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BackTable / VI / Podcast / Episode #188
Deep Dive on Anticoagulation Regimens for Venous Interventions
with Dr. Fred Bertino
Dr. Fred Bertino educates us on anticoagulation regimens for patients after deep venous interventions.
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BackTable, LLC (Producer). (2022, February 18). Ep. 188 – Deep Dive on Anticoagulation Regimens for Venous Interventions [Audio podcast]. Retrieved from https://www.backtable.com
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Podcast Contributors
Dr. Fred Bertino
Dr. Fred Bertino is a practicing peidatric interventional radiologist with the University of Washington in Seattle.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Synopsis
In this episode, pediatric interventional radiologist Dr. Fred Bertino joins our host Dr. Chris Beck to discuss new data on anticoagulation regimes before, during, and after venous stenting and/or mechanical thrombectomy.
Dr. Bertino starts by reviewing the difference between the compositions of arterial versus venous clots. Arterial clots are formed as a response to endothelial injury and exposure of von Willebrand factor, so these clots are usually platelet-rich. On the other hand, venous clots are formed due to stasis, and these are usually platelet-poor. Therefore, antiplatelet therapy may not be ideal for venous clots. However, Dr. Bertino notes that stent placement can cause endothelial injury at the apposition points of the stent, so the treatment algorithm can become more complex in these cases.
The doctors note that there are non-thrombotic diseases that require venous stenting, such as May Thurner syndrome. Dr. Bertino says that addressing this early in the pediatric population can be a safe way to prevent future DVT, as long as children are monitored carefully.
Next, Dr. Bertino walks us through his preferred anticoagulation routine for stent placement. Four hours before the procedure, he starts with a dose of Factor Xa inhibitor (apixaban or rivaroxaban) to prevent in-stent thrombosis. The patient is maintained on heparin during the procedure. After the procedure, anticoagulation varies depending on whether a stent was placed, or solely mechanical thrombectomy was performed.
Finally, the doctors discuss preferred anticoagulation for special scenarios such as covered stents (which can be more thrombophilic) and patients with malignancies. Dr. Bertino encourages IRs to reach out to their hematology colleagues to stay updated on anticoagulation research, as well as physical and occupational therapists to help patients form long-term DVT prevention plans.
Resources
Pathophysiology/Animal models/Bench work:
• Zhou, Ji, et al. "Inferior vena cava ligation rapidly induces tissue factor expression and venous thrombosis in rats." Arteriosclerosis, thrombosis, and vascular biology 29.6 (2009): 863-869.
• Henke P, Sharma S, Wakefield T, Myers D, Obi A. Insights from experimental post-thrombotic syndrome and potential for novel therapies. Translational Research. 2020 May 19.
• McBane, Robert D., et al. "Iliac venous stenting: antithrombotic efficacy of PD0348292, an oral direct factor Xa inhibitor, compared with antiplatelet agents in pigs." Arteriosclerosis, thrombosis, and vascular biology 28.3 (2008): 413-418.
• Bech, Fritz R., Spencer W. Galt, and Jack L. Cronenwett. "Increased platelet deposition on polytetrafluoroethylene grafts after balloon catheter thrombectomy." Journal of vascular surgery 11.6 (1990): 804-811.
• Jaffer, Iqbal H., et al. "Dabigatran is less effective than warfarin at attenuating mechanical heart valve‐induced thrombin generation." Journal of the American Heart Association 4.8 (2015): e002322.
Clinical Trials:
• WARFASA Trial: Aspirin for Preventing the Recurrence of Venous Thromboembolism
o Becattini, Cecilia, et al. "Aspirin for preventing the recurrence of venous thromboembolism." New England Journal of Medicine 366.21 (2012): 1959-1967.
• ASPIRE Trial: Low-dose Aspirin for Preventing Recurrent Venous Thromboembolism
o Brighton, Timothy A., et al. "Low-dose aspirin for preventing recurrent venous thromboembolism." N Engl J Med 367 (2012): 1979-1987.
• Jupiter Trial cohort VTE: A Randomized Trial of Rosuvastatin in the Prevention of Venous Thromboembolism
o Glynn, Robert J., et al. "A randomized trial of rosuvastatin in the prevention of venous thromboembolism." New England Journal of Medicine 360.18 (2009): 1851-1861.
• RE-LY Trial: Dabigatran versus warfarin in patients with atrial fibrillation
o Connolly SJ, et al. "Dabigatran versus warfarin in patients with atrial fibrillation". The New England Journal of Medicine. 2009. 361(12):1139-51
• RE-ALIGN Trial: Dabigatran versus warfarin in patients with mechanical heart valves
o Eikelboom, John W., et al. "Dabigatran versus warfarin in patients with mechanical heart valves." N Engl J Med 369 (2013): 1206-1214.
• CLOT Trial: Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer.
o Lee, Agnes YY, et al. "Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer." New England journal of medicine 349.2 (2003): 146-153.
DOAC Trials
• RE-COVER: Dabigatran vs Warfarin
• RE-COVER II: Dabigatran vs Warfarin
• Pooled RE-COVER: Dabigatran vs Warfain
• EINSTEIN-DVT: Rivaroxaban vs Enoxaparin + Warfain
• EINSTEIN-PE: Rivaroxaban vs Enoxaparin + Warfain
• AMPLIFY: Apixaban vs Enoxaparin vs Warfain
• HOKUSAI-VTE: Edoxaban vs Warfarin
ATTRACT Trial and Post-Hoc Studies
• Vedantham, Suresh, et al. "Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis." New England Journal of Medicine 377.23 (2017): 2240-2252.
• Comerota, Anthony J., et al. "Endovascular thrombus removal for acute iliofemoral deep vein thrombosis: analysis from a stratified multicenter randomized trial." Circulation 139.9 (2019): 1162-1173.
• Kahn, Susan R., et al. "Quality of life after pharmacomechanical catheter-directed thrombolysis for proximal deep venous thrombosis." Journal of Vascular Surgery: Venous and Lymphatic Disorders 8.1 (2020): 8-23.
• Weinberg, Ido, et al. "Relationships between the use of pharmacomechanical catheter-directed thrombolysis, sonographic findings, and clinical outcomes in patients with acute proximal DVT: results from the ATTRACT multicenter randomized trial." Vascular Medicine 24.5 (2019): 442-451.
Practical Applications
• Drabkin, Michael J., et al. "Anticoagulation reduces iliocaval and iliofemoral stent thrombosis in patients with cancer stented for nonthrombotic venous obstruction." Journal of Vascular Surgery: Venous and Lymphatic Disorders 9.1 (2021): 88-94.
• Notten, Pascale, Hugo Ten Cate, and Arina J. ten Cate‐Hoek. "Postinterventional antithrombotic management after venous stenting of the iliofemoral tract in acute and chronic thrombosis: A systematic review." Journal of Thrombosis and Haemostasis 19.3 (2021): 753-796.
• Sebastian, Tim, et al. "Rivaroxaban or vitamin-K antagonists following early endovascular thrombus removal and stent placement for acute iliofemoral deep vein thrombosis." Thrombosis research 172 (2018): 86-93.
• Notten, Pascale, et al. "Quality of anticoagulant therapy and the incidence of in‐stent thrombosis after venous stenting." Research and practice in thrombosis and haemostasis 4.4 (2020): 594-603.
• Attaran, Robert R., et al. "Evaluation of anticoagulant and antiplatelet therapy after iliocaval stenting: Factors associated with stent occlusion." Journal of Vascular Surgery: Venous and Lymphatic Disorders 7.4 (2019): 527-534.
• Milinis, Kristijonas, et al. "Antithrombotic therapy following venous stenting: international Delphi consensus." European Journal of Vascular and Endovascular Surgery 55.4 (2018): 537-544.
• Hillegass, Ellen, et al. "Role of physical therapists in the management of individuals at risk for or diagnosed with venous thromboembolism: evidence-based clinical practice guideline." Physical therapy 96.2 (2016): 143-166.
• Kahn, Susan R., et al. "Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial." The Lancet 383.9920 (2014): 880-888.
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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