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Unprovoked VTE
Extended treatment for long‐term prevention of
recurrent VTE is indicated for patients with unprovoked
VTE, unless bleeding risk is high.
Negative (normal) D‐dimer levels measured serially after
stopping anticoagulation are associated with a low risk of
recurrent VTE and may be used to guide the decision to
stop anticoagulant treatment in women but not in men,
because they have an unacceptably high risk of recurrent
VTE even if D‐dimer levels are normal (9.7% per patient‐
year; 95% CI, 6.7–13.7%) [26, 27]. However, the
requirement for measurement of D‐dimers while not
receiving treatment, the use of different cut‐offs to define
a normal test result, and the use of different D‐dimer
assays in the validation studies call into question the
utility of this approach.
Oral Anticoagulants
The 2016 American College of Chest Physicians and the
2014 and 2017 European Society of Cardiology
guidelines suggest extended therapy with DOACs over
VKAs or low‐dose aspirin in patients without cancer [6,
8, 9]. Compared with placebo or aspirin, extended
therapy with DOACs or VKAs significantly reduces the
risk of recurrent VTE [14,28–30]. Compared with VKAs,
dabigatran and edoxaban are as effective and are
associated with a lower risk of major bleeding (0.9% vs.
1.8%; HR, 0.52; 95% CI, 0.27–1.02 for dabigatran; 0.3%
vs. 0.7%; HR, 0.45; 95% CI, 0.22–0.92 for edoxaban)
[14, 30, 31]. In contrast to extended treatment with
VKAs, the introduction of DOACs has enabled extended
anticoagulant therapy at a lower dosage, as apixaban and
rivaroxaban at prophylactic dosages (10 mg once daily
and 2.5 mg twice daily, respectively) are associated with
similar efficacy as at therapeutic dosages (20 mg once
daily and 5 mg twice daily, respectively) and a bleeding
risk comparable with placebo and aspirin (absolute risk
of major bleeding <0.5% per year) [29, 32].
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Conclusion
When left untreated, VTE was associated with early
recurrences (29%) and death (26%) in landmark studies
[33, 34]. Based on this evidence, early anticoagulant
treatment should be started in patients with suspected
VTE who are estimated to not be at high risk for bleeding
while they wait for diagnostic confirmation [8, 35].
Pivotal studies showed that failure to rapidly receive
therapeutic anticoagulation [36, 37] and time spent
while receiving subtherapeutic anticoagulation are both
associated with recurrent VTEs [38]. Thus, the
availability of anticoagulants with rapid onset of action
and predictable dose‐effect response are essential for
reducing early adverse effects.
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15
Lower‐Extremity Venous Stenting
Asma Khaliq1, Sandrine Labrune1, and Cristina
Sanina
2
1
Department of Cardiology, Lenox Hill Heart &
Vascular Institute, Donald and Barbara Zucker
School of Medicine at Hofstra/Northwell Health,
New York, NY, USA
2
Division of Cardiology, Department of Medicine,
Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA, USA
Introduction
There three major type of outflow obstruction: 1) Post‐
thrombotic non‐occlusive obstruction; 2) Post‐
thrombotic occlusive; 3) Non‐thrombotic iliac vein
lesions (May‐Thurner Syndrome).
Post‐thrombotic syndrome (PTS) (non‐occlusive and
occlusive) occur as a complication of acute deep vein
thrombosis manifesting in leg pain that limits activity,
edema, and leg ulcers. PTS will develop in 20–50% of
patients and severe PTS, including venous ulcers in up to
10% of patients [1]. Risk of PTS is high with proximal
DVT involving iliac or common femoral vein [2]. The
Villalta scale has been developed, used and validated to
diagnose PTS (Table 15.1) [3]. In selected patients with
severe PTS endovascular treatment of chronic
femoroiliocaval venous disease can be safely performed
with acceptable patency result and symptoms alleviation
[4].
For May‐Thurnes syndrome (non‐thrombotic left
common iliac vein compression by right common iliac
artery [Figure 15.1]), endovascular treatment is highly
successful, leading to significant clinical improvement:
50% of patients has symptoms resolution, 33%
experience symptoms relieve and 55% has complete
healing of venous ulcers. Patency of iliac stent is 75% in 3
years. Close follow‐up is mandatory to recognize the
recurrence of the symptoms which can indicate stent
thrombosis or re‐stenosis [5, 6].
Step 1. Place the patient in the supine position for
planned femoral vein access in case of iliofemoral DVT.
Choose prone positioning if planning on popliteal vein
access. The popliteal vein is located in the popliteal fossa
between the popliteal artery and tibial nerve. Generally,
the vein is lateral to the artery proximally in the popliteal
fossa and medial to the popliteal artery distally.
Table 15.1 Villalta PTS Scale.
Source: Adopted from Utne et al. [3].
Villalta PTS scale
Assessment of:
Five symptoms (pain, cramps, heaviness, pruritus,
paresthesia) by patient self‐report
Six signs (edema, skin induration,
hyperpigmentation, venous ectasia, redness, pain
during calf compression) by clinician assessment
Severity of each symptom and sign is rated as 0
(absent), 1 (mild), 2 (moderate), or 3 (severe). In
addition, ulcer is noted as present or absent.
Points are summed to yield the total Villalta score:
0–4: No PTS
5–9: Mild PTS
10–14: Moderate PTS
≥15, or presence of ulcer Severe PTS
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Figure 15.1 CT scan axial view showing left common
iliac vein (CIV) compression by right common iliac artery
(CIA).
Source: Case courtesy of Donna D’Souza, Radiopaedia.org, rID: 4373.
TIP: Place the patient in a slight reverse Trendelenburg
position. It helps dilate the vein for easier puncture.
Step 2. Anesthesia:
Light conscious sedation is favored over general
anesthesia.
Step 3. Intraprocedural use of anticoagulation.
a. Use of unfractionated heparin or bivalirudin during
the procedure varies depending on the patient’s
pathology and the proceduralist preferences.
b. For patients with DVT, after thrombolysis,
underlying occlusive venous disease might be
noticed on intravascular ultrasound (IVUS).
Step 4. Use the ultrasound to identify the best femoral
vein access point:
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