Worse outcomes in peripartum compared to non-pregnant women stented for DVT

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Peripartum women with deep vein thrombosis (DVT) treated with catheter-directed thrombolysis and venous stenting had significantly increased rates of reintervention and loss of stent patency compared with non-pregnant women treated at the same centre.

Katalin Lestak (St Thomas’ Hospital, London, UK) presented the outcomes from a database of patients treated at St Thomas’ Hospital at the European Society for Vascular Surgery (ESVS) annual meeting (25–28 September, Valencia, Spain).

Lestak pointed out that acute iliofemoral DVT affects around 100,000 people in the UK alone and 42% will go on to develop post-thrombotic syndrome. As it stands, maternal DVT is one of the leading causes of direct mortality and morbidity in pregnant women. The current management of maternal DVT is primarily with conservative methods, but trials have shown the benefit of early clot removal and catheter-directed thrombolysis with or without stenting reducing the amount of post-thrombotic syndrome. However, pregnant women have been excluded from these trials due to the procedural risk of maternal and foetal complication.

In lieu of this, the team at St Thomas’ Hospital wanted to examine the outcomes of peripartum women with acute iliofemoral DVT presenting to their centre who have undergone catheter-directed thrombolysis and venous stenting. They performed a retrospective review of peripartum women from a database on 190 patients treated for acute iliofemoral DVT from 2012–2017. In the study, peripartum was defined as within pregnancy or up to and including six weeks post birth.

Stent patency was assessed by duplex ultrasonography at one day, two weeks, six weeks, three months, one year and annually postintervention. It was defined as <50% reduction in stent diameter.

The results were compared to non-pregnant women from the same database. The researchers found nine peripartum women treated for acute iliofemoral DVT. Of those nine, two were treated with catheterdirected thrombolysis alone and seven were treated with catheter-directed thrombolysis and venous stenting.

Lestak reported that all patients were in the peripartum with an average of four weeks post-birth. “This reflects the maximum risk time for maternal venous thromboembolism, which is zero to six weeks postbirth, where 50% of maternal venous thromboembolism occurs. No patients had any history of venous thromboembolism or thrombophilia and none were on any anti-coagulation. Importantly, management by this method did not lead to any major or minor post-operative complications, including haemorrhage or other bleeding. Our rate of post-thrombotic syndrome was 14% at six-month follow-up,” she explained.

Another important and novel finding from the study, Lestak added, came when looking at cumulative rates of patency and reintervention, when substantial differences were noted between peripartum women and their non-pregnant counterparts. “When compared, peripartum women were significantly more likely to suffer loss of patency generally occurring early on, at around eight weeks post-stenting. This then followed through into rates of reintervention, where the peripartum state once again proved to be correlated to the need for further operative management,” she emphasised.

Lestak maintained that one potential explanation for these results is the hyper coagulable post thrombotic state of pregnancy, which contributes to the increased risk of thrombus formation and therefore blocking these patients’ stents.

This study has some limitations, including its retrospective nature and small sample size. Further, all of the patients were post-partum, and the results therefore cannot be extrapolated to the period before birth.

Concluding, Lestak said that this study found that peripartum women are significantly more likely to require reintervention and experience stent patency loss compared to their non-pregnant counterparts.

“Although symptomatically these women do well, higher thresholds for intervention may need to be considered, as well as more tailored case by case management of those patients undergoing catheter-directed thrombolysis and stenting in pregnancy,” she stated.

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