Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Gordon H. Guyatt , MD, FCCP ; Elie A. Akl , MD, PhD, MPH ; Mark Crowther , MD ; David D. Gutterman, MD, FCCP; Holger J. Schünemann, MD, PhD, FCCP;
....Postthrombotic syndrome and quality of life in patients with iliofemoral venous thrombosis treated with catheter-directed thrombolysis
Rikke Broholm, MD, PhD,a Henrik Sillesen, MD, DMSc,a Mogens Trab Damsgaard, MS,b Maja Jørgensen, MD,c Sven Just, MD,d Leif Panduro Jensen, MD,a and Niels Bækgaard, MD,a Copenhagen, Denmark
.....Position of valves within the subclavian and axillary veins
Halil Celepci and Erich Brenner, MD, PhD, MME, Innsbruck, Austria
.....The American Venous Forum and the lessons learned from the battle of Thermopolae
Peter J. Pappas, MD, Brooklyn, NY
.....Long-term low-molecular-weight heparin and the post-thrombotic syndrome: a systematic review.
Hull RD, Liang J, Townshend G.
.....Catheter-Based Therapies for DVT
The current state of endovascular technology for treating deep vein thrombosis and the improvements that are still needed.
BY MAHMOOD K. RAZAVI, MD
.....Iliocaval Stenting for Advanced Chronic Venous Disease
Stenting iliocaval venous lesions on the basis of clinical suspicion and IVUS.
BY JOSE I. ALMEIDA, MD, FACS, RPVI, RVT, AND CRISTAL BOATRIGHT, MMS, PA-C
.....The changing face of care for venous disease
Peter Gloviczki, MD Joe M. and Ruth Roberts Professor of Surgery Division of Vascular and Endovascular Surgery Mayo Clinic Rochester, Minn
.....The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum
Peter Gloviczki, MD,a Anthony J. Comerota, MD,b Michael C. Dalsing, MD,c Bo G. Eklof, MD,d David L. Gillespie, MD,e Monika L. Gloviczki, MD, PhD,f Joann M. Lohr, MD,g Robert B. McLafferty, MD,h Mark H. Meissner, MD,i M. Hassan Murad, MD, MPH,j Frank T. Padberg, MD,k Peter J. Pappas, MD,k Marc A. Passman, MD,l Joseph D. Raffetto, MD,m Michael A. Vasquez, MD, RVT,n and Thomas W. Wakefield, MD,o Rochester, Minn; Toledo, Ohio; Indianapolis, Ind; Helsingborg, Sweden; Rochester, NY;Cincinnati, Ohio; Springfield, Ill; Seattle, Wash; Newark, NJ; Birmingham, Ala; West Roxbury, Mass; North Tonawanda,NY; and Ann Arbor, Mich
.....A systematic review and meta-analysis of the treatments of varicose veins
M. Hassan Murad, MD, MPH, a,b,c Fernando Coto-Yglesias, MD, a,d Magaly Zumaeta-Garcia, MD, a Mohamed B. Elamin, MBBS, a Murali K. Duggirala, MD, a,c Patricia J. Erwin, MLS, a Victor M. Montori, MD, MSc, a,c,e and Peter Gloviczki, MD, f Rochester, Minn; and San José, Costa Rica
.....SCAI: Stenting OK for Deep Vein Thrombosis
Published: May 07, 2011
Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.
BALTIMORE -- Stenting is safe and more effective than balloon venoplasty alone for patients with deep vein thrombosis in the femoropopliteal vein, a randomized trial showed. Among patients who had residual stenosis after thrombolytic therapy, the rate of recurrent DVT at approximately three years of follow up was lower in the stenting group (4% versus 10%), according to Mohsen Sharifi, MD, of Arizona Cardiovascular Consultants in Mesa. In both groups, DVT was either asymptomatic or mildly symptomatic, and was easily managed with re-do percutaneous endovenous intervention, Sharifi reported here at the Society for Cardiovascular Angiography and Interventions meeting.
Action Points
Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
Explain that stenting appeared safe and more effective than balloon venoplasty for patients with >70% residual stenosis and following percutaneous endovenous intervention for deep venous thrombosis.
Note that the mechanism of recurrent DVT in stented patients appeared because of thrombus extension and external compression rather than neointimal proliferation.
The study shows that stenting is a safe and effective option for patients who require additional treatment after undergoing thrombolytic therapy, he said.
"Stenting is never a first option for the treatment of DVT,". "The first option would be some form of mechanical or pharmacologic intervention, which we call in general percutaneous endovenous intervention. Once that has been accomplished, and if there is residual stenosis, then the practitioner should think about stenting, even if the lesion is below the inguinal ligament."
According to Sharifi, percutaneous endovenous intervention with stenting and other strategies has been shown to be an effective way to treat acute proximal DVT.
The TORPEDO trial, which Sharifi presented last year at the Transcatheter Cardiovascular Therapeutics meeting, was the first randomized trial to show that percutaneous endovenous intervention reduced post-thrombotic syndrome and recurrent venous thromboembolism.
But data had been lacking regarding the use of stents in the femoropopliteal veins, he said.
"In general, the venous circulation has been a forgotten field for the interventional cardiologist," Sharifi said. "With the results of the EVISTA trial, I think there would be a spark for more enthusiasm and work in the venous circulation, and I think that practitioners would take DVT more seriously, especially in the interventional cardiology field."
The EVISTA-DVT trial enrolled 141 patients with high-grade residual stenosis of more than 70% in the femoropopliteal vein after percutaneous endovenous intervention and thrombolytic therapy. The mean age of the participants was about 65 and 56% were men.
The 71 patients in the stenting group received a total of 85 stents.
The average length of follow up was 35 months. Patients underwent venous duplex scanning every six months or sooner if they became symptomatic and yearly x-rays. Those with suspected recurrent DVT underwent venography with intravascular ultrasound evaluation.
All patients were on warfarin and daily aspirin for six months; 42 patients were also on clopidogrel (Plavix) for two-to-four weeks. The researchers advised all of the patients to wear 30-to-40 mm Hg compression stockings.
During follow up, six patients in the stenting group and 15 in the control underwent invasive evaluation for DVT. Ultimately, 4% of the stenting group and 10% of the control group had recurrent DVT that was either asymptomatic or mildly symptomatic.
Sharifi noted that the mechanism of stent thrombosis was different in these patients versus what would be seen with stents in the arterial circulation. Thrombosis was caused by thrombus extension from adjacent non-treated sites and external compression due to venosclerosis. There was no neointimal proliferation.
All of the cases of stent thrombosis were manageable by re-do percutaneous endovenous intervention, Sharifi said, adding that stent thrombosis in these patients is "not a catastrophic event."
"The message is that after appropriate thrombolysis, if there is residual significant stenosis in the infra-inguinal segment, you should feel free to move ahead and take care of those significant lesions," Sharifi concluded.
Sharifi reported that he had no conflicts of interest.
Primary source: Society for Cardiovascular Angiography and Interventions
Source reference:Sharifi M, et al "Endovenous infra-inguinal stenting and angioplasty in deep venous thrombosis trial (EVISTA-DVT)" SCAI 2011.
