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Anticoagulation after Interventions
for MTS: What is the Optimal
Method?
David Rigberg, M.D.Clinical Professor of Surgery
Division of Vascular Surgery
University of California Los Angeles
DISCLOSUREDavid Rigberg, MD
• No relevant financial relationship reported
Venous Compression Syndromes
• May-Thurner Syndrome
– Left CIV compression by right CIA
– Compression/webs in symptomatic pts
(under-recognized)
• External Iliac compression
• Compression of right or left EIV by
crossing hypogastric arteries
• Extrinsic Compression
• Malignancy
• Fibroids and benign lesionsLINC 2012 Evidence for Venous
Intervention
Pelvic Venous Anatomy
Wilengberg T, LINC 2014
Interventional Management of Venous
Occlusive Disease
Options for Percutaneous Intervention : Chronic Venous Occlusions / Stenoses
RCIA
LCIA
LCIV Compression
–Venography with Intravascular Ultrasound
–Venous angioplasty and stenting
16 x 90 Wallstent
14 x 40 Atlas Balloon
Post Stent IVUS
Immediate, 3, 6, 12 months and annually…
May-Thurner with DVT
May-Thurner with DVT
• Popliteal / femoral + IJ approach
• Diagnostic venography
• IVUS in all patients without chronic total occlusions
• Patients without known DVT
• Angioplasty and stenting alone
• Dual antiplatelet Rx
• Patients with acute DVT
• CD-thrombolysis / perc mech thrombectomy
• Angioplasty and stenting of underlying lesions
• Lovenox/Coumadin and dual antiplatelet Rx
Procedural Details
Technique and Lessons Learned
• Use of intravascular ultrasound
Essential for stent sizing and positioning
Post-stent assessment for residual stenosis or wall apposition
• Aggressive anticoagulation
Glycosaminoglycan (Arixtra) for 4-6 weeks in Thrombotic MT patients postop (before transition to Coumadin)
Full antiplatelet therapy in Non-thrombotic MT patients
• Correct all underlying venous lesions
Extend stent into IVC
Extend with nitinol stents into CFV if needed
Aggressive lysis to improve inflow (from femoral vein / PFV)
What is the appropriate antithrombotic management of these patients? Is there evidence???
Patency
Neglen et al. JVS, 2010.
Primary patency
Raju et al, J Vas Surg 2019
Secondary Patency
Protocol: Non-thrombotic
ASA 325 mg
Clopidogrel 75 mg
Essentially replaced the thrombotic risk of compression
with risk of stent
Low risk meds
Continuation of ASA – reasonable
Systematic review by Eijgenraam et al 4/12 studies
antiplatelet after venous stenting procedures.
Anti-platelet/stent evidence arterial
Experimental models, asa, clopid performed poorly compared to Xa inhibs
Venous stent clotting more linked more closely to thrombin activity
Protocol - DVT
Enoxaparin 40 mg (preop period)
Bivalirudin 75 mg (at time of procedure)
Oral anticoagulant – minimum 3 months
ASA
Cilostazol (6 weeks) – time for re-endotheliazation s/p
venous trauma
Patient Characteristics
Rollo et al. J Vas Surg, 2017.
Hypercoagulable State
MTS following initiation of OCP’s”unmasks” hypercoagulable conditionFactor V Leiden increases 7 x DVTFactor V Leiden plus OCP 35 x DVTLeft side predominates for both and together
Murphy et al. JVS, 2009
Hypercoaguable State
Hetero or homozygote?
Co-existing conditions
-APLA
-PN hemoglobinuria
-MPD’s
-clotting factor levels
Only manifestation?
For many, can d/c after inciting factor is removed
-The first acute thrombosis is treated according to standard
guidelines. The duration of oral anticoagulation therapy should be
based on an assessment of the risks for VTE recurrence and
anticoagulant-related bleeding.
Data(?)
Swiss venous stent registryRivaroxaban vs CoumadinNo difference in primary and secondary patencyOne major bleeding complication in each group
89 % supported d/c anticoagulation for non-thrombotic
MTS after 6–12 months if post U/S good
Consensus (67%) regarding LMWH in initial treatment
period
Indefinite anticoagulation in patients following multiple
DVTs by 85%
reflects the recommendations set out by guidelines
regarding the treatment of recurrent VTE
Consensus (67%) for thrombophilia screening after DVT
to guide anticoagulation duration. 30–50% venous
stenting for MTS DVT with thrombophilia.
Conclusions
If no DVT, antiplatelet therapy
-excellent results, low risk
If DVT:
-anticoagulation for DVT before intervention
-Post stent usually anticoagulation, asa, Plavix
Anatomy is fixed, so if no hypercoag, issue is stent
Need to ensure no hypercoag problem
“There is no standard type, dose, or duration of
antithrombotic management after endovascular stenting”
for MTS…”*
*Padrnos et al. Res Pract Thromb Haemost. 2019.
UCLA Ronald Reagan Medical Center
ULCA Division of Vascular Surgery
David Geffen School of Medicine at UCLA
Thank You