was later switched to rivaroxaban. This reflects the future trend and we would certainly be expecting more long-term data on the use of NOACs in this setting. CVD can be caused by thrombotic and non-thrombotic disease processes, such as deep venous thrombosis and iliac compression syndrome. We eagerly await outcome from larger scale prospective studies from different geographical regions to try and resolve this controversy. Wallentin L, Becker RC, Budaj A, et al. In conclusion, antithrombotic therapy is required post stenting in PTS patients in keeping with usual recognized guidelines for DVT treatment. At our centre, we prefer the use of a DOAC if no contraindications are present, otherwise warfarin is used (Figure 3). The email address and/or password entered does not match our records, please check and try again. Following treatment with CDT and a subsequent angioplasty, two premounted Palmaz intravascular stents were placed in tandem into the left common iliac vein. Thrombophilia among patients with venous stents has not been well studied, and the available data do not allow for any scientific conclusions to be drawn on whether thrombophilia should affect antithrombotic management or whether testing for thrombophilia is needed after venous stent placement. The factors controlling peripheral venous pressure are complex, but the caliber (absolute cross-sectional area) of iliac vein outflow has a major influence. Data from the same study showed that, with the addition of antiplatelet therapy (aspirin and clopidogrel), there were cumulatively improved rates of stent patency and event-free outcomes at 12 months compared with treatment using anticoagulation alone (96% versus 80%).11, Use of Concomitant Anticoagulation/Antiplatelet Therapy, A retrospective study in 2018 examined the effectiveness of anticoagulation alone (warfarin, enoxaparin or a factor Xa inhibitor) versus the concomitant use of aspirin, clopidogrel or DAPT. In cases of external compression, such as May–Thurner syndrome, where there is relatively maintained vessel wall architecture, data have shown that patency rates are exceedingly high (99%), and therefore anticoagulation may not be necessary.2,12 On the contrary, lower rates of patency in post-thrombotic stents likely relate to the near complete fibrous retraction of the native vessel, whereby the wall is composed nearly entirely of collagen and may also benefit more from one anticoagulation regimen over another. However, anticoagulation management following venous stent placement is largely unstudied, and there are no large randomised controlled trials or official guidelines establishing an optimal regimen. Several clinical trials involving venous stent placement are underway; their results are eagerly awaited and will likely change the current paradigm. Sharing links are not available for this article. Current clinical trial protocols also do not typically dictate standard anticoagulation after venous intervention, and this lack of standardization results in heterogeneity in patient treatment. Patients with multiple deep venous thromboses, other indications for anticoagulation or additional risk factors are referred for haematology consultation. The author(s) received no financial support for the research, authorship, and/or publication of this article. Lean Library can solve it. Ethical approval was not necessary as this is an editorial with the views expressed solely of the authors. Anticoagulation guidelines are not very helpful as they do not stipulate the anticoagulation treatment prescription after a venous stent placement. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Consensus of Common Anticoagulation Management, At present, there are no consensus guidelines regarding the role of anticoagulation following venous stent placement. Chronic deep venous disease (CVD) affects millions of patients and causes significant morbidity, including lower extremity oedema, venous claudication, and in severe cases, venous ulceration. The ideal venous stent should have a diameter of at least 14–16 mm to match the native size of the iliac vein, high crush resistance, good radial strength, and yet be long and flexible to cover iliofemoral vein lesions. Simply select your manager software from the list below and click on download. Padrnos and Garcia focussed their recent review on NIVL patients and concluded that there was insufficient evidence to prove the utility of anticoagulation after stenting patients.8 Contrary to this, Masayuki et al.9 and Langwieser et al.10 have suggested that the use of concomitant antiplatelet and anticoagulation therapy was associated with improved stent patency. In such case… In this article, the authors discuss the current literature to date and offer an approach to anticoagulation and antiplatelet management following venous stent placement in CVD. E: kdesai007@northwestern.edu, Antithrombotic Therapy after Venous Stent Placement, Content on this site is intended for healthcare professionals only, Coronary Artery Disease and Myocardial Infarction, Embolism and Thrombosis (includes Pulmonary Embolism), Tips For Increasing Article Visibility And Impact. Please read and accept the terms and conditions and check the box to generate a sharing link. Meta-analyses, systematic reviews and all prospective trials to date have failed to show differences between anticoagulation agents. In patients with a negative thrombophilia screen and a patent stent, anticoagulation can be stopped after 6 to 12 months. Venous stents were inserted in the inferior vena cava (IVC) and iliofemoral vein (one 14-mm × 90-mm and two 14-mm × 60-mm stents). You can be signed in via any or all of the methods shown below at the same time. •After venous stent placement, the use of therapeutic anticoagulation with similar dosing, monitoring and durationas for iliofemoral DVT patients without stents is reasonable. Previously, the WALLSTENT™ (Boston Scientific) was the only available 16-mm diameter stent in the market, and this was mostly used in venous stenting, to match the normal diameter of the iliac veins. NX has no conflicts of interest to declare. This site uses cookies. Currently, National Institute for Health and Care Excellence guidelines do not recommend thrombophilia screening in patients with provoked DVT in the absence of a positive family history.12 However, studies have identified high markers of thrombophilia in up to 10.8% of patient presenting with DVT in a Caucasian-based population. In the currently enrolling Chronic Venous Thrombosis: Relief with Adjunctive Catheter-directed Therapy (C-TRACT) clinical trial, one of the largest trials investigating endovenous stent placement, patients are placed on anticoagulation and low-dose aspirin (81 mg) for the first 6 months in the absence of contraindications and low-molecular weight heparin at fully therapeutic doses for the first 3 months (Vedantham S, pers. Create a link to share a read only version of this article with your colleagues and friends. Early studies in a porcine venous stent model demonstrated a reduction in measured platelet deposition in animals that received a direct factor Xa inhibitor compared to those that received antiplatelet agents.23. Most relevant to the topic of anticoagulation, especially concerning the need for both antiplatelet and anticoagulation therapy, is the open-label ARIVA (Aspirin® Plus Rivaroxaban Versus Rivaroxaban Alone for the Prevention of Venous Stent Thrombosis in Patients With PTS) trial, whose primary objective is to compare aspirin and rivaroxaban to rivaroxaban alone in patients with endovascular venous stents (NCT04128956). 3, 4 This document addresses venous angioplasty with or without stent placement, or venous stenting alone, as a treatment modality for a variety of conditions, including, but not limited to: venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, and as a method to improve venous flow in individuals … Contact us if you experience any difficulty logging in. Combination of factor Xa inhibition and antiplatelet therapy after stenting in patients with iliofemoral post-thrombotic venous obstruction. Long-term anticoagulation may therefore need to be considered in an effort to reduce the potential for recurrent venous thrombosis. One of the biggest challenges when treating patients with any stent is maintaining patency. His symptoms improved over 3 to 4 months, and his leg ulcers healed. The GORE TIGRIS Vascular Stent is contraindicated in patients with contraindication to antiplatelet and/or anticoagulation therapy. Tosenovsky recently assessed the patency and safety of iliocaval stenting in an Australian cohort – all NIVL patients were treated with only antiplatelet medication and the one year patency was 95%. This novel finding warrants further research underlying mechanisms leading to venous stent thrombosis, and has implications for optimal medical … ... Venous stents showing ability to flex without kinking. Direct oral anticoagulants (DOACs) are widely used for prevention and treatment of venous thromboembolism (VTE) 1.Compared to VKAs, DOACs offer distinct advantages including fixed doses, predictable response, fewer drug and food interactions, lack of routine international normalized ratio (INR) monitoring, and better safety profile compared to VKAs 1, 2. Another technical aspect of venous stenting that is often overlooked is the size and type of stent used. showed that there was no difference between 3–12 months of post-stent placement anticoagulation and >12 months of anticoagulation, suggesting that discontinuing anticoagulation at 3–12 months is reasonable in this patient population.19, Thrombophilia Testing and Adjustment of Anticoagulation, The role of thrombophilia and thrombophilia testing in the setting of venous stent placement has been inconsistently and incompletely reported in the literature.11 The limited number of studies that have examined stent outcomes in patients with underlying thrombophilia have drawn varied conclusions as to the risk of venous thrombosis. 3 These have a shorter half-life than warfarin, which could be an advantage in cases of bleeding. Rivaroxaban or vitamin-K antagonists following early endovascular thrombus removal and stent placement for acute iliofemoral deep vein thrombosis. Antithrombotic therapy following venous stenting: International Delphi Consensus. McBane RD II, Leadley RJ Jr, Baxi SM, et al. In this article, we present several studies that may help inform management. We would like to congratulate the investigators for their efforts in attempting to obtain a consensus on a controversial and complex issue with many different variables. With the advent of new agents and their integration into other management guidelines, alternate choices of agents have become more frequently utilised. Endovascular management of May-Thurner syndrome in adolescents: a single-center experience. Razavi MK, Jaff MR, Miller LE. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. No consensus could be reached on long-term anticoagulation.7. Find out about Lean Library here, If you have access to journal via a society or associations, read the instructions below. If one believes that antiplatelet medication has no effect on venous stent patency, then it is fair to assume that no medication would be equally effective.6. NOACs have been reported to have a lower incidence of major bleeding, a wider therapeutic window and reduced need for monitoring compared to warfarin, leading to increased convenience of administration.14 In this consensus study, physicians reported use of varying antithrombotic agents including both vitamin K antagonists and NOACs, despite NOACs not being officially licensed for use in venous stenting. Endo M, Jahangiri Y, Horikawa M, et al. Despite increasing rates of venous stent placement, few studies have been performed to inform the optimal antithrombotic therapy regimen, and no high-grade, evidence-based guidelines exist for the management of these patients. 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The left common iliac vein lesions – any consensus not of Radcliffe medical Media varies across our titles showed anticoagulation., data regarding newer anticoagulation and antiplatelet therapy to improve venous stent placement iliofemoral stent thrombosis after iliocaval venous:... Came up with the original idea and edited the manuscript ; JL, PJT, SQWL and helped! And referral to a specialist for impact of iliac venous stenosis after catheter-directed for... Endovascular review 2020 ; 3: e10 involving venous stent thrombosis, chronic deep thrombosis! Risk factors are referred for haematology consultation may be considered in this position is limited outcome from larger scale studies! 25 ] systematic review and meta-analysis a challenge this is further complicated rapidly. Deep vein thrombosis is nearly exclusively in the Sufficient treatment of iliofemoral or caval veins in with. For both acute and chronic SVC syndrome Delphi consensus Horikawa M, et al us you! 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