Optimal Medical Therapy Following Deep Venous Interventions: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel

Published:September 22, 2021DOI:


      The optimal medical management of patients following endovascular deep venous interventions remains ill-defined. As such, the Society of Interventional Radiology Foundation (SIRF) convened a multidisciplinary group of experts in a virtual Research Consensus Panel (RCP) to develop a prioritized research agenda regarding antithrombotic therapy following deep venous interventions. The panelists presented the gaps in knowledge followed by discussion and ranking of research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were identified as high priority: 1) characterization of biological processes leading to in-stent stenosis/rethrombosis; 2) identification and validation of methods to assess venous flow dynamics and their effect on stent failure; 3) elucidation of the role of inflammation and anti-inflammatory therapies; and 4) clinical studies to compare antithrombotic strategies and improve venous outcome assessment. Collaborative, multicenter research is necessary to answer these questions and thereby enhance the care of patients with venous disease.


      ACCP (American College of Chest Physicians), ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis), CEA (cost-effectiveness analyses), COVID-19 (coronavirus disease 2019), DOAC (direct oral anticoagulants), DRG (diagnosis-related group), DVT (deep venous thrombosis), FDA (Food and Drug Administration), ICER (incremental cost-effectiveness ratio), IR (interventional radiologist), ISTH (International Society on Thrombosis and Haemostasis), LMWH (Low-molecular-weight heparin), PCDT (pharmacomechanical catheter-directed thrombolysis), PE (pulmonary embolism), PTS (post-thrombotic syndrome), QALY (quality-adjusted life year), QoL (quality of life), RCP (Research Consensus Panel), SIR (Society of Interventional Radiology), SIRF (Society of Interventional Radiology Foundation), VCSS (venous clinical severity Scale), VEINES-QOL (Venous Insufficiency Epidemiological and Economic Study on Quality of Life), VKA (vitamin K antagonists), VTE (venous thromboembolism), WTP (willingness to pay)
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        • Semba C.P.
        • Dake M.D.
        Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis.
        Radiology. 1994; 191: 487-494
        • Razavi M.K.
        • Hansch E.C.
        • Kee S.T.
        • et al.
        Chronically occluded inferior venae cavae: endovascular treatment.
        Radiology. 2000; 214: 133-138
        • Razavi M.K.
        • Jaff M.R.
        • Miller L.E.
        Safety and effectiveness of stent placement for iliofemoral venous outflow obstruction: systematic review and meta-analysis.
        Circ Cardiovasc Interv. 2015; 8e002772
        • Kahn S.R.
        • Julian J.A.
        • Kearon C.
        • et al.
        Quality of life after pharmacomechanical catheter-directed thrombolysis for proximal deep venous thrombosis.
        J Vasc Surg Venous Lymphat Disord. 2020; 8: 8-23.e18
        • Comerota A.J.
        • Kearon C.
        • Gu C.S.
        • et al.
        Endovascular thrombus removal for acute iliofemoral deep vein thrombosis.
        Circulation. 2019; 139: 1162-1173
        • Sista A.K.
        Postprocedural management of patients undergoing endovascular therapy for acute and chronic lower-extremity deep venous disease.
        Tech Vasc Interv Radiol. 2014; 17: 127-131
        • Drebes A.B.
        • Davies N.H.
        Anticoagulation after iliofemoral vein stenting- old versus new.
        Curr Pharm Des. 2018; 2: 4525-4533
        • Thukral S.
        • Vedantham S.
        Catheter-based therapies and other management strategies for deep vein thrombosis and post-thrombotic syndrome.
        J Clin Med. 2020; 9: 1439
        • Metz A.K.
        • Diaz J.A.
        • Obi A.T.
        • et al.
        Venous thrombosis and post-thrombotic syndrome: from novel biomarkers to biology.
        Methodist Debakey Cardiovasc J. 2018; 14: 173-181
        • Haig Y.
        • Enden T.
        • Grøtta O.
        • et al.
        Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis (CaVenT): 5-year follow-up results of an open-label, randomised controlled trial.
        Lancet Haematol. 2016; 3: e64-e71
        • Weinberg I.
        • Vedantham S.
        • Salter A.
        • et al.
        Relationships between the use of pharmacomechanical catheter-directed thrombolysis, sonographic findings, and clinical outcomes in patients with acute proximal DVT: Results from the ATTRACT Multicenter Randomized Trial.
        Vasc Med. 2019; 24: 442-451
        • Magnuson E.A.
        • Chinnakondepalli K.
        • Vilain K.
        • et al.
        Cost-effectiveness of pharmacomechanical catheter-directed thrombolysis versus standard anticoagulation in patients with proximal deep vein thrombosis: Results from the ATTRACT trial.
        Circ Cardiovasc Qual Outcomes. 2019; 12e005659
        • Grosse S.D.
        • Nelson R.E.
        • Nyarko K.A.
        • et al.
        The economic burden of incident venous thromboembolism in the United States: A review of estimated attributable healthcare costs.
        Thromb Res. 2016; 137: 3-10
        • Cushman M.
        • Barnes G.D.
        • Creager M.A.
        • et al.
        Venous thromboembolism research priorities: a scientific statement from the American Heart Association and the International Society on Thrombosis and Haemostasis.
        Circulation. 2020; 142: e85-e94
        • Grover S.P.
        • Evans C.E.
        • Patel A.S.
        • et al.
        Assessment of venous thrombosis in animal models.
        Arterioscler Thromb Vasc Biol. 2016; 36: 245-252
        • von Brühl M.L.
        • Stark K.
        • Steinhart A.
        • et al.
        Monocytes, neutrophils, and platelets cooperate to initiate and propagate venous thrombosis in mice in vivo.
        J Exp Med. 2012; 209: 819-835
        • Stein-Merlob A.F.
        • Kessinger C.W.
        • Erdem S.S.
        • et al.
        Blood accessibility to fibrin in venous thrombosis is thrombus age-dependent and predicts fibrinolytic efficacy: an in vivo fibrin molecular imaging study.
        Theranostics. 2015; 5: 1317-1327
        • Diaz J.A.
        • Obi A.T.
        • Myers D.D.
        • et al.
        Critical review of mouse models of venous thrombosis.
        Arterioscler Thromb Vasc Biol. 2012; 32: 556-562
        • Albadawi H.
        • Witting A.A.
        • Pershad Y.
        • et al.
        Animal models of venous thrombosis.
        Cardiovasc Diagn Ther. 2017; 7: S197-S206
        • Andraska E.A.
        • Luke C.E.
        • Elfline M.A.
        • et al.
        Pre-clinical model to study recurrent venous thrombosis in the inferior vena cava.
        Thromb Haemost. 2018; 118: 1048-1057
        • Obi A.T.
        • Andraska E.
        • Kanthi Y.
        • et al.
        Endotoxaemia-augmented murine venous thrombosis is dependent on TLR-4 and ICAM-1, and potentiated by neutropenia.
        Thromb Haemost. 2017; 117: 339-348
        • Münster A.M.
        • Olsen A.K.
        • Bladbjerg E.M.
        Usefulness of human coagulation and fibrinolysis assays in domestic pigs.
        Comp Med. 2002; 52: 39-43
        • Ortel T.L.
        • Neumann I.
        • Ageno W.
        • et al.
        American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism.
        Blood Adv. 2020; 4: 4693-4738
        • Iorio A.
        • Kearon C.
        • Filippucci E.
        • et al.
        Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review.
        Arch Intern Med. 2010; 170: 1710-1716
        • Lecumberri R.
        • Alfonso A.
        • Jiménez D.
        • et al.
        Dynamics of case-fatalilty rates of recurrent thromboembolism and major bleeding in patients treated for venous thromboembolism.
        Thromb Haemost. 2013; 110: 834-843
        • Carrier M.
        • Le Gal G.
        • Wells P.S.
        • et al.
        Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism.
        Ann Intern Med. 2010; 152: 578-589
        • Schulman S.
        How I treat recurrent venous thromboembolism in patients receiving anticoagulant therapy.
        Blood. 2017; 129: 3285-3293
        • Williams Z.F.
        • Dillavou E.D.
        A systematic review of venous stents for iliac and venacaval occlusive disease.
        J Vasc Surg Venous Lymphat Disord. 2020; 8: 145-153
        • Murphy E.H.
        • Johns B.
        • Varney E.
        • et al.
        Endovascular management of chronic total occlusions of the inferior vena cava and iliac veins.
        J Vasc Surg Venous Lymphat Disord. 2017; 5: 47-59
        • Ye K.
        • Lu X.
        • Li W.
        • et al.
        Outcomes of stent placement for chronic occlusion of a filter-bearing inferior vena cava in patients with severe post-thrombotic syndrome.
        Eur J Vasc Endovasc Surg. 2016; 52: 839-846
        • te Riele W.W.
        • Overtoom T.T.
        • van den Berg J.C.
        • et al.
        Endovascular recanalization of chronic long-segment occlusions of the inferior vena cava: midterm results.
        J Endovasc Ther. 2006; 13: 249-253
        • Williams D.M.
        Iliocaval reconstruction in chronic deep vein thrombosis.
        Tech Vasc Interv Radiol. 2014; 17: 109-113
        • McAree B.J.
        • O'Donnell M.E.
        • Fitzmaurice G.J.
        • et al.
        Inferior vena cava thrombosis: a review of current practice.
        Vasc Med. 2013; 18: 32-43
        • Carroll B.J.
        • Piazza G.
        Hypercoagulable states in arterial and venous thrombosis: When, how, and who to test?.
        Vasc Med. 2018; 23: 388-399
        • Middeldorp S.
        • Prins M.H.
        • Hutten B.A.
        Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism.
        Cochrane Database Syst Rev. 2014; 2014: CD001367
        • Fox B.D.
        • Kahn S.R.
        • Langleben D.
        • et al.
        Efficacy and safety of novel oral anticoagulants for treatment of acute venous thromboembolism: direct and adjusted indirect meta-analysis of randomised controlled trials.
        BMJ. 2012; 345: e7498
        • Kearon C.
        • Akl E.A.
        • Ornelas J.
        • et al.
        Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.
        Chest. 2016; 149: 315-352
        • Lyman G.H.
        • Khorana A.A.
        • Kuderer N.M.
        • et al.
        Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update.
        J Clin Oncol. 2013; 31: 2189-2204
        • Branchford B.R.
        • Carpenter S.L.
        The role of inflammation in venous thromboembolism.
        Front Pediatr. 2018; 6: 142
        • Al-Ani F.
        • Chehade S.
        • Lazo-Langner A.
        Thrombosis risk associated with COVID-19 infection. A scoping review.
        Thromb Res. 2020; 192: 152-160
        • Folsom A.R.
        • Lutsey P.L.
        • Astor B.C.
        • et al.
        C-reactive protein and venous thromboembolism. A prospective investigation in the ARIC cohort.
        Thromb Haemost. 2009; 102: 615-619
        • Vazquez-Garza E.
        • Jerjes-Sanchez C.
        • Navarrete A.
        • et al.
        Venous thromboembolism: thrombosis, inflammation, and immunothrombosis for clinicians.
        J Thromb Thrombolysis. 2017; 44: 377-385
        • Milinis K.
        • Thapar A.
        • Shalhoub J.
        • et al.
        Antithrombotic therapy following venous stenting: international Delphi consensus.
        Eur J Vasc Endovasc Surg. 2018; 55: 537-544
        • Mabud T.S.
        • Cohn D.M.
        • Arendt V.A.
        • et al.
        Lower extremity venous stent placement: A large retrospective single-center analysis.
        J Vasc Interv Radiol. 2020; 31: 251-259.e2
        • Mewissen M.W.
        • Seabrook G.R.
        • Meissner M.H.
        • et al.
        Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry.
        Radiology. 1999; 211: 39-49
        • Hays K.
        • Jolly M.
        • Silver M.
        • et al.
        Outcomes of endovascular venous stenting in patients on direct oral anticoagulants and antiplatelet therapy at a tertiary referral center.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 753-759.e1
        • Sebastian T.
        • Hakki L.O.
        • Spirk D.
        • et al.
        Rivaroxaban or vitamin-K antagonists following early endovascular thrombus removal and stent placement for acute iliofemoral deep vein thrombosis.
        Thromb Res. 2018; 172: 86-93
        • Endo M.
        • Jahangiri Y.
        • Horikawa M.
        • et al.
        Antiplatelet therapy is associated with stent patency after iliocaval venous stenting.
        Cardiovasc Intervent Radiol. 2018; 41: 1691-1698
        • Cohn D.M.
        • Mabud T.S.
        • Arendt V.A.
        • et al.
        Toward data-driven learning healthcare systems in interventional radiology: implementation to evaluate venous stent patency.
        J Digit Imaging. 2020; 33: 25-36
        • Neglén P.
        • Hollis K.C.
        • Olivier J.
        • et al.
        Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result.
        J Vasc Surg. 2007; 46: 979-990
        • Wik H.S.
        • Enden T.R.
        • Ghanima W.
        • et al.
        Diagnostic scales for the post-thrombotic syndrome.
        Thromb Res. 2018; 164: 110-115
        • Kahn S.R.
        • Desmarais S.
        • Ducruet T.
        • et al.
        Comparison of the villalta and ginsberg clinical scales to diagnose the post-thrombotic syndrome: correlation with patient-reported disease burden and venous valvular reflux.
        J Thromb Haemost. 2006; 4: 907-908
        • Villalta S.
        • Bagatella P.
        • Piccioli A.
        • et al.
        Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome.
        Haemostasis. 1994; 24: 158a
        • Vasquez M.A.
        • Rabe E.
        • McLafferty R.B.
        • et al.
        Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American Venous Forum Ad Hoc Outcomes Working Group.
        J Vasc Surg. 2010; 52: 1387-1396
        • Kahn S.R.
        • Shapiro S.
        • Wells P.S.
        • et al.
        Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial.
        Lancet. 2014; 383: 880-888
        • Vedantham S.
        • Goldhaber S.Z.
        • Julian J.A.
        • et al.
        Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis.
        N Engl J Med. 2017; 377: 2240-2252
        • Jayaraj A.
        • Meissner M.H.
        A comparison of villalta-prandoni scale and venous clinical severity score in the assessment of post thrombotic syndrome.
        Ann Vasc Surg. 2014; 28: 313-317
        • Lamping D.L.
        • Schroter S.
        • Kurz X.
        • Kahn S.R.
        • Abenhaim L.
        Evaluation of outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life.
        J Vasc Surg. 2003; 37: 410-419
      1. U.S. Department of Health and Human Services FDA Center for Drug Evaluation and Research, U.S. Department of Health and Human Services FDA Center for Biologics Evaluation and Research, and U.S. Department of Health and Human Services FDA Center for Devices and Radiological Health. Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims: draft guidance.
        Health Qual Life Outcomes. 2006; 4: 79
        • Prandoni P.
        • Villalta S.
        • Bagatella P.
        • et al.
        The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients.
        Haematologica. 1997; 82: 423-428
        • Rognoni C.
        • Lugli M.
        • Maleti O.
        • et al.
        Venous stenting for patients with outflow obstruction and leg ulcers: cost-effectiveness and budget impact analyses.
        J Comp Eff Res. 2020; 9: 705-720
        • Aujesky D.
        • Smith K.J.
        • Roberts M.S.
        Oral anticoagulation strategies after a first idiopathic venous thromboembolic event.
        Am J Med. 2005; 118: 625-635
        • Tosetto A.
        • Castaman G.
        • Rodeghiero F.
        Bleeders, bleeding rates, and bleeding score.
        J Thromb Haemost. 2013; 11: 142-150
        • Bergmark B.A.
        • Kamphuisen P.W.
        • Wiviott S.D.
        • et al.
        Comparison of events across bleeding scales in the ENGAGE AF-TIMI 48 trial.
        Circulation. 2019; 140: 1792-1801
        • Landefeld C.S.
        • Anderson P.A.
        • Goodnough L.T.
        • et al.
        The bleeding severity index: validation and comparison to other methods for classifying bleeding complications of medical therapy.
        J Clin Epidemiol. 1989; 42: 711-718
        • Graafsma Y.P.
        • Prins M.H.
        • Lensing A.W.
        • et al.
        Bleeding classification in clinical trials: observer variability and clinical relevance.
        Thromb Haemost. 1997; 78: 1189-1192
        • Knight C.
        • Paisley S.
        • Wight J.
        • et al.
        Economic modelling of different treatment strategies for haemophilia A with high-responding inhibitors.
        Haemophilia. 2003; 9: 521-540