Deep Dive on Anticoagulation Regimens for Venous Interventions

In this episode, pediatric interventional radiologist Dr. Fred Bertino joins our host Dr. Chris Beck to discuss new data on anticoagulation regimes before, during, and after venous stenting and/or mechanical thrombectomy.

Dr. Bertino starts by reviewing the difference between the compositions of arterial versus venous clots. Arterial clots are formed as a response to endothelial injury and exposure of von Willebrand factor, so these clots are usually platelet-rich. On the other hand, venous clots are formed due to stasis, and these are usually platelet-poor. Therefore, antiplatelet therapy may not be ideal for venous clots. However, Dr. Bertino notes that stent placement can cause endothelial injury at the apposition points of the stent, so the treatment algorithm can become more complex in these cases.

The doctors note that there are non-thrombotic diseases that require venous stenting, such as May Thurner syndrome. Dr. Bertino says that addressing this early in the pediatric population can be a safe way to prevent future DVT, as long as children are monitored carefully.

Next, Dr. Bertino walks us through his preferred anticoagulation routine for stent placement. Four hours before the procedure, he starts with a dose of Factor Xa inhibitor (apixaban or rivaroxaban) to prevent in-stent thrombosis. The patient is maintained on heparin during the procedure. After the procedure, anticoagulation varies depending on whether a stent was placed, or solely mechanical thrombectomy was performed.

Finally, the doctors discuss preferred anticoagulation for special scenarios such as covered stents (which can be more thrombophilic) and patients with malignancies. Dr. Bertino encourages IRs to reach out to their hematology colleagues to stay updated on anticoagulation research, as well as physical and occupational therapists to help patients form long-term DVT prevention plans.