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Brown C, Tokessy L, Delluc A, Carrier M. Risk of developing post thrombotic syndrome after deep vein thrombosis with different anticoagulant regimens: A systematic review and pooled analysis. Thromb Res 2024; 240:109057. [PMID: 38875846 DOI: 10.1016/j.thromres.2024.109057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) is common in patients with deep vein thrombosis (DVT). It is unclear if different types of anticoagulant therapies (e.g. vitamin K antagonists (VKA), direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH)) are associated with different risks of PTS. We sought to assess the incidence rates of PTS development following a proximal DVT of the lower extremity managed with different types of anticoagulation regimens. METHODS A systematic search of MEDLINE, EMBASE and PubMed, from inception to June 2023 was performed. The primary outcome was development of PTS. The secondary outcomes included severe PTS, venous ulcers, and major bleeding. Incidence rates were pooled using the random effects model and expressed as event per 100 patient-years with its associated 95 % confidence intervals (CI) using R software. RESULTS A total of 21 (4342 patients) articles were included in the analysis. The adjusted pooled incidence of PTS was 15.1 (95 % CI: 8.7 to 26.1), 18.2 (95 % CI: 9.4 to 35.1) and 24.6 (95 % CI: 9.2 to 65.5) per 100 patient-years patients managed with VKA, DOAC and LMWH, respectively. The adjusted pooled incidence of severe PTS was 5.1 (95 % CI: 2.6 to 10.0) and 0.2 (95 % CI: 0.01 to 2.7) per 100 patient-years for VKAs and DOACs, respectively. CONCLUSIONS The development of PTS is common in patients with proximal lower extremity DVT. The incidence rates of PTS seem to be similar across the different anticoagulation regimens, but severe PTS may be lower among patients receiving a DOAC.
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Affiliation(s)
- Cameron Brown
- Department of Medicine, The Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada; Faculty of Arts and Science, Queen's University, Kingston, Canada
| | - Lauren Tokessy
- Department of Medicine, The Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada; Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Aurélien Delluc
- Department of Medicine, The Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada.
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2
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Lee Cervi A, Applegate D, Stevens SM, Woller SC, Baumann Kreuziger LM, Punchhalapalli K, Wang TF, Lecumberri R, Greco K, Bai Y, Bolger S, Fontyn S, Schulman S, Foster G, Douketis JD. Antithrombotic management of patients with deep vein thrombosis and venous stents: an international registry. J Thromb Haemost 2023; 21:3581-3588. [PMID: 37739038 DOI: 10.1016/j.jtha.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/31/2023] [Accepted: 09/10/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND In patients with acute deep vein thrombosis (DVT) treated with catheter-based thrombolysis and venous stenting, poststenting anticoagulant management is uncertain. OBJECTIVES To determine the type and duration of antithrombotic therapy used in patients who have received venous stents for treatment of acute lower extremity DVT. METHODS We created an international registry of patients with leg DVT from 2005 to 2019 who received venous stents as part of their acute management. We collected data on baseline clinical characteristics and pre-venous and post-venous stent antithrombotic therapy. RESULTS We studied 173 patients with venous stents: 101 (58%) were aged ≤50 years, 105 (61%) were female, and 128 (74%) had risk factors for thrombotic disease. DVT was iliofemoral in 150 (87%) patients, and catheter-based treatment was given within 7 days of diagnosis in 92 (53%) patients. After venous stenting, 109 (63%) patients received anticoagulant-only therapy with a direct oral anticoagulant (29%), warfarin (22%), or low-molecular-weight heparin (10%), and 59 (34%) received anticoagulant-antiplatelet therapy. In patients taking anticoagulant-only therapy, 29% received indefinite treatment; in patients on anticoagulant-antiplatelet therapy, 19% received indefinite treatment. Factors associated with combined anticoagulant-antiplatelet therapy vs anticoagulant-only therapy were use of thrombolytic, thrombectomy, and aspiration interventions (odds ratio [OR], 5.11; 95% CI, 1.45-18.05); use of balloon angioplasty (OR, 2.62; 95% CI, 1.20-5.76); and immediate stent restenosis (OR, 7.2; 95% CI, 1.45-5.89). CONCLUSION Anticoagulant therapy without concomitant antiplatelet therapy appears to be the most common antithrombotic strategy in patients with DVT and venous stenting. More research is needed to determine outcomes of venous stenting in relation to antithrombotic therapy.
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Affiliation(s)
- Andrea Lee Cervi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Scott M Stevens
- Intermountain Healthcare, Murray, Utah, USA; University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Scott C Woller
- Intermountain Healthcare, Murray, Utah, USA; University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lisa M Baumann Kreuziger
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA; Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ramon Lecumberri
- Hematology Service, University Clinic of Navarra, Pamplona, Spain
| | - Kaity Greco
- Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Yuxin Bai
- Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Samantha Bolger
- Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Stephanie Fontyn
- Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Gary Foster
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
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Wang J, Smeath E, Lim HY, Nandurkar H, Kok HK, Ho P. Current challenges in the prevention and management of post-thrombotic syndrome-towards improved prevention. Int J Hematol 2023; 118:547-567. [PMID: 37651058 PMCID: PMC10615940 DOI: 10.1007/s12185-023-03651-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/15/2023] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
Post-thrombotic syndrome (PTS) is a common and potentially debilitating complication of deep vein thrombosis (DVT), affecting up to 50% of DVT patients. The consequence of this chronic condition includes reduced quality of life, increased use of the healthcare system and decreased productivity. The societal impact of this condition is projected to increase, given our ageing population and increased burden of thrombotic diseases. Despite significant recent advances in our understanding of PTS, many unanswered questions remain. Currently, there are few effective and proven options for established PTS; hence, the emphasis should be on instituting effective prevention to reduce the progression to PTS. Effective anticoagulation lowers the risk of PTS, with direct oral anticoagulants appearing to outperform vitamin-K antagonists. However, the evidence for elastic compression stockings and endovascular thrombolysis or thrombectomy techniques remains unclear. Accurate identification of individuals at high risk of developing PTS may also improve the targeting of preventative interventions. This review will examine the current body of evidence regarding PTS, with a focus on preventative strategies as well as novel biomarkers.
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Affiliation(s)
- Julie Wang
- Northern Health, Epping, Melbourne, VIC, Australia.
- University of Melbourne, Melbourne, VIC, Australia.
- Department of Haematology, Northern Hospital, 185 Cooper St., Epping, Melbourne, 3076, VIC, Australia.
| | - Elise Smeath
- University of Melbourne, Melbourne, VIC, Australia
| | - Hui Yin Lim
- Northern Health, Epping, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | | | - Hong Kuan Kok
- Northern Health, Epping, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Prahlad Ho
- Northern Health, Epping, Melbourne, VIC, Australia
- Australian Centre for Blood Diseases, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
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Makedonov I, Kahn S, Abdulrehman J, Schulman S, Delluc A, Gross PL, Galanaud JP. TILE pilot trial study protocol: Tinzaparin Lead-in to Prevent the Post-Thrombotic syndrome study protocol. BMJ Open 2023; 13:e064715. [PMID: 37907305 PMCID: PMC10618981 DOI: 10.1136/bmjopen-2022-064715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/11/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency due to a prior ipsilateral deep venous thrombosis (DVT). This is a frequent complication that develops in 20%-50% of patients after a proximal DVT and is associated with significant healthcare, economic and societal consequences. In the absence of effective and well-tolerated treatment options for established PTS, effective preventative measures are needed. Anticoagulation itself reduces the risk of PTS, and low-molecular-weight heparin may reduce this further through anti-inflammatory properties targeting the initial acute inflammatory phase of DVT. METHODS AND ANALYSIS The Tinzaparin Lead-In to Prevent the Post-Thrombotic syndrome pilot trial is an investigator-initiated, multicentre, open-label assessor-blinded trial that will randomise patients with first acute symptomatic common femoral or iliac DVT to receive either a 3-week lead-in course of tinzaparin, followed by rivaroxaban (experimental arm) or rivaroxaban alone (control arm). Its primary objectives are to assess: (1) proportion of PTS at 6 months using the Villalta scale and (2) study feasibility, which consists of (a) the proportion of screened patients eligible for the study, (2) the proportion of eligible patients recruited and (c) the proportion of recruited patients adherent to treatment (defined as at least 80% of drug taken). This study will determine the feasibility of a subsequent larger definitive trial. Secondary outcomes include change of quality of life scores, PTS severity, global improvement, patient satisfaction, bleeding, recurrent venous thromboembolism, leg pain, death and lost to follow-up. Target recruitment will be a total of 60 participants, recruited at 5-6 centres. ETHICS AND DISSEMINATION Primary ethics approval was received from the Sunnybrook Health Sciences Center Research Ethics Board (approval ID 3315). Results of the study will be disseminated via peer-reviewed presentation at scientific conferences and open access publication. TRIAL REGISTRATION NUMBER NCT04794569.
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Affiliation(s)
- Ilia Makedonov
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Susan Kahn
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
| | - Jameel Abdulrehman
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aurelien Delluc
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter L Gross
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Potere N, Abbate A, Kanthi Y, Carrier M, Toldo S, Porreca E, Di Nisio M. Inflammasome Signaling, Thromboinflammation, and Venous Thromboembolism. JACC Basic Transl Sci 2023; 8:1245-1261. [PMID: 37791298 PMCID: PMC10544095 DOI: 10.1016/j.jacbts.2023.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 10/05/2023]
Abstract
Venous thromboembolism (VTE) remains a major health burden despite anticoagulation advances, suggesting incomplete management of pathogenic mechanisms. The NLRP3 (NACHT-, LRR- and pyrin domain-containing protein 3) inflammasome, interleukin (IL)-1, and pyroptosis are emerging contributors to the inflammatory pathogenesis of VTE. Inflammasome pathway activation occurs in patients with VTE. In preclinical models, inflammasome signaling blockade reduces venous thrombogenesis and vascular injury, suggesting that this therapeutic approach may potentially maximize anticoagulation benefits, protecting from VTE occurrence, recurrence, and ensuing post-thrombotic syndrome. The nonselective NLRP3 inhibitor colchicine and the anti-IL-1β agent canakinumab reduce atherothrombosis without increasing bleeding. Rosuvastatin reduces primary venous thrombotic events at least in part through lipid-lowering independent mechanisms, paving the way to targeted anti-inflammatory strategies in VTE. This review outlines recent preclinical and clinical evidence supporting a role for inflammasome pathway activation in venous thrombosis, and discusses the, yet unexplored, therapeutic potential of modulating inflammasome signaling to prevent and manage VTE.
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Affiliation(s)
- Nicola Potere
- Department of Medicine and Ageing Sciences, “G. d'Annunzio” University, Chieti, Italy
| | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Yogendra Kanthi
- Vascular Thrombosis & Inflammation Section, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Stefano Toldo
- Robert M. Berne Cardiovascular Research Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, School of Medicine and Health Sciences, “G. d'Annunzio” University, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, “G. d'Annunzio” University, Chieti, Italy
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Ryu SM, Park SM, Yang SR, Cho SJ, Ryu SW, Lee SH. Direct Oral Anticoagulants for Anticoagulation after Initial Management of Venous Thromboembolism. Phlebology 2022. [DOI: 10.37923/phle.2022.20.1.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Se Min Ryu
- Department of Thoracic and Cardiovascular Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sung-Min Park
- Department of Thoracic and Cardiovascular Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Se-Ran Yang
- Department of Thoracic and Cardiovascular Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seong-Joon Cho
- Department of Thoracic and Cardiovascular Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sook Won Ryu
- Department of Laboratory Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seung-Hwan Lee
- Department of Neurology, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
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Dowling AR, Luke CE, Cai Q, Pellerito AM, Obi AT, Henke PK. Modulation of interleukin-6 and its effect on late vein wall injury in a stasis mouse model of deep vein thrombosis. JVS Vasc Sci 2022; 3:246-255. [PMID: 35647566 PMCID: PMC9133633 DOI: 10.1016/j.jvssci.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Deep vein thrombosis (DVT) and its sequela, post-thrombotic syndrome (PTS), remain a clinically significant problem. Interleukin-6 (IL-6) is a proinflammatory cytokine that is elevated in patients who develop PTS. We hypothesized that genetic deletion of IL-6 and the use of anti-IL-6 pharmacologic agents would be associated with decreased late vein wall injury. Methods Wild-type C57BL/6J (WT) and IL-6-/- mice underwent induction of stasis venous thrombosis by ligation of the infrarenal IVC. Vein wall inferior vena cava and thrombus were harvested at 21 days after ligation and analyzed by Western blot and immunohistochemistry of the vein wall using monocyte markers CCR2 and arginase 1, the endothelial marker CD31, and fibroblast markers DDR2 and FSP-1. Two anti-IL-6 pharmacologic agents (gp130 [glycoprotein 130] and tocilizumab) were tested and compared with low-molecular-weight heparin (LMWH) as the reference standard in WT mice. Plasma was collected at 4 and 48 hours to confirm the pharmacologic agents' effects. Results Less fibrosis but no increase in luminal endothelialization was found in IL-6-/- mice compared with WT mice at 21 days. The IL-6-/- mice had fewer DDR2- and arginase 1-positive cells in the vein wall compared with the WT mice. However, no difference was found in the CCR2+ cells. Despite documented in vivo activity, exogenous gp130 and tocilizumab were not associated with decreased vein wall fibrosis or increased endothelial luminal coverage at 21 days. LMWH therapy, both before and after treatment, was not associated with decreased vein wall fibrosis at 21 days. Conclusions IL-6 genetic deletion was associated with less fibrotic vein wall injury at a late time point, consistent with the PTS timeframe. However, neither the standard of care LMWH nor two available anti-IL-6 agents showed antifibrotic biologic effects in this model.
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Affiliation(s)
- Abigail R. Dowling
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Catherine E. Luke
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Qing Cai
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Antonio M. Pellerito
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Andrea T. Obi
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Peter K. Henke
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
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Cosmi B, Stanek A, Kozak M, Wennberg PW, Kolluri R, Righini M, Poredos P, Lichtenberg M, Catalano M, De Marchi S, Farkas K, Gresele P, Klein-Wegel P, Lessiani G, Marschang P, Pecsvarady Z, Prior M, Puskas A, Szuba A. The Post-thrombotic Syndrome-Prevention and Treatment: VAS-European Independent Foundation in Angiology/Vascular Medicine Position Paper. Front Cardiovasc Med 2022; 9:762443. [PMID: 35282358 PMCID: PMC8907532 DOI: 10.3389/fcvm.2022.762443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 01/10/2022] [Indexed: 12/11/2022] Open
Abstract
ImportanceThe post-thrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT), occurring in up to 40–50% of cases. There are limited evidence-based approaches for PTS clinical management.ObjectiveTo provide an expert consensus for PTS diagnosis, prevention, and treatment.Evidence-ReviewMEDLINE, Cochrane Database review, and GOOGLE SCHOLAR were searched with the terms “post-thrombotic syndrome” and “post-phlebitic syndrome” used in titles and abstracts up to September 2020.Filters WereEnglish, Controlled Clinical Trial / Systematic Review / Meta-Analysis / Guideline. The relevant literature regarding PTS diagnosis, prevention and treatment was reviewed and summarized by the evidence synthesis team. On the basis of this review, a panel of 15 practicing angiology/vascular medicine specialists assessed the appropriateness of several items regarding PTS management on a Likert-9 point scale, according to the RAND/UCLA method, with a two-round modified Delphi method.FindingsThe panelists rated the following as appropriate for diagnosis: 1-the Villalta scale; 2- pre-existing venous insufficiency evaluation; 3-assessment 3–6 months after diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards periodically, according to a personalized schedule depending on the presence or absence of clinically relevant PTS. The items rated as appropriate for symptom relief and prevention were: 1- graduated compression stockings (GCS) or elastic bandages for symptomatic relief in acute DVT, either iliofemoral, popliteal or calf; 2-thigh-length GCS (30–40 mmHg at the ankle) after ilio-femoral DVT; 3- knee-length GCS (30–40 mmHg at the ankle) after popliteal DVT; 4-GCS for different length of times according to the severity of periodically assessed PTS; 5-catheter-directed thrombolysis, with or without mechanical thrombectomy, in patients with iliofemoral obstruction, severe symptoms, and low risk of bleeding. The items rated as appropriate for treatment were: 1- thigh-length GCS (30–40 mmHg at the ankle) after iliofemoral DVT; 2-compression therapy for ulcer treatment; 3- exercise training. The role of endovascular treatment (angioplasty and/or stenting) was rated as uncertain, but it could be considered for severe PTS only in case of stenosis or occlusion above the inguinal ligament, followed by oral anticoagulation.Conclusions and RelevanceThis position paper can help practicing clinicians in PTS management.
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Affiliation(s)
- Benilde Cosmi
- Division of Angiology and Blood Coagulation, Department of Specialty, Diagnostic and Experimental Medicine, S. Orsola Malpighi University Hospital Research Institute IRCSS, University of Bologna, Bologna, Italy
- Inter-University Research Center on Vascular Diseases & Angiology Unit, University of Milan, L Sacco Hospital, VAS-European Independent Foundation in Angiology/Vascular Medicine, Milan, Italy
- *Correspondence: Benilde Cosmi ;
| | - Agata Stanek
- Department of Internal Medicine, Angiology and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Bytom, Poland
| | - Matja Kozak
- Department for Vascular Diseases, Medical Faculty of Ljubljana, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Paul W. Wennberg
- Department of Cardiovascular Medicine, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States
| | - Raghu Kolluri
- Cardiovascular Medicine, OhioHealth/Riverside Methodist Hospital, Columbus, OH, United States
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pavel Poredos
- Department for Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Mariella Catalano
- Inter-University Research Center on Vascular Diseases & Angiology Unit, University of Milan, L Sacco Hospital, VAS-European Independent Foundation in Angiology/Vascular Medicine, Milan, Italy
| | - Sergio De Marchi
- Inter-University Research Center on Vascular Diseases & Angiology Unit, University of Milan, L Sacco Hospital, VAS-European Independent Foundation in Angiology/Vascular Medicine, Milan, Italy
- Unit of Angiology, Department of Medicine - University of Verona, Cardiovascular and Thoracic Department, Verona University Hospital, Verona, Italy
| | - Katalin Farkas
- Department of Angiology, Szent Imre University Teaching Hospital, Budapest, Hungary
| | - Paolo Gresele
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Peter Klein-Wegel
- Angiologic Clinic, Interdisciplinary Center of Vascular Medicine, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Gianfranco Lessiani
- Angiology Unit, Department of Internal Medicine, Città Sant'Angelo Hospital, Pescara, Italy
| | - Peter Marschang
- Department of Internal Medicine, Central Hospital of Bolzano (SABES-ASDAA), Bolzano, Italy
| | - Zsolt Pecsvarady
- 2nd Department of Internal Medicine - Vascular Center, Flor Ferenc Teaching Hospital, Kistarcsa, Hungary
| | - Manlio Prior
- Inter-University Research Center on Vascular Diseases & Angiology Unit, University of Milan, L Sacco Hospital, VAS-European Independent Foundation in Angiology/Vascular Medicine, Milan, Italy
- Unit of Angiology, Department of Medicine - University of Verona, Cardiovascular and Thoracic Department, Verona University Hospital, Verona, Italy
| | - Attila Puskas
- Angio Center-Vascular Medicine Private Clinic, Tirgu Mures, Romania
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
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Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, Henninger N, Elnazeir M, Liberman AL, Moncrieffe K, Lu J, Sharma R, Cheng Y, Zubair AS, Simpkins AN, Li GT, Kung JC, Perez D, Heldner M, Scutelnic A, Seiffge D, Siepen B, Rothstein A, Khazaal O, Do D, Kasab SA, Rahman LA, Mistry EA, Kerrigan D, Lafever H, Nguyen TN, Klein P, Aparicio H, Frontera J, Kuohn L, Agarwal S, Stretz C, Kala N, El Jamal S, Chang A, Cutting S, Xiao H, de Havenon A, Muddasani V, Wu T, Wilson D, Nouh A, Asad SD, Qureshi A, Moore J, Khatri P, Aziz Y, Casteigne B, Khan M, Cheng Y, Mac Grory B, Weiss M, Ryan D, Vedovati MC, Paciaroni M, Siegler JE, Kamen S, Yu S, Leon Guerrero CR, Atallah E, De Marchis GM, Brehm A, Dittrich T, Psychogios M, Alvarado-Dyer R, Kass-Hout T, Prabhakaran S, Honda T, Liebeskind DS, Furie K. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke 2022; 53:728-738. [PMID: 35143325 DOI: 10.1161/strokeaha.121.037541] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. METHODS This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. RESULTS Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140-720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51-1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22-2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48-1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15-0.82]; P=0.02). CONCLUSIONS In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | | | - Setareh Salehi Omran
- Department of Neurology, University of Colorado School of Medicine, Aurora (S.S.O.)
| | - James A Giles
- Department of Neurology, Washington University, Saint Louis, MO (J.A.G., J.Y.A.)
| | - Jordan Y Amar
- Department of Neurology, Washington University, Saint Louis, MO (J.A.G., J.Y.A.)
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester. (N.H., M.E.).,Department of Psychiatry, University of Massachusetts, Worcester. (N.H.)
| | - Marwa Elnazeir
- Department of Neurology, University of Massachusetts, Worcester. (N.H., M.E.)
| | - Ava L Liberman
- Department of Neurology, Weill Cornell Medical Center, NY (A.L.L.)
| | | | - Jenny Lu
- Department of Neurology, Montefiore Medical Center, NY (K.M., J.L.)
| | - Richa Sharma
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Yee Cheng
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Adeel S Zubair
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Alexis N Simpkins
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Grace T Li
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Justin Chi Kung
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Dezaray Perez
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Mirjam Heldner
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Adrian Scutelnic
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - David Seiffge
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Bernhard Siepen
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Aaron Rothstein
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - Ossama Khazaal
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - David Do
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston (S.A.K., L.A.R.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (S.A.K.)
| | - Line Abdul Rahman
- Department of Neurology, Medical University of South Carolina, Charleston (S.A.K., L.A.R.)
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Deborah Kerrigan
- Department of Neurology, Vanderbilt University, Nashville, TN (D.K., H.L.)
| | - Hayden Lafever
- Department of Neurology, Vanderbilt University, Nashville, TN (D.K., H.L.)
| | - Thanh N Nguyen
- Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | - Piers Klein
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.).,Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | - Hugo Aparicio
- Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | | | - Lindsey Kuohn
- Department of Neurology, New York University, NY (J.F., L.K., S.A.)
| | - Shashank Agarwal
- Department of Neurology, New York University, NY (J.F., L.K., S.A.)
| | - Christoph Stretz
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Narendra Kala
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Sleiman El Jamal
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Alison Chang
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Shawna Cutting
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Han Xiao
- Department of Biostatistics, University of California Santa Barbara (H.X.)
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Varsha Muddasani
- Department of Neurology, University of Utah, Salt Lake City (V.M.)
| | - Teddy Wu
- Department of Neurology, Christchurch hospital, New Zealand (T.W., D.W.)
| | - Duncan Wilson
- Department of Neurology, Christchurch hospital, New Zealand (T.W., D.W.)
| | - Amre Nouh
- Department of Neurology, Hartford Hospital, CT (A.N., S.D.A.)
| | | | - Abid Qureshi
- Department of Neurology, University of Kansas, Kansas City (A.Q., J.M.)
| | - Justin Moore
- Department of Neurology, University of Kansas, Kansas City (A.Q., J.M.)
| | | | - Yasmin Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Bryce Casteigne
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Muhib Khan
- Department of Neurology, Spectrum Health, Michigan State University, Grand Rapids (M.K., Y.C.)
| | - Yao Cheng
- Department of Neurology, Spectrum Health, Michigan State University, Grand Rapids (M.K., Y.C.)
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | - Martin Weiss
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | - Dylan Ryan
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | | | | | - James E Siegler
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | - Scott Kamen
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | - Siyuan Yu
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | | | - Eugenie Atallah
- Department of Neurology, George Washington University, District of Columbia (C.R.L.G., E.A.)
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (G.M.D.M., T.D.)
| | - Alex Brehm
- Department of interventional and diagnostic Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland (A.B., M.P.)
| | - Tolga Dittrich
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (G.M.D.M., T.D.)
| | - Marios Psychogios
- Department of interventional and diagnostic Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland (A.B., M.P.)
| | | | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, IL (R.A.-D., T.K.-H., S.P.)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, IL (R.A.-D., T.K.-H., S.P.)
| | - Tristan Honda
- Department of Neurology, University of California at Los Angeles (T.H., D.S.L.)
| | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles (T.H., D.S.L.)
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
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10
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Spiezia L, Campello E, Simion C, Poretto A, Dalla Valle F, Simioni P. Risk Factors for Post-Thrombotic Syndrome in Patients With a First Proximal Deep Venous Thrombosis Treated With Direct Oral Anticoagulants. Angiology 2022; 73:649-654. [DOI: 10.1177/00033197211070889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The incidence of post-thrombotic syndrome (PTS) in patients with deep vein thrombosis (DVT) treated with direct oral anticoagulants (DOACs) remains a matter of debate. Hence, our endeavor to investigate a large cohort of patients with a first episode of proximal DVT treated with DOACs to ascertain the incidence and predisposing risk factors for PTS. All consecutive patients referred to the Thrombotic and Haemorrhagic Diseases Unit of Padova University Hospital (Italy) between January 2014 and January 2018 for a first episode of proximal DVT were considered for enrollment. Participants received DOACs for a minimum period of 3 months. PTS was assessed using the Villalta score up to 36 months after DVT diagnosis. Among 769 enrolled patients (M/F 353/416, age range 26–87 years), 152 (19.8%) developed PTS and 30 (3.9%) developed severe PTS. The adjusted hazard ratio was significant for obesity (1.64, 95% CI 1.28–2.39) and DVT site (femoral and/or iliac veins vs popliteal vein) (1.23, 95% CI 1.15–3.00). The incidence of PTS is not negligible in patients with proximal DVT despite the use of DOACs. We identified obesity and iliofemoral DVT as possible risk factors for PTS. Larger prospective studies are needed to confirm our findings and optimize therapeutic strategies.
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Affiliation(s)
- Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine - DIMED, Padova University Hospital, Padova, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine - DIMED, Padova University Hospital, Padova, Italy
| | - Chiara Simion
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine - DIMED, Padova University Hospital, Padova, Italy
| | - Anna Poretto
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine - DIMED, Padova University Hospital, Padova, Italy
| | - Fabio Dalla Valle
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine - DIMED, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine - DIMED, Padova University Hospital, Padova, Italy
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11
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Lobastov KV, Schastlivtsev IV, Bargandzhiya AB. [Risk of post-thrombotic syndrome following direct oral anticoagulant intake: a systematic review and meta-analysis]. Khirurgiia (Mosk) 2022:89-99. [PMID: 35147007 DOI: 10.17116/hirurgia202202189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of data devoted to the risk of post-thrombotic syndrome (PTS) following direct oral anticoagulant (DOAC) intake. MATERIAL AND METHODS A systematic review and meta-analysis of trials available in the PubMed database were performed in March 2021. Analysis included the reports with known Villalta score for PTS in patients receiving DOACs or alternative anticoagulation. We analyzed the incidence and risk of any form of PTS. RESULTS We found 10 comparative studies comprising 3161 patients. Incidence of PTS under DOAC therapy was 30.8% (95% confidence interval (CI) 22.2-39.3%), severe PTS - 2.2% (95% CI 1.0-3.4%). DOACs were associated with significantly less risk of any form of PTS (odds ratio (OR) 0.57; 95% CI 0.48-0.68; p<0.001) and severe PTS (OR 0.56; 95% CI 0.36-0.87; p=0.010) compared to vitamin K antagonists. Among various DOACs, specified data were available only for rivaroxaban (OR 0.54, 95% CI 0.42-0.71, p<0.001 for any PTS; OR 0.49, 95% CI 0.27-0.89, p=0.019 for severe PTS). The use of flavonoids in adjunction to rivaroxaban was associated with additional risk reduction for PTS (OR 0.14; 95% CI 0.06-0.31; p<0.001). CONCLUSION Moderate quality evidence suggests that DOACs are associated with significant less risk of any PTS and severe PTS compared to VKA in patients with deep vein thrombosis. Among all DOACs, only rivaroxaban has clear data confirming PTS risk reduction. The use of flavonoids in adjunction to rivaroxaban can further improve treatment outcomes.
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Affiliation(s)
- K V Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Schastlivtsev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A B Bargandzhiya
- Pirogov Russian National Research Medical University, Moscow, Russia
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12
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Efficacy of rivaroxaban in prevention of post-thrombotic syndrome: a systematic review and meta-analysis. J Vasc Surg Venous Lymphat Disord 2021; 9:1568-1576.e1. [PMID: 33965611 DOI: 10.1016/j.jvsv.2021.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/26/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Direct oral anticoagulants (DOACs) have been recommended for the treatment of deep vein thrombosis (DVT). However, the benefits are uncertain for the prevention of post-thrombotic syndrome (PTS). We performed a systematic review and meta-analysis of reported studies to assess the efficacy of DOACs vs vitamin K antagonists for the risk reduction of PTS in patients with DVT. METHODS We searched PubMed, Medline, the Cochrane Library, Embase, and the Web of Science for studies reporting on the development of PTS after acute DVT. The outcomes were the risk reduction of PTS, PTS severity, the presence of residual vein thrombosis, and the incidence of recurrent venous thromboembolic (VTE) events. RESULTS A total of 59,199 patients from six retrospective and two randomized controlled studies had received DOAC treatment and were followed up for the development of PTS. In all studies, rivaroxaban had been compared with initial low-molecular-weight heparin followed by warfarin. Of the 59,199 patients, 19,840 (33.5%) had received rivaroxaban and 39,377 (66.5%), warfarin. The rivaroxaban group had a significant reduction in PTS development compared with the warfarin group (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.43-0.63; P < .001). Severe PTS was less common in the rivaroxaban group than in the warfarin group (3.7% vs 6.4%; OR, 0.55; 95% CI, 0.36-0.85; P = .024). Additionally, rivaroxaban was associated with a significant reduction in VTE recurrence (OR, 0.83; 95% CI, 0.59-1.18; P = .03) and low rates of residual vein thrombosis compared with warfarin (36.5% vs 51.8%; P = .037). CONCLUSIONS Rivaroxaban after acute DVT was associated with a reduced risk of PTS compared with warfarin. Patients treated with rivaroxaban more rarely developed severe PTS and recurrent VTE events compared with patients treated with warfarin.
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13
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Abstract
Postthrombotic syndrome (PTS) remains one of the major late complications of deep vein thrombosis (DVT) with a reported prevalence from 10 to 50%. Many factors were found to be related with the development and severity of PTS such as ipsilateral recurrent DVT, advanced age, obesity, ilio-femoral DVT and primary chronic venous disease presence. Some PTS prediction models have been proposed based on risk factor weight. However, it is still difficult to predict which patient with DVT will develop PTS and thus, the clinical application of these models remains limited. Among the identified problems the heterogeneity of the DVT patient population together with the variety of PTS clinical presentations and difficulties concerning PTS severity assessment should be mentioned. Difficulties on the implementation of the specific and objective PTS identification method have also the significant influence on the research focusing on PTS prevention modalities including risk factor modification, compression treatment, anticoagulation and invasive DVT treatment. In this review, the current approach and knowledge on PTS prediction and prevention are presented, including the conservative and invasive DVT treatment possibilities.
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Affiliation(s)
- Tomasz Urbanek
- Department of General and Vascular Surgery, Medical University of Silesia, Katowice, Poland
| | - Nicos Labropoulos
- Department of Surgery, Stony Brook University School of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
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14
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Zhang X, Huang J, Peng Z, Lu X, Yang X, Ye K. Comparing Safety and Efficacy of Rivaroxaban with Warfarin for Patients after Successful Stent Placement for Chronic Iliofemoral Occlusion: A Retrospective Single Institution Study. Eur J Vasc Endovasc Surg 2020; 61:484-489. [PMID: 33388238 DOI: 10.1016/j.ejvs.2020.11.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 11/05/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim was to compare the safety and effectiveness of rivaroxaban and warfarin as anticoagulants for treating patients with post-thrombotic syndrome (PTS) with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting. METHODS This single institution retrospective study analysed patients with PTS with chronic iliofemoral venous occlusion who were prescribed rivaroxaban or warfarin for one year after successfully undergoing iliofemoral venous stenting. The primary safety and efficacy endpoints were bleeding complication rate and primary patency rate at one year. Secondary outcomes included Villalta score, symptom recurrence rate, ulcer healing rate, and clinically driven target lesion revascularisation (CD-TLR) rate during follow up. RESULTS From January 2016 to December 2017, 154 legs from 154 patients were included in this study (69 in rivaroxaban group and 85 in warfarin group). The groups were well matched for patient demographics, clinical characteristics, and procedural details. There was no significant difference between the rivaroxaban group and warfarin group in bleeding complication rate (10% vs. 16%, p = .23, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.25 - 1.37) at one year, as well as major bleeding complication rate (0% vs. 2%, p = .20, HR 0.16, 95% CI 0.01 - 2.61) and minor bleeding complication rate (10% vs. 14%, p = .40, HR 0.67, 95% CI 0.27 - 1.66). The primary patency rate was higher in the rivaroxaban group at one year (84% vs. 71%, p = .049, HR 0.50, 95% CI 0.26 - 0.96) and at two years (79% vs. 63%, p = .037, HR 0.52, 95% CI 0.29 - 0.93). At a mean follow up of 24 months (range 1 - 42 months), the rivaroxaban group had a significantly lower post-operative Villalta score (4.87 ± 3.51 vs. 6.88 ± 5.85, p = .010, t = 2.64, 95% CI 0.50 - 3.52), lower rate of symptom recurrence (4% vs. 32%, p < .001), lower CD-TLR rates (3% vs. 13%, p = .039), and higher ulcer healing rate (90% vs. 59%, p = .004) than the warfarin group. CONCLUSION For PTS patients with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting, rivaroxaban probably exhibited similar safety but superior efficacy to warfarin. However, further prospective control studies with large sample size are necessary to confirm the results.
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Affiliation(s)
- Xing Zhang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Jiaqi Huang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Zhiyou Peng
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Xinrui Yang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China.
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15
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Li R, Yuan M, Cheng J, Yu S, Wei W, Fu W, Prandoni P, Chen Y. Risk of post-thrombotic syndrome after deep vein thrombosis treated with rivaroxaban versus vitamin-K antagonists: A systematic review and meta-analysis. Thromb Res 2020; 196:340-348. [DOI: 10.1016/j.thromres.2020.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/27/2020] [Accepted: 09/11/2020] [Indexed: 11/25/2022]
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16
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Henke P, Sharma S, Wakefield T, Myers D, Obi A. Insights from experimental post-thrombotic syndrome and potential for novel therapies. Transl Res 2020; 225:95-104. [PMID: 32442728 PMCID: PMC7487018 DOI: 10.1016/j.trsl.2020.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 12/20/2022]
Abstract
Post-thrombotic syndrome (PTS) is an end stage manifestation of deep vein thrombosis. This is an inherently inflammatory process, with consequent fibrosis. Multiple cellular types are involved, and are likely driven by leukocytes. Herein, we review the current gaps in therapy, and insights from rodent models of venous thrombosis that suggest possible targets to treat and prevent PTS.
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Affiliation(s)
- Peter Henke
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI.
| | - Sriganesh Sharma
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
| | - Thomas Wakefield
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
| | - Dan Myers
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
| | - Andrea Obi
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
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17
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Safety of dabigatran etexilate for the secondary prevention of venous thromboembolism in children. Blood 2020; 135:491-504. [PMID: 31805182 DOI: 10.1182/blood.2019000998] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 11/21/2019] [Indexed: 02/07/2023] Open
Abstract
This open-label, single-arm, prospective cohort trial is the first phase 3 safety study to describe outcomes in children treated with dabigatran etexilate for secondary venous thromboembolism (VTE) prevention. Eligible children aged 12 to <18 years (age stratum 1), 2 to <12 years (stratum 2), and >3 months to <2 years (stratum 3) had an objectively confirmed diagnosis of VTE treated with standard of care (SOC) for ≥3 months, or had completed dabigatran or SOC treatment in the DIVERSITY trial (NCT01895777) and had an unresolved clinical thrombosis risk factor requiring further anticoagulation. Children received dabigatran for up to 12 months, or less if the identified VTE clinical risk factor resolved. Primary end points included VTE recurrence, bleeding events, and mortality at 6 and 12 months. Overall, 203 children received dabigatran, with median exposure being 36.3 weeks (range, 0-57 weeks); 171 of 203 (84.2%) and 32 of 203 (15.8%) took capsules and pellets, respectively. Overall, 2 of 203 children (1.0%) experienced on-treatment VTE recurrence, and 3 of 203 (1.5%) experienced major bleeding events, with 2 (1.0%) reporting clinically relevant nonmajor bleeding events, and 37 (18.2%) minor bleeding events. There were no on-treatment deaths. On-treatment postthrombotic syndrome was reported for 2 of 162 children (1.2%) who had deep vein thrombosis or central-line thrombosis as their most recent VTE. Pharmacokinetic/pharmacodynamic relationships of dabigatran were similar to those in adult VTE patients. In summary, dabigatran showed a favorable safety profile for secondary VTE prevention in children aged from >3 months to <18 years with persistent VTE risk factor(s). This trial was registered at www.clinicaltrials.gov as #NCT02197416.
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Nicolaides A, Kakkos S, Baekgaard N, Comerota A, de Maeseneer M, Eklof B, Giannoukas A, Lugli M, Maleti O, Mansilha A, Myers KA, Nelzén O, Partsch H, Perrin M. Management of chronic venous disorders of the lower limbs. Guidelines According to Scientific Evidence. Part II. INT ANGIOL 2020; 39:175-240. [PMID: 32214074 DOI: 10.23736/s0392-9590.20.04388-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | | | | | | | | | - Bo Eklof
- American Venous Forum, Hoffman Eastates, IL, USA
| | | | | | | | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Department of Angiology and Vascular Surgery, S. João Hospital, Porto, Portugal
| | | | - Olle Nelzén
- Vascular Surgery Unit, Skaraborg Hospital, Kärnsjukhuset, Skövde, Sweden
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19
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Thukral S, Vedantham S. Catheter-Based Therapies and Other Management Strategies for Deep Vein Thrombosis and Post-Thrombotic Syndrome. J Clin Med 2020; 9:E1439. [PMID: 32408611 PMCID: PMC7290684 DOI: 10.3390/jcm9051439] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/07/2020] [Indexed: 02/07/2023] Open
Abstract
Acute deep vein thrombosis (DVT) causes substantial short-term and long-term patient morbidity. Medical, lifestyle, and compressive therapies have been investigated for the prevention of pulmonary embolism (PE) and recurrence of venous thromboembolism (VTE). However, patient-centered outcomes such as resolution of presenting DVT symptoms and late occurrence of post-thrombotic syndrome (PTS) have not been prioritized to the same degree. Imaging-guided, catheter-based endovascular therapy has been used in selected patients to alleviate these sequelae, but important questions remain about their optimal use. In this article, we review the available evidence and summarize the rationale for use of catheter-based therapy in specific patient groups.
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Affiliation(s)
- Siddhant Thukral
- School of Medicine, University of Missouri—Kansas City, Kansas City, MO 64108, USA;
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO 63110, USA
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20
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Palareti G, Cosmi B. The direct oral anticoagulants may also be effective against the risk of post-thrombotic syndrome. Intern Emerg Med 2020; 15:365-367. [PMID: 31872344 DOI: 10.1007/s11739-019-02251-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Gualtiero Palareti
- "Arianna Anticoagulazione" Foundation, via Paolo Fabbri 1/3, 40138, Bologna, Italy.
| | - Benilde Cosmi
- Dept Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni 15, 40138, Bologna, Italy
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21
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Galanaud JP, Righini M, Le Collen L, Douillard A, Robert-Ebadi H, Pontal D, Morrison D, Barrellier MT, Diard A, Guénnéguez H, Brisot D, Faïsse P, Accassat S, Martin M, Delluc A, Solymoss S, Kassis J, Carrier M, Quéré I, Kahn SR. Long-term risk of postthrombotic syndrome after symptomatic distal deep vein thrombosis: The CACTUS-PTS study. J Thromb Haemost 2020; 18:857-864. [PMID: 31899848 DOI: 10.1111/jth.14728] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/08/2019] [Accepted: 12/31/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND After a proximal lower limb deep vein thrombosis (DVT; involving popliteal veins or above), up to 40% of patients develop postthrombotic syndrome (PTS) as assessed by the Villalta scale (VS). Poor initial anticoagulant treatment is a known risk factor for PTS. The risk of developing PTS after isolated distal DVT (infra-popliteal DVT without pulmonary embolism), and the impact of anticoagulant treatment on this risk, are uncertain. METHODS Long-term follow-up of CACTUS double-blind trial comparing 6 weeks of s.c. nadroparin (171 IU/kg/d) versus s.c. placebo for a first symptomatic isolated distal DVT. At least 1 year after randomization, patients had a PTS assessment in clinic or by phone using the VS. RESULTS After a median follow-up of 6 years, PTS was present in 30% (n = 54) of the 178 patients who had a PTS assessment. PTS was moderate or severe in 24% (n = 13) of cases. There was no statistically significant difference in prevalence of PTS in the nadroparin versus placebo groups (29% versus 32%, P = .6), except in patients without evidence of primary chronic venous insufficiency (9% versus 24%, P = .04). Rates of venous thromboembolism recurrence during follow-up in the nadroparin and placebo groups were, respectively, 8% (n = 7) and 14% (n = 13; P = .2). CONCLUSION After a first isolated distal DVT, the risk of PTS is substantial but much lower than that reported after proximal DVT. Anticoagulation with nadroparin doesn't provide any clear benefit to prevent PTS, except in patients without preexisting chronic venous insufficiency. Anticoagulation might be associated with a lower risk of venous thromboembolism recurrence.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Lorris Le Collen
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
| | - Aymeric Douillard
- Clinical Research and Epidemiology Unit, University Hospital, Montpellier, France
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Daniel Pontal
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
| | - David Morrison
- Department of Medicine and Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | | | | | | | - Dominique Brisot
- Vascular Medicine Unit, Clinique du Parc, Castelnau Le Lez, France
| | | | - Sandrine Accassat
- Clinical Investigation Centre, Saint Etienne University Hospital, Saint Etienne, France
| | | | - Aurélien Delluc
- Department of Medicine, Brest University Hospital, Brest, France
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Susan Solymoss
- Division of Hematology, St Mary's Hospital, Montreal, QC, Canada
| | - Jeannine Kassis
- Division of Hematology, Hôpital Rosemont-Maisonneuve, Montréal, QC, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Isabelle Quéré
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
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22
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Prevention and Management of the Post-Thrombotic Syndrome. J Clin Med 2020; 9:jcm9040923. [PMID: 32230912 PMCID: PMC7230648 DOI: 10.3390/jcm9040923] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency secondary to prior deep vein thrombosis (DVT). It affects up to 50% of patients after proximal DVT. There is no effective treatment of established PTS and its management lies in its prevention after DVT. Optimal anticoagulation is key for PTS prevention. Among anticoagulants, low-molecular-weight heparins have anti-inflammatory properties, and have a particularly attractive profile. Elastic compression stockings (ECS) may be helpful for treating acute DVT symptoms but their benefits for PTS prevention are debated. Catheter-directed techniques reduce acute DVT symptoms and might reduce the risk of moderate-severe PTS in the long term in patients with ilio-femoral DVT at low risk of bleeding. Statins may decrease the risk of PTS, but current evidence is lacking. Treatment of PTS is based on the use of ECS and lifestyle measures such as leg elevation, weight loss and exercise. Venoactive medications may be helpful and research is ongoing. Interventional techniques to treat PTS should be reserved for highly selected patients with chronic iliac obstruction or greater saphenous vein reflux, but have not yet been assessed by robust clinical trials.
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23
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Cosmi B, Palareti G. "Early thrombus removal" in iliac-femoral deep vein thrombosis for prevention of post-thrombotic syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:S343. [PMID: 32016061 DOI: 10.21037/atm.2019.09.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Benilde Cosmi
- Department of Angiology & Blood Coagulation, University Hospital S. Orsola-Malpighi, University of Bologna, Bologna, Italy
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24
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Ferreira T, Huber SC, de Moraes Martinelli B, Junior AL, Menezes FH, Orsi FA, Bittar LF, de Oliveira LFG, Sodre LR, Mello TT, Rielli G, Colella MP, de Paula EV, Yamaguti-Hayakawa GG, Montalvão S, Annichino-Bizzacchi JM. Low prevalence of Post-thrombotic syndrome in patients treated with rivaroxaban. Vascul Pharmacol 2020; 124:106608. [DOI: 10.1016/j.vph.2019.106608] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/14/2019] [Accepted: 10/22/2019] [Indexed: 11/17/2022]
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25
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de Athayde Soares R, Matielo MF, Brochado Neto FC, Nogueira MP, Almeida RD, Sacilotto R. Comparison of the recanalization rate and postthrombotic syndrome in patients with deep venous thrombosis treated with rivaroxaban or warfarin. Surgery 2019; 166:1076-1083. [DOI: 10.1016/j.surg.2019.05.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/13/2019] [Accepted: 05/25/2019] [Indexed: 10/26/2022]
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26
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Metz AK, Luke CE, Dowling A, Henke PK. Acute experimental venous thrombosis impairs venous relaxation but not contraction. J Vasc Surg 2019; 71:1006-1012.e1. [PMID: 31248758 DOI: 10.1016/j.jvs.2019.03.064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/27/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Venous thrombosis (VT) damages the vein wall, both physically by prolonged distension and from inflammation. These factors contribute to post-thrombotic syndrome (PTS). Interleukin (IL)-6 might play a role in experimental PTS and vein wall responses. Previous assessments of post-thrombotic vein wall injury used static measures such as histologic examination and immunologic assays. The purpose of the present study was to use myography to quantify the changes in contraction and relaxation of murine vessels exposed to an acute VT. METHODS Wild-type (WT) C57BL/6 mice were used to determine the baseline vein wall passive tension on a DMT 610m myograph (DMT-USA, Inc., Ann Arbor, Mich), including dosing concentrations of phenylephrine (Phe) and acetylcholine (Ach). WT and IL-6-/- mice underwent VT using inferior vena cava (IVC) ligation (complete stasis) and stenosis (partial stasis), with no-surgery mice used as controls. The mice were harvested at 2 days (2D) and analyzed using a myograph. The vessels were stimulated with Phe and Ach to stimulate a contraction and relaxation response. The endothelial responses to VT were quantified by CD31 immunohistochemistry, Greiss assay, polymerase chain reaction, and Evans blue assay. RESULTS Optimal passive tension was determined to be 2 mN, with an optimal concentration of Phe and Ach of 7E-3M and 1E-5M, respectively. No significant differences were found in the contractions when exposed to Phe between the WT control, WT 2D ligation, and WT 2D stenosis IVC segments and the IL-6-/- mice with and without thrombus (P > .05 for all). When treated with Ach, significantly more relaxation was found in the nonthrombosed control IVC segments than in those IVC segments that had had a 2D thrombus from either ligation- or stenosis-derived thrombotic mechanisms in both WT and IL-6-/- mice. CD31 staining showed ∼20% less luminal endothelium after stasis thrombosis (P ≤ .01) but no loss in the controls (P > .05). Evans blue staining showed a trend toward increased leakiness in post-thrombotic vein walls. No significant difference in the endothelial gene markers or nitric oxide production was found. CONCLUSIONS Compared with the controls, acute thrombosis in the total or partial stasis models did not impair IVC contractile responses, suggesting no effect on the medial vascular smooth muscle response. The relaxation response was significantly reduced in the post-thrombotic groups, likely from direct endothelial injury. These findings suggest, at acute points, that VT impairs the endothelial function of a vein wall while retaining the vascular smooth muscle cell function and might be a mechanism that promotes PTS.
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Affiliation(s)
- Allan K Metz
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Cathy E Luke
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Abigail Dowling
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich.
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27
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Antignani PL, Allegra C, Fareed J. Treatment of deep vein thrombosis with rivaroxaban and its potential to prevent the post-thrombotic syndrome. INT ANGIOL 2019; 38:17-21. [DOI: 10.23736/s0392-9590.18.04031-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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28
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Carter RLR, Talbot K, Hur WS, Meixner SC, Van Der Gugten JG, Holmes DT, Côté HCF, Kastrup CJ, Smith TW, Lee AYY, Pryzdial ELG. Rivaroxaban and apixaban induce clotting factor Xa fibrinolytic activity. J Thromb Haemost 2018; 16:2276-2288. [PMID: 30176116 DOI: 10.1111/jth.14281] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 12/26/2022]
Abstract
Essentials Activated clotting factor X (FXa) acquires fibrinolytic cofactor function after cleavage by plasmin. FXa-mediated plasma fibrinolysis is enabled by active site modification blocking a second cleavage. FXa-directed oral anticoagulants (DOACs) alter FXa cleavage by plasmin. DOACs enhance FX-dependent fibrinolysis and plasmin generation by tissue plasminogen activator. BACKGROUND When bound to an anionic phospholipid-containing membrane, activated clotting factor X (FXa) is sequentially cleaved by plasmin from the intact form, FXaα, to FXaβ and then to Xa33/13. Tissue-type plasminogen activator (t-PA) produces plasmin and is the initiator of fibrinolysis. Both FXaβ and Xa33/13 enhance t-PA-mediated plasminogen activation. Although stable in experiments using purified proteins, Xa33/13 rapidly loses t-PA cofactor function in plasma. Bypassing this inhibition, covalent modification of the FXaα active site prevents Xa33/13 formation by plasmin, and the persistent FXaβ enhances plasma fibrinolysis. As the direct oral anticoagulants (DOACs) rivaroxaban and apixaban bind to the FXa active site, we hypothesized that they similarly modulate FXa fibrinolytic function. METHODS DOAC effects on fibrinolysis and the t-PA cofactor function of FXa were studied in patient plasma, normal pooled plasma and purified protein experiments by the use of light scattering, chromogenic assays, and immunoblots. RESULTS The plasma of patients taking rivaroxaban showed enhanced fibrinolysis correlating with FXaβ. In normal pooled plasma, the addition of rivaroxaban or apixaban also shortened fibrinolysis times. This was related to the cleavage product, FXaβ, which increased plasmin production by t-PA. It was confirmed that these results were not caused by DOACs affecting activated FXIII-mediated fibrin crosslinking, clot ultrastructure and thrombin-activatable fibrinolysis inhibitor activation in plasma. CONCLUSION The current study suggests a previously unknown effect of DOACs on FXa in addition to their well-documented anticoagulant role. By enabling the t-PA cofactor function of FXaβ in plasma, DOACs also enhance fibrinolysis. This effect may broaden their therapeutic indications.
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Affiliation(s)
- R L R Carter
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - K Talbot
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - W S Hur
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Michael Smith Laboratories and Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - S C Meixner
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - J G Van Der Gugten
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, St Paul's Hospital, Vancouver, British Columbia
| | - D T Holmes
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, St Paul's Hospital, Vancouver, British Columbia
| | - H C F Côté
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - C J Kastrup
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Michael Smith Laboratories and Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - T W Smith
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Y Y Lee
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - E L G Pryzdial
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
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29
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Reduced incidence of vein occlusion and postthrombotic syndrome after immediate compression for deep vein thrombosis. Blood 2018; 132:2298-2304. [PMID: 30237155 DOI: 10.1182/blood-2018-03-836783] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/02/2018] [Indexed: 11/20/2022] Open
Abstract
Thus far, the association between residual vein occlusion and immediate compression therapy and postthrombotic syndrome is undetermined. Therefore, we investigated whether compression therapy immediately after diagnosis of deep vein thrombosis affects the occurrence of residual vein obstruction (RVO), and whether the presence of RVO is associated with postthrombotic syndrome and recurrent venous thromboembolism. In a prespecified substudy within the IDEAL (individualized duration of elastic compression therapy against long-term duration of therapy for prevention of postthrombotic syndrome) deep vein thrombosis (DVT) study, 592 adult patients from 10 academic and nonacademic centers across The Netherlands, with objectively confirmed proximal DVT of the leg, received no compression or acute compression within 24 hours of diagnosis of DVT with either multilayer bandaging or compression hosiery (pressure, 35 mm Hg). Presence of RVO and recurrent venous thromboembolism was confirmed with compression ultrasonography and incidence of postthrombotic syndrome as a Villalta score of at least 5 at 6 and 24 months. The average time from diagnosis until assessment of RVO was 5.3 (standard deviation, 1.9) months. A significantly lower percentage of patients who did receive compression therapy immediately after DVT had RVO (46.3% vs 66.7%; odds ratio, 0.46; 95% confidence interval, 0.27-0.80; P = .005). Postthrombotic syndrome was less prevalent in patients without RVO (46.0% vs 54.0%; odds ratio, 0.65; 95% confidence interval, 0.46-0.92; P = .013). Recurrent venous thrombosis showed no significant association with RVO. Immediate compression should therefore be offered to all patients with acute DVT of the leg, irrespective of severity of complaints. This study was registered at ClinicalTrials.gov (NCT01429714) and the Dutch Trial registry in November 2010 (NTR2597).
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30
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Ueda J, Tsuji A, Ogo T, Asano R, Konagai N, Fukui S, Morita Y, Fukuda T, Yasuda S. Beneficial Effect of Endovascular Treatment on Villalta Score in Japanese Patients With Chronic Iliofemoral Venous Thrombosis and Post-Thrombotic Syndrome. Circ J 2018; 82:2640-2646. [PMID: 30033947 DOI: 10.1253/circj.cj-17-1210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS), the most common complication of deep venous thrombosis (DVT), develops in ≥50% of patients with iliofemoral DVT. However, the benefit of endovascular treatment in Japanese patients with chronic DVT and PTS remains unclear. Methods and Results: Between June 2014 and May 2016, endovascular treatment was performed in 11 consecutive Japanese patients with chronic iliofemoral DVT and PTS refractory to anticoagulant therapy and elastic compression stockings. We evaluated the technical success rate, complications, patency, Villalta score, calf circumference, and popliteal vein reflux in both the acute stage (the day following endovascular treatment) and chronic stage (after 6 months). Imaging follow-up included venous duplex scanning and/or magnetic resonance venography. The technical success rate was 81.8%, without complications. In patients with successful intervention, the Villalta score improved significantly, from 9.0±3.7 preoperatively to 3.6±2.5 in the acute phase (P<0.01) and 2.9±2.1 in the chronic phase (P<0.001). The bilateral difference in lower thigh circumference also improved significantly, from 2.6±1.0 cm preoperatively to 1.4±1.0 cm in the chronic phase (P<0.001). However, popliteal vein reflux did not improve. In patients with successful intervention, venous patency rate was 100% at 6 months post-intervention. CONCLUSIONS Endovascular treatment is safe and effective in Japanese patients with chronic iliofemoral DVT and PTS.
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Affiliation(s)
- Jin Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Akihiro Tsuji
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ryotaro Asano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Nao Konagai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shigefumi Fukui
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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31
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Prevention and treatment of the post-thrombotic syndrome. Thromb Res 2018; 164:116-124. [DOI: 10.1016/j.thromres.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/19/2017] [Accepted: 07/10/2017] [Indexed: 11/21/2022]
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32
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ten Cate‐Hoek AJ. Prevention and treatment of the post-thrombotic syndrome. Res Pract Thromb Haemost 2018; 2:209-219. [PMID: 30046723 PMCID: PMC6055553 DOI: 10.1002/rth2.12085] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/14/2018] [Indexed: 11/12/2022] Open
Abstract
Post thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis of the leg (DVT). Treatment options are limited therefore emphasis is placed on its prevention. Several risk factors have been recognized, but were so far not used for risk stratification or translation into prediction models. Early interventions did not yet result in more successful preventive treatment strategies; for the acute phase of DVT there is equipoise on the value of elastic compression, as well as on catheter directed thrombolysis. There are no drugs specifically targeted at PTS prevention. The use of anticoagulant medication such as direct oral anticoagulants (DOACs) might decrease PTS incidence, but this needs to be corroborated. Both research into more effective treatment options as well as future PTS management may benefit from a uniform diagnostic strategy and the use of prediction rules to better allocate treatment and thereby increase treatment efficacy.
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Affiliation(s)
- Arina J. ten Cate‐Hoek
- Heart+ and Vascular Center, Internal MedicineCardiovascular Research InstituteMaastricht University Medical CenterMaastrichtthe Netherlands
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Coleman CI, Beyer-Westendorf J, Bunz TJ, Mahan CE, Spyropoulos AC. Postthrombotic Syndrome in Patients Treated With Rivaroxaban or Warfarin for Venous Thromboembolism. Clin Appl Thromb Hemost 2018. [PMID: 29514466 PMCID: PMC6714693 DOI: 10.1177/1076029618758955] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Postthrombotic syndrome (PTS) is a frequent complication of venous thromboembolism (VTE).
Using MarketScan claims data from January 2012 to June 2015, we identified adults with a
primary diagnosis code for VTE during a hospitalization/emergency department visit, ≥6
months of insurance coverage prior to the index event and newly started on rivaroxaban or
warfarin within 30 days of the index VTE. Patients with <4-month follow-up postindex
event or a claim for any anticoagulant during 6-month baseline period were excluded.
Differences in baseline characteristics between rivaroxaban and warfarin users were
adjusted for using inverse probability of treatment weights based on propensity scores.
Patients were followed for the development of PTS starting 3 months after the index VTE.
Cox regression was performed and reported as hazard ratios with 95% confidence intervals
(CIs). In total, 10 463 rivaroxaban and 26 494 warfarin users were followed for a mean of
16 ± 9 (range, 4-39) months. Duration of anticoagulation was similar between cohorts
(median = 6 months). Rivaroxaban was associated with a 23% (95% CI: 16-30) reduced hazard
of PTS versus warfarin. Rivaroxaban was associated with a significant risk reduction in
symptoms of PTS compared to warfarin in patients with VTE treated in routine practice.
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Affiliation(s)
- Craig I Coleman
- 1 Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Jan Beyer-Westendorf
- 2 Division Hematology, Department of Medicine I, Thrombosis Research Unit, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany.,3 Department of Hematology, Kings Thrombosis Service, Kings College London, London, United Kingdom
| | - Thomas J Bunz
- 4 New England Health Analytics, LLC, Granby, CT, USA
| | - Charles E Mahan
- 5 Presbyterian Healthcare Services, University of New Mexico, Albuquerque, NM, USA
| | - Alex C Spyropoulos
- 6 Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health System, Hofstra Northwell School of Medicine, Manhasset, NY, USA
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Ma J, Li X, Wang Y, Yang Z, Luo J. Rivaroxaban attenuates thrombosis by targeting the NF-κB signaling pathway in a rat model of deep venous thrombus. Int J Mol Med 2017; 40:1869-1880. [PMID: 29039441 PMCID: PMC5716436 DOI: 10.3892/ijmm.2017.3166] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 09/04/2017] [Indexed: 11/21/2022] Open
Abstract
Anticoagulant therapy is commonly used for the prevention and treatment of patients with deep venous thrombus. Evidence has shown that rivaroxaban is a potential oral anticoagulant drug for the acute treatment of venous thromboembolism. However, the rivaroxaban-mediated molecular mechanism involved in the progression of deep venous thrombosis has not been investigated. In the present study, we investigated the efficacy of rivaroxaban and the underlying signaling pathways in the prevention and treatment of rats with deep venous thrombosis. A rat model with deep vein thrombus formation was established and received treatment with rivaroxaban or PBS as control. The thrombin-activatable fibrinolysis inhibitor (TAFI) and plasminogen activator inhibitor-1 (PAI-1) were analyzed both in vitro and in vivo. The progression of thrombosis and stroke was evaluated after treatment with rivaroxaban or PBS. Nuclear factor-κB (NF-κB) signaling pathway in venous endothelial cells and in the rat model of deep venous thrombus was assessed. The therapeutic effects of rivaroxaban were evaluated as determined by changes in deep venous thrombosis in the rat model. Our results showed that rivaroxaban markedly inhibited TAFI and PAI-1 expression levels, neutrophils, tissue factor, neutrophil extracellular traps (NETs), myeloperoxidase and macrophages in venous endothelial cells and in the rat model of deep venous thrombus. Expression levels of ADP, PAIs, von Willebrand factor (vWF) and thromboxane were downregulated in vein endothelial cells and in serum from the experimental rats. Importantly, the incidences of inferior vena cava filter thrombus were protected by rivaroxaban during heparin-induced thrombolysis deep venous thrombosis in the rat model. We observed that activity of the NF-κB signaling pathway was inhibited by rivaroxaban in vein endothelial cells both in vitro and in vivo. Notably, immunohistology indicated that rivaroxaban attenuated deep venous thrombosis and the accumulation of inflammatory factors in the lesions in venous thrombus. Matrix metalloproteinase (MMP) expression and activity were downregulated in rivaroxaban-treated rats with deep venous thrombus. Rivaroxaban inhibited the elasticity of the extracellular matrix and collagen-elastin fibers. On the whole, these results indicate that rivaroxaban attenuates deep venous thrombus through MMP-9-mediated NF-κB signaling pathway.
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Affiliation(s)
- Junhao Ma
- Department of Blood Vessels of Thyroid Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, Xinjiang 830000, P.R. China
| | - Xinxi Li
- Department of Blood Vessels of Thyroid Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, Xinjiang 830000, P.R. China
| | - Yang Wang
- Department of Blood Vessels of Thyroid Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, Xinjiang 830000, P.R. China
| | - Zhenwei Yang
- Department of Blood Vessels of Thyroid Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, Xinjiang 830000, P.R. China
| | - Jun Luo
- Department of Blood Vessels of Thyroid Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, Xinjiang 830000, P.R. China
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Rivaroxaban versus warfarin in the prevention of post-thrombotic syndrome. Thromb Res 2017; 157:46-48. [DOI: 10.1016/j.thromres.2017.05.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/20/2017] [Accepted: 05/25/2017] [Indexed: 11/17/2022]
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Abstract
Venous thromboembolism (VTE) is a common disease (~700 per 100 000) that is associated with significant risk of recurrence, chronic complications, and substantial mortality, with reported death rates of up to 40% at 10 years. The development of novel anticoagulants has revolutionized the treatment of acute VTE, while strategies for prevention and treatment of chronic complications still seek for such a landmark change. Impaired thrombus resolution is the common denominator behind VTE complications, which are postthrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTEPH). PTS and CTEPH are associated with substantial morbidity and high healthcare expenses. While PTS occurs in up to 50% of patients after symptomatic deep vein thrombosis, only a small and poorly defined number of patients are diagnosed with CTEPH after pulmonary embolism. This review is a comprehensive summary of VTE-related chronic complications, their epidemiology, diagnosis, and treatment.
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Affiliation(s)
- M-P Winter
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - G H Schernthaner
- Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - I M Lang
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Galanaud JP, Monreal M, Kahn SR. Epidemiology of the post-thrombotic syndrome. Thromb Res 2017; 164:100-109. [PMID: 28844444 DOI: 10.1016/j.thromres.2017.07.026] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/20/2017] [Accepted: 07/21/2017] [Indexed: 01/15/2023]
Abstract
The post thrombotic syndrome (PTS) refers to clinical manifestations of chronic venous insufficiency (CVI) following a deep-vein thrombosis (DVT). PTS is the most frequent complication of DVT, which develops in 20 to 50% of cases after proximal DVT and is severe in 5-10% of cases. The reported prevalence of PTS differs widely among studies because of differences in study populations, tools used to assess PTS, and time interval between acute DVT and PTS assessment. The two most important predictors of PTS are extensive proximal character of DVT and previous ipsilateral DVT. Other reported risk factors include pre-existing CVI, obesity, quality of anticoagulant treatment, older age and residual venous obstruction. Standardization of PTS assessment tools combined with the development of patient self-reported PTS scales are likely to constitute a breakthrough in research of the epidemiology of PTS, by allowing comparison between studies, meta-analyses and increasing the feasibility of longer follow-up of DVT patients. This should enable identification of patient populations at high risk of severe PTS, new predictors of PTS and targets for potential new treatments. In this perspective, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial in ongoing research.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of General Internal Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada; Department of Internal Medicine, Montpellier University Hospital, Montpellier, France.
| | - Manuel Monreal
- Department of Internal Medicine, Hospital de Badalona Germans Trias I Pujol, Barcelona, Spain
| | - Susan R Kahn
- Department of Medicine, McGill University and Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Canada
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Prandoni P, Ageno W, Mumoli N, Zanatta N, Imberti D, Visonà A, Ciammaichella M, Simioni L, Cappelli R, Bucherini E, Di Nisio M, Avruscio G, Camporese G, Parisi R, Cuppini S, Turatti G, Noventa F, Sarolo L. Recanalization rate in patients with proximal vein thrombosis treated with the direct oral anticoagulants. Thromb Res 2017; 153:97-100. [DOI: 10.1016/j.thromres.2017.03.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/19/2017] [Accepted: 03/25/2017] [Indexed: 01/01/2023]
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Rabinovich A, Kahn SR. The postthrombotic syndrome: current evidence and future challenges. J Thromb Haemost 2017; 15:230-241. [PMID: 27860129 DOI: 10.1111/jth.13569] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Indexed: 01/18/2023]
Abstract
Postthrombotic syndrome (PTS) is a chronic complication of deep vein thrombosis (DVT) that develops in 20-50% of patients. PTS manifests as a spectrum of symptoms and signs of chronic venous insufficiency that can impose significant morbidity and have a negative impact on quality of life. Chronic venous hypertension caused by a combination of residual venous obstruction and valvular reflux is believed to play a major role in the pathophysiology of PTS. The Villalta scale is the most widely applied clinical scale used to diagnose and define PTS. Proximal DVT and recurrent ipsilateral DVT are the two principal established risk factors for PTS, and efforts in recent years have been focused on identifying a combination of clinical and biomarker predictors that will define high-risk patients and possibly new therapeutic targets. The best way to prevent PTS is to prevent the occurrence of DVT, and to provide optimal anticoagulation for the acute phase of DVT once it occurs. Recent years have brought progress in our understanding of the role of endovascular techniques in the prevention and treatment of PTS and the subgroups of patients that may benefit from these modalities. Pharmacomechanical catheter-directed thrombolysis is the most promising interventional modality for prevention of PTS. This review summarizes the current state of evidence on PTS of the lower limbs, and highlights areas where uncertainty still exists that require further research.
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Affiliation(s)
- A Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - S R Kahn
- Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Division of Internal Medicine and Department of Medicine, McGill University, Montreal, Canada
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