Anticoagulation after Interventions for MTS: What is the...

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