COMPRENDRE LA LITTÉRATURE DES RECANALISATIONS VEINEUSES…

JM Pernès . PCVI 92. Hôpital Privé Antony

QU’ ATTEND LE LECTEUR « ECLAIRE(?) » DES INFORMATIONS PUBLIEES DANS UN ARTICLE?

• RESPECT DES GUIDELINES ET RECOMMANDATIONS

• INDICATIONS CLINIQUES ++

• INDICATIONS et CONTRE-INDICATIONS ANATOMIQUES ++++

-LE MYSTERE DES NIVC !!!!! AVANT LA THROMBOSE (Nonthrombotic Iliac VeinCompression …., NIVL (Nonthrombotic Iliac Vein Lesion et du IVCS (Iliac VeinCompression Syndrom)

• TECHNIQUE UTILISEE (VOIES D’ABORD, STENTING, …) : PROGRES?

• COMPLICATIONS

• ENVIRONNEMENT PERIPROCEDURE

• QUALITE DU SUIVI ET LES RESULTATS A DISTANCE

2015- 2016: 2 (TENTATIVES ) DE META-ANALYSES

INTERESSANT QUAND MEME CAR ANALYSE UNE POPULATION ANATOMIQUE CIBLEE (IDEALE)

Main inclusion criteria included studies with

VFC ,IE et IP•(1) primary diagnosis of obstructive lesions of the common femoral vein, external iliac vein, and the common iliac vein

• (2) stent placement in the common femoral vein, external iliac vein, common iliac vein, and the inferior vena cava,

•(3) outcomes reported by acute/subacute (<30 days) or chronic (≥30 days; AT and CPT groups only),

• (4) sample size ≥10, and (5) at least 1 extractable safety or effectiveness outcome

•Main outcomes of this study included technical success, periproceduralcomplications (major bleeding, pulmonary embolism, death, and early thrombosis), patient symptom resolution (ie, pain, edema, and ulcer) at final follow-up, and primary and secondary patency through 5 years

• Many additional outcomes ( stented length, primary assisted patency, change in CEAP class, change in Villalta scores, and change in quality of life) were initially considered for inclusion, but were discarded after pilot testing because of lack of available data.

• Study Selection After screening 793 studies for eligibility, 37 studies reporting 45 treatment effects (nonthrombotic,AT, and CPT) from 2869 unique patients (nonthrombotic, 1122; AT, 629; and CPT, 1118) were included in the meta-analysis.

WALLSTENT++++

50/ 50:NTIV et SPT

INFO MAJEURE 85% PERMEABILITE SECONDAIRE A 5 ANS!!!

• 16 studies were included (14 before-and-after studies, 1 controlled before-and-after study, and 1 case series) encompassing successful deep venous stenting in 2,373 and 2,586 post-thrombotic or nonthrombotic limbs and patients respectively.

• The data were too heterogeneous to perform a meta-analysis.

INCLUSION ANATOMIQUE PLUS LARGEET EVALUATION CLINIQUE SUR CEAP, VCSS, VILLALTA

• Participants of all ages suffering from CVD related to post-thrombotic or NIVL obstruction, confirmed on imaging, were included if iliac vein stenting with or without extension of) into the inferior vena cava (IVC) or common femoral vein (CFV) and more caudally

• A minimum of 20 eligible stented limbs and 6 months’follow-up was required.

• The primary outcome : any change in severity of CVD as determined by validated measures or scores such as (C of CEAP),the Venous Clinical Severity Score (VCSS), or validated measures of PTS severity such as the Villalta score.

• QOL scores such as the Chronic Venous InsufficiencyQuestionnaire (CIVIQ)20

reports on other signs or symptoms of CVD such a pain or oedema; primary, assisted-primary (AP) and secondary stent patency and complications.

PAS DE LIMITE DE POSITION DES STENTS

MELANGE DE NIVL ET PT

• Endovascular stenting was attempted in 2,649 limbs of 2,431 patients with procedural success in 2,586 (97.6%).

• Two out of 16 studies considered only patients with NIVL (a total of 507 and 483 procedures attempted in limbs and patients respectively), seven considered only patients with PTS (509limbs and 474 patients) and seven evaluated a mixture

Severity of CVD

5 studies reported one or more of the defined measures of CVD severity with sufficient follow-up duration (a total of 295 stentedpatients

Quality of life measures

3studies reported changes in CVD-specific QOL scores following stentingand one also included a general QOL score (SF-36).

• Stent patency

14 studies reported data on stent patency (a total of 2,410 limbs stented), with follow-up duration ranging between 6 months and a median of 4 years.

The last available, overall primary patency rates ranged from 32% to 98.7%..

Complications

•1 study reported one unrelated death;

• 6 studies specifically stated that there was no 30-day or perioperative mortality stent fracture and no reports of pulmonary emboli.

•The percentage of major complications per limb stented ranged from 0% to 8.7%

•Of note, three studies reported contralateral DVTs (1.1% per limb stented,2.2%,and 2.2%).

• Stent migration occurred in four studies (range 0.9% to 4.3%), with further stenting required to fix the stent or surgical removal.

ON APPREND DONC QUE LE NIVEAU D’EVIDENCE EST FAIBLE

ABSENCE DE GROUPE CONTROLE

Ann Vasc Surg 2014; 28: 695–704

Journal of Vascular Surgery: Venous and Lymphatic Disorders November 2017

REVUE BIBLIO DES 5 DERNIERES ANNEES….

Y A PAS QUE LA CEAP ou LE VILLALTA…… PRISE EN COMPTE DE LA CLAUDICATION ET DE LA GENE FONCTIONNELLE (QUESTIONNAIRE DE QUALITE DE VIE)

• RAPPEL DES RECOMMANDATIONS DE BONNE PRATIQUE

SCORE DE VILLALTA

QUESTIONNAIRE DE QUALITE DE VIE

CIVIQ TEST = test de qualité de vie de l’insuffisance veineuse

R Launois, J Reboul-Marty and B Henry Construction and valkidationof a quality of life questionnaire in chronic lower limb venous insufficiency (CIVIQ). Quality of life research, 1996 : 5, pp 539-554.

2019: REFLEXIONS(1)

• L’indication de traitement ne doit pas être portée à notre sens sur la SEULE présence d’un SPT défini par un score de Villalta supérieur à 4 mais sur la gêne clinique que ressent le patient et sa demande.

• Evaluation de la claudication+++++

• L'indication est posée sur la demande du patient et l'évaluation du rapport bénéfice risque.

2019: REFLEXIONS(2)

ANALYSE DES RESULTATS CLINIQUES ET TECHNIQUES ETROITEMENT LIEE A L’INDICATION ANATOMIQUE

POT-POURRI DES ARTICLES PUBLIES : FORCES ET FAIBLESSES

SYNTHESE DIFFICILE………

PICORER CHAQUE INFO INTERESSANTE!!!

• patients in whom conservative management, maintained for 6 months, failed to improve clinical CEAP or VCSS score.

• Limbs with extensive obstructive lesions involving femoral, popliteal, and distal veins and poor inflow were not considered for treatment.

-“extensive obstructive lesions and poor inflow”=when femoral, profunda, popliteal, and distal veins were simultaneously affected, and inflowwas too low to maintain stent patency.

we rejected these patients due to their high risk of stent thrombosis.

(J Vasc Surg: Venous and Lym Dis 2014;2:2-7.)

• cava, iliac, and femoral veins and with a clinical CEAP class 3 or higher.

• Patients with a CEAP class 0 to 2 could also be considered for treatment if they had venous pain requiring narcotics for control

• All treated segments were covered with braided steel stents (Wallstent)or Nitinol stents(ZilverVena)

• The upper landing zone was 4cm above the common iliac confluence inside the IVC.

• When IVC was involved or when bilateral obstructions were present, the double barrel technique described by Neglen et al was used.

• If the double-barrel technique could not be performed, the new contralateral stent was placed through a fenestration created in the IVC portion of the previously placed stent (Y-fenestration technique).

MESSAGE:

STENT 4 CM DANS LA VCI,PAS DE SOUCI APPAREMMENT ……

(15 mm classiquement admis….)

24 PATIENTS the vena cava was stented with a diameter of 24 mm. Bilateral extensions were performed with 16 mm nitinolstents (sinus XL, sinus Venous and sinus XL-flex, Optimed, Ettlingen, Germany and Zilver Vena (Cook, Galway, Ireland), which were placed parallel inside the vena cava stent with a 2 cm overlap

Materials and Methods Between 11/2009 and 08/2014 we treated 40 patients for chronic total bi-iliocaval obstructions. Pre-operative magnetic resonance venography showed bilateral extensive post-thrombotic scarring in common and external iliac veins as well as obstruction of the inferior vena cava (IVC)

STENT EXPANDABLE SUR BALLON

• In order to minimize stent strut interactions at the confluence, an alternative technique was used where two balloon-expandable stents (AndraStent,) were placed in the vena cava stent toward the common iliac veins (BECS group)

• Bilateral iliac extensions were then performed with 16 mm nitinolstents (sinus Venous or Zilver Vena stents) In both groups

16 PATIENTS

SPECIFICITE HOLLANDO-CHIRURGICALE…..

• Extension of post-thrombotic changes at the level of the femoral vein inflow was seen in 15 (38 %) patients.

• The decision to perform adjunctive surgical desobstructionwas pre-operatively made based on MRV imaging.

- When trabeculations were visible in the common femoral vein extending to both the femoral and the deep femoral (profunda) vein, peripheral venous inflow was deemed insufficient

- -. In these 15 patients, a hybrid procedure consisting of endovascular recanalization and stenting combined with surgical groin incision, endophlebectomy, and creation of an arteriovenous fistula (AVF)

• Acute bilateral DVT was the indication for treatment in 6 (15 %) patients, skin changes and ulceration in 18 (45 %) patients, venous claudication in 15 (38 %) patients, and chronic lower extremity pain without claudication in one (3 %) patient.

CONE BEAM CT EN FIN DE PROCEDURE

Twelve-month patency rates in the SECS group were 85, 85, and 95 % for primary, assisted-primary, and secondary patency, respectively (Fig. 3B). In the BECS group, primary patency was 100 % during a mean follow-up period of 134 ± 118 (range 29–337) day

Conclusion-Stenting of chronic bi-iliocavalobstruction shows relatively high patency rates at medium follow-up.-Short-term patency seems to favor confluence stenting with balloon-expandable stents.

It should however be noted that the BECS technique might not be the best option in women at child bearing age, since these stents may non-reversibly compress during pregnancy or birth.

MESSAGES

•STENT EXPANDABLE :PAS BETE…..

(MAIS NE DONNE PAS LES DIAMETRES…): SI VCI 24 mm, QUID DES DIAMETRES ILIAQUES :2 X 12 ?(PETIT BRAS….)

•CONE BEAM EN FIN DE GESTE : BON PLAN

• Iliac vein compression syndrome (IVCS),(MayThurneror Cockett syndrome): clinical condition resulting from pelvic and lower extremity venous flow obstruction caused by the compression of the iliac vein by the overlying iliac artery.

• The compression is associated with left lower extremitydeep venous thrombosis (DVT) and other chronic venous diseaseswithout thrombosis, such as asymmetrical edema of the left lowerlimb, pain, varicose veins, and venous ulcer

• Purpose of this study :

-estimate the prevalence of IVCS in patients with unilateral left lower limb chronic venous disease (CVD)

-assess the sensitivity and specificity of modified computed tomography venography (CTV) in the diagnosis of IVCS,

-evaluate the feasibility and effectiveness of the endovascular treatment of IVCS.

Ann Vasc Surg 2014; 28: 695–704

Diagnosis of IVCS on the visualization of a >50% reduction in the luminal diameter of the vein, the formation of collateral circulation, and a pressure gradient of >2 mm Hg across the stenosis while the patient was in a supine position

We identified IVCS in 14.8% (48/324)of patients with unilateral left lower limb CVD.

- The 56 patients who met the inclusion criteria for our study underwent duplex ultrasonography, ascending venography, and CTV.

-We divided the patients into 2 treatment groups: thrombotic IVCS (n : 14) and nonthrombotic IVCS (n :42).

-8 patients refused stent implantation.

- The remaining 48 patients (n: 12)thrombotic IVCS and n: 36 non thrombotic IVCS) enrolled in the trial

• Conclusions:

-IVCS is more common than previously thought among patients with unilateral left lower limb chronic venous disease.

• Endovascular therapy, a minimally invasive approach to treating venous lesions, is a feasible and effective treatment for left-sided IVCS and has a high technical success rate and an acceptable complication profile.

MESSAGES:

•15 % des patients avec symptômes d’Insuffisance Veineuse Chronique auraient un syndrome de compression …..INFO OU INTOX?

•FREQUENCE DE LA DOULEUR DORSALE PERIPROCEDURALE: UN VRAI « PROBLEME »

• Access of one or both common femoral veins (CFVs) or proximal femoral veins and the right internal jugular vein (RIJV) was obtained in all case

. We typically start the procedure from the CFV and attempt crossing and dilation of the iliac veins and the IVC, then from the RIJV approach continue dilation of the contralateral iliac vein

J Vasc Surg: Venous and Lym Dis 2018;6:173-82

• Twenty-five patients (38%) had an IVC filter;

• 30%had thrombophilia.

• The obstruction involved the infrarenalIVC in 44 patients and both the infrarenal and suprarenal IVC in 22 patients.

TECHNIQUE: UN GROS STENT VCI + APPOSITION 2 STENTS ILIAQUES

• The IVC is stented using a single-barrel technique with a large-diameter stent, such as the Wallstent (20 40 mm and 22 45 mm; often in combination with the Gianturco (20 mm stent.

• At the bifurcation, we simultaneously bring stents across the common iliac veins (CIVs) ,inferior edges of the CIV stents just touch at the bifurcation.

• We avoid bringing the stents parallel into the IVC

All IVC filters, when present, were pushed and crushed to the side of the IVC and covered with a stent. Most stents used were Wallstents(53 [56%]), followed by Gianturco stents (37 [39%]), 15.6 mm, respectively.Most stents used for the treatment of the iliac veins were Protégé stents (45 [64%]), Wallstents (17 [24%]), Gianturco stents (7 [10%]),

MESSAGES:

• PERMEABILITE 36 MOIS: 85%

•INTERET DE L ABORD JUGULAIRE

•PAS DE SOUCI DE BROYER LES FILTRES

•MAIS TECHNIQUE UN PEU “BAROQUE”

•PROPOSITION D UNE CLASSIFICATION

ON RESTE DANS LE PARTICULARISME CHIRURGICO-BATAVE

369 consecutive patients

-symptoms of venous hypertension like pain interfering with daily activities, and/or clinical signs classified according to the CEAP classification as C3 (edema) or C4aeC6

-Additionally, venous claudication was a symptom indicating treatment (the onset or worsening of pain during routine exercise, which subsides during rest, especially while sitting or lying down)

Patients with an occlusion extending far into the FV and DFV were not eligible for treatment as it is impossible to re-establish the inflow to the stent.

Clinical assessment before intervention :At baseline, CEAP classification and the Venous Clinical Severity Score (VCSS) were scored for all patients.PTS was diagnosed using the Villalta score.

With increasing clinical experience, the importance of venous claudication was recognised and a separate scoring for this item was added to the baseline and follow-up data collection

3 GROUPES DE PATIENT S « ANATOMIQUES »

• IVCS patients with non-thrombotic syndrome had percutaneous stent placement alone.

• Percutaneous stent placement (P-PTS group) patients :when obstruction was limited to segments central to the saphenofemoraljunction (SFJ) in the CFV or when a trabeculation free landing zone in the CFV between the SFJ and the DFV and FV confluence was identified.

• H-PTS group: obstruction involving the veins below the saphenofemoraljunction in which a hybrid procedure was performed, combining stentingwith open surgical disobliteration

• Venous claudication was calculated

• This reduced in 26/29 (90%) patients with IVCS after a median follow-up of 17 months (range 12e26 months), In 64/78 (82%) P-PTS patients venous claudicationwas absent after a median of 13 months (range 11e24 months) and in 50/60 (83%) H-PTS patients after 16 months (range 11e25 months

• Mortality was zero

• However, minor and major bleeding, necessitating supplementary treatment or re-intervention, was seen after treatment of 32 (9%) and 13 (4%) patients, respectively, and occurred mainly in the H-PTS group.

• Of special concern in the hybrid subpopulation was the high incidence of wound related complications, such as wound infections in 23 (27%), lymphorrhoea in 28 (33%), and wound dehiscence in 10 (12%) patients.

CONCLUSION

Percutaneous stent placement to treat non-thrombotic iliac vein lesions, and post-thrombotic ilio-femoral obstructions is safe, effective, and showed patency rates comparable with previous research.

Patients with advanced disease needing a hybrid procedure showed lower patency rates and more complications.

However, when successful, the clinical outcome is favourable at mid-term follow-up and the procedure may be offered to selected patients.

MESSAGES:•TYPE DE PRISE EN CHARGE« PEU FAMILIERE »CHEZ NOUS

•RESTRICTIONS ANATOMIQUES A L ANGIOPLASTIE NE CORRESPONDENT PAS A NOTRE PRATIQUE ,BEAUCOUP PLUS INCLUSIVE EN TERME D EXTENSION SOUS INGUINALE

•EFFICACE SUR LA CLAUDICATION

• clinically significant signs and symptoms of chronic obstructive venous disease were present, and

the femoral and deep femoral veins were patent. • Patients with inferior vena cava involvement or bilateral

iliofemoral occlusive disease were excluded.

• Furthermore, patients were excluded in whom post-thrombotic aberrations extended below the level of the saphenofemoraljunction in the common femoral vein, as these patients are treated in a hybrid fashion, stent placement combined with endophlebectomy and AV fistula creation.

• Moreover, patients with a history of DVT less than 1 year ago were excluded as sufficientnatural recanalization might still occur.

• baseline data were collected, consisting of CEAP, Venous Clinical Severity Score (VCSS), Villalta score, and assessment of venous claudication.

2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 18 August 2014, Accepted 22 May 2015, Available online 14 July 2015

All venous segments were stented with the sinus Venous

Venous access was obtained through the ipsilateral femoral vein, at least 15 cm distal to the femoral confluence

• Standardized follow up was performed at 2 and 6 weeks and 3, 6, and 12 months post intervention.

• Follow up data collection consisted of VCSS and Villalta score assessment, rate of relief of venous claudication and ulcer healing (defined as full re-epithelialization)

MESSAGES:

RESULTATS MEILLEURS/ STENTS TRADITIONNELS, DANS UNE POPULATION IDEALE ?

3% RE-HOSPIT POUR DOULEURS POST STENT…..

The cumulative primary patency rates of the post-thrombotic group at 12 months :85%

large diameter (20-24 mm) self expanding stents (Wallstent).

The iliac stents were placed in a parallel fashion into the IVC stentwith20mm overlap.

At the iliocaval confluence the iliac stents were simultaneouslyballoon inflated

Concurrent iliac, common femoral, and profunda femoral veinobstructions were similarly recanalised and stented distally to a nonobstructed vein segment to ensure inflow.

Iliac stent diameter was 14e18 mm; infra-inguinal stent diameterwas 12-14 mm.

All stents were post-dilated with a balloon diameter 2 mm smallerthan the stent

• Stent placement in the IVC obstruction was technically successful in 19 of 20 patients.

• Fourteen patients had stents extending into the suprarenal segment of the IVC covering the renal veins.

• Eleven patients had stents extending below the inguinal ligament

• Pneumatic serial compression was applied immediately after the procedure and used while the patient was constrained in bed.

• Following stent placement the patients received dalteparin 100 IU/kg twice daily at least 3 months followed by transition to oral anticoagulation with warfarin..

MESSAGES:•WALLSTENT : plus trop tendance chez nous, et pourtant…

•COUVERTURE DES VEINES RENALES:RAS

•PLACE DE LA COMPRESSION PNEUMATIQUE INTERMITTENTE en per et peri-procédure +++++++

• Patients who presented NIVLs, PTVL not affecting the ilio-femoral veins were not treated and/or not included.

• Clinical symptoms were quantified using the Villalta score, and quality of life using the chronic venous insufficiency quality of life (CIVIQ-20) questionnaire ..

For PTVLs caudal to the CFV, their extension into the thigh was graded using the diameter of the veins, presence of synechia inside the veins, and possibility for stenting with an expected good flow in the stents:

The recanalization was routinely performed using a right internal jugular approach (n = 73, 76%), and less frequently through femoral, great saphenous, or popliteal vein routes

Patient was prompted to walk as soon as possible.

Class 2 or 3 venous compression stockings were systematic.

For patients with reduced mobility or in the case of low venous flow after recanalization, an intermittent pneumatic compression device was used the following night.

After patient discharge, for the first month anticoagulation treatment included antiplatelet treatment (aspirin 75–100 mg daily) and an oral anticoagulant [warfarin or direct oral anticoagulant (Apixaban, Rivaroxaban)].

Oral anticoagulation was prescribed for 3–6 months postinterventional treatment.

• Patients were monitored clinically and with a CDUS at day 1, months 1 and 6, years 1, 3, and 5.

• The Villalta and CIVIQ-20 scores were obtained at every follow-up visit

we found no association between the extension of stenting caudal to the CFV and venous patency for an equal grade of lesions

MESSAGES:

- RELATION SEVERITE DE L’ATTEINTE DU « INFLOW »/ PERMEABILITE ++++

- 60 % PERMEABILITE II POUR LES PLUS SEVERES !!

- PAS D’EFFET DELETERE DU STENTING CAUDAL A LA VFC

- ROLE MAJEUR DU PHLEBOSCANNER

- VOIE D’ABORD JUGULAIRE

Using retrospective review of a prospectively maintained database, 105 patients with symptomatic iliocaval venous occlusive D

. Of these patients 9 were excluded because of lack of follow-up of >1 month, and 64 were excluded because of the presence of iliac vein compression syndromes

Journal of Vascular Surgery: Venous and Lymphatic Disorders November 2017

proceeded directly to single-session angioplasty and stenting for patients with subacute (>30 days) or chronic (>90 days) DVT.

6F sheath access of the popliteal or femoral vein

Iliofemoral and caval stenting with self-expanding stainless steel Wallstents

• Patients treated within 6 months of their DVT diagnosis and patients with known hypercoagulableconditions requiring therapeutic anticoagulation were maintained on oral anticoagulants and single-agent antiplatelet therapy.

• 17 Patients not requiring therapeutic anticoagulation were prescribed dual-agent antiplatelettherapy with clopidogrel (Plavix) 75 mg and aspirin 81 mg daily for 3 months, then aspirin alone thereafter.

Cumulativeprimaryandsecondarypatencyat12months for the entire population of patients was 66% and 75%,

• There was no difference in primary patency at 12 months between those who underwent stentingconfined to the supra inguinal allocation and those who require infrainguinal stent extension(68%vs65%);

MESSAGES

- WALLSTENT INFRA INGUINAL OK

- ECHODOPPLER J1 ET < J30 ++++++

- TIMING ANGIOPLASTIE/ TVPA RACCOURCI….(pas sur que ce soit bien..)

• The majority of stent failures in our study occurred within 30 days.

• Early stent failures appeared to be related to technical errors, which generally included inadequate stenting of diseased veins or inadequate venous inflow.

• Therefore, we advocate for the firstpostoperative follow-up visit to occur within the first 30 days to identify and to correct these potential technical problems.

• Most patients who achieve 30-day primary patency remain patent long term. Significant controversy

• Acute thrombosis, non-thrombotic obstructive lesions, mental deficiency, age <18 years, and both a baseline CIVIQ-20 =20 and a Villalta score ≤4 were exclusion criteria.

• Villalta score and CIVIQ 20 scale evaluation

• Every patient had an US exam at 1 day, 1, 3, 6, 12 months after the procedure, and every 6 months until 2 years, and then annually

Available online 27 April 2019

• Ipsilateral popliteal cannulation was the first approach

• Nitinol stents were used: Protege®or mainly Sinus-XL Flex Stent or Sinus Superflex-635,

• each patient received 3 months of dual-therapy: subcutaneous injections of low molecular weight heparin for 1 month followed by 2 months of antivitamin K (with a target INR of 2.0–3.0) or new oral anticoagulant medication, and antiplateletdrug (Aspegic® per os 100 mg per day).

• Every patient had an US exam at 1 day, 1, 3, 6, 12 months after the procedure, and every 6 months until 2 years, and then annually.

• Angio-CT scan at 2 months was also systematically performed

primary patency, primary assisted patency and secondary patency rates at the end of the median follow-up of 18.1 months were 66.7% (29 of 42), 78.6 % (33 of 42) and 88.1% (37 of 42),

MESSAGES

-CLASSIFICATION LET (élegant!, mais définie pour les TVPA)

-CONFIRME l’EFFICACITE SUR LA QUALITE DE VIE(CIVIQ 20)

-20 % DE RETHROMBOSE PRECOCE

-SOULIGNE L’ABSENCE DE CONSENSUS SUR LE TTT ANTICOAGULANT PERI PROCEDURE

• Despite easy endovascular management, early in-stent thrombosis within 1 month occurred in 9 (21.4%) of the 42 patients, which is far away from the 2-10% rate reported in the literature

Deep venous stenting in the context of post-thrombotic syndrome. A third of respondents employed lifelong anticoagulation with VKA, with a further 19% choosing lifelong anticoagulation with DOACs (Fig. 3). Discontinuation of anticoagulation between 6 and 12 months was reported by 35%. The use of antiplateletagents following discontinuation of anticoagulation was chosen by 25%.

Using the Delphi technique the opinions of 106 experts were obtained, and consensus was established on fiveimportant issues regarding antithrombotic therapy following venous stenting

Results:. Low molecular weight heparin was the antithrombotic agent of choice during the first 2 to 6 weeks. Lifelong anticoagulation was recommended after multiple DVTs.Discontinuation of anticoagulation after 6e12 months was advised following venous stenting for a single acute

DVT. No agreement was reached regarding the role of long-term antiplatelet therapy.

PROPOSITION DU GROUPE DELPHI FRANCAIS

• En l'absence de données d'essais thérapeutiques dans le domaine de la recanalisation veineuse et par analogie avec le stenting artériel, il est suggéré de manière empirique de proposer une bithérapie anti-plaquettaire + anticoagulant pendant au moins un mois, suivi d'une anticoagulation seule pendant au moins 2 mois, si le risque hémorragique le permet.

• La proposition est d'utiliser Aspirine 75-100 mg/j.

• Le choix du traitement anticoagulant entre HBPM ou AOD approuvés en France (Rivaroxaban ou Apixaban) est laissé à la discrétion de l'équipe médicale pendant les premières semaines pour éviter tout risque de sous-dosage;

• par la suite l'anticoagulation utilisera des AOD ou des AVK.

• - La durée totale du traitement anticoagulant sera décidée tenant compte des caractéristiques de la thrombose initiale selon les recommandations en vigueur (thrombose provoquée ou non).

CONCLUSIONS

• MONDE ASSEZ HETEROGENE AVEC DES PRATIQUES DIVERSES

• ASSEZ PEU DE MEDECINE FACTUELLE

• EQUATION A PLUSIEURS INCONNUES