Katalin Lestak1, Anna Louise Pouncey1, Adam Gwozdz1, Justinas Silickas1, Leslie Fiengo1, Oscar Johnson1, Alberto Smith1, Prakash Saha1, Beverley Hunt2, Catherine Nelson-Piercy3, Susan Robinson2, Karen Breen2, Stephen Black4. 1. School of Cardiovascular Medicine and Science, Academic Department of Vascular Surgery, St Thomas' Hospital, King's College London, London, United Kingdom. 2. Clinical Haematology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom. 3. Division of Women's Health, Women's Health Academic Centre, King's College London, London, United Kingdom. 4. School of Cardiovascular Medicine and Science, Academic Department of Vascular Surgery, St Thomas' Hospital, King's College London, London, United Kingdom. Electronic address: stephen.black@kcl.ac.uk.
Abstract
BACKGROUND: The development of post-thrombotic syndrome (PTS) after iliofemoral deep vein thrombosis (DVT) continues to be a considerable issue for both pregnant and postpartum women with rates as high as 70% among those managed with anticoagulation alone. This study aims to characterize the outcomes of interventional treatment for acute iliofemoral DVT in this at-risk population. METHODS: A retrospective analysis of all postpartum patients treated for acute iliofemoral DVT with lysis and stenting between January 2012 and December 2017 at a referral center. Patient demographics, risk factors, procedural factors. and complications were collected. Post-treatment outcomes were compared with all nonpostpartum females treated within the same time period. These included the severity of PTS evaluated using the Villalta scale, duration of vessel patency and factors affecting reintervention timing and success. Further detailed review of cases needing reintervention was also conducted through a retrospective review of documentation and an analysis of all imaging by a consultant radiologist. RESULTS: A total of 11 postpartum women were identified. The median age was 28 years (range, 22-41 years) and intervention was performed at a median of 3 weeks after birth (range 2-12 weeks). No major or minor complications associated with intervention were reported in any patients. The median Villalta score was 3 at 6 months, improving to 2 at 12 months. Overall, two patients were classified as mild having PTS (18%), with no cases of moderate to severe PTS. On comparison with nonpostpartum (n = 68) Villalta scores, no significant difference in outcome was observed at 6 months (median score, 3; range, 0-15 months; P = .95) or at 1 year (median score, 1; range, 0-15; P = .84). Cumulative patency at 1 year was found to be 64% in postpartum women compared with 93% in nonpostpartum women. The postpartum state was found to be a significant predictor of cumulative patency loss (hazard ratio, 0.10; 95% confidence interval, 0.02-0.62; P = .01). However, no significant difference in primary and primary-assisted patency was observed. Of the postpartum patients, 55% required reintervention (6/11) compared with 29% of nonpostpartum patients (20/68). The mean time to initial reintervention was 62 days (range, 7-233 days). Reintervention was unsuccessful in all cases presenting with 100% vessel occlusion (4/11), but successful in both cases with partial occlusion (2/11). Analysis of the etiologic factors associated with reintervention revealed that all reintervention cases were associated with technical failure to fully lyse and stent beyond residual disease at the initial procedure. No technical, flow, or hematologic factors were identified in the four cases that retained primary patency. CONCLUSIONS: This study suggests that percutaneous intervention to achieve early thrombus removal and venous stenting provides a favorable alternative to conservative therapies owing to its potential to decrease the severity of PTS. Completion of lysis and adequate stenting of disease is essential to prevent reocclusion, for which reintervention carries a lower likelihood of success. Further research is warranted to further characterize the appropriate management of postpartum women with iliofemoral DVT.
BACKGROUND: The development of post-thrombotic syndrome (PTS) after iliofemoral deep vein thrombosis (DVT) continues to be a considerable issue for both pregnant and postpartum women with rates as high as 70% among those managed with anticoagulation alone. This study aims to characterize the outcomes of interventional treatment for acute iliofemoral DVT in this at-risk population. METHODS: A retrospective analysis of all postpartum patients treated for acute iliofemoral DVT with lysis and stenting between January 2012 and December 2017 at a referral center. Patient demographics, risk factors, procedural factors. and complications were collected. Post-treatment outcomes were compared with all nonpostpartum females treated within the same time period. These included the severity of PTS evaluated using the Villalta scale, duration of vessel patency and factors affecting reintervention timing and success. Further detailed review of cases needing reintervention was also conducted through a retrospective review of documentation and an analysis of all imaging by a consultant radiologist. RESULTS: A total of 11 postpartum women were identified. The median age was 28 years (range, 22-41 years) and intervention was performed at a median of 3 weeks after birth (range 2-12 weeks). No major or minor complications associated with intervention were reported in any patients. The median Villalta score was 3 at 6 months, improving to 2 at 12 months. Overall, two patients were classified as mild having PTS (18%), with no cases of moderate to severe PTS. On comparison with nonpostpartum (n = 68) Villalta scores, no significant difference in outcome was observed at 6 months (median score, 3; range, 0-15 months; P = .95) or at 1 year (median score, 1; range, 0-15; P = .84). Cumulative patency at 1 year was found to be 64% in postpartum women compared with 93% in nonpostpartum women. The postpartum state was found to be a significant predictor of cumulative patency loss (hazard ratio, 0.10; 95% confidence interval, 0.02-0.62; P = .01). However, no significant difference in primary and primary-assisted patency was observed. Of the postpartum patients, 55% required reintervention (6/11) compared with 29% of nonpostpartum patients (20/68). The mean time to initial reintervention was 62 days (range, 7-233 days). Reintervention was unsuccessful in all cases presenting with 100% vessel occlusion (4/11), but successful in both cases with partial occlusion (2/11). Analysis of the etiologic factors associated with reintervention revealed that all reintervention cases were associated with technical failure to fully lyse and stent beyond residual disease at the initial procedure. No technical, flow, or hematologic factors were identified in the four cases that retained primary patency. CONCLUSIONS: This study suggests that percutaneous intervention to achieve early thrombus removal and venous stenting provides a favorable alternative to conservative therapies owing to its potential to decrease the severity of PTS. Completion of lysis and adequate stenting of disease is essential to prevent reocclusion, for which reintervention carries a lower likelihood of success. Further research is warranted to further characterize the appropriate management of postpartum women with iliofemoral DVT.