Abstract
Background
The optimal antithrombotic strategy after iliofemoral venous stenting remains uncertain.
Objectives
This study aimed to evaluate the association of dual-pathway antithrombotic therapy with primary patency after iliofemoral venous stenting.
Methods
This ambispective, multicenter observational study included consecutive patients who underwent successful iliofemoral venous stent implantation between 2019 and 2024. Patients were categorized according to their postoperative antithrombotic regimen into dual-pathway antithrombotic therapy (anticoagulation plus antiplatelet therapy [AC+APT]) and anticoagulation (AC) alone groups. The primary outcome was primary stent patency. Cox regression was used to identify independent predictors of loss of patency.
Results
A total of 247 patients were included, with 145 receiving AC+APT and 102 receiving AC alone. During a median follow-up of 24 months (IQR, 15-38 months), the overall primary patency rate was 91.1%. Primary patency did not differ significantly between the AC+APT and AC groups in the overall cohort (log-rank P = 1.00). However, in the post-thrombotic syndrome subgroup, AC alone was associated with a higher risk of patency loss compared with AC+APT (hazard ratio, 3.31; 95% CI, 1.02-10.74; P = .047).
Conclusion
Primary patency after iliofemoral venous stenting was similarly high with dual-pathway antithrombotic therapy and AC alone. An exploratory analysis suggested a possible association between AC+APT and improved patency in patients with post-thrombotic syndrome. Adequately powered randomized trials with longer follow-up are needed to confirm this finding and assess long-term safety.
Keywords: anticoagulants, iliac vein, platelet aggregation inhibitors, post-thrombotic syndrome, stents, vascular patency
Essentials
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The best antithrombotic strategy after venous stenting remains uncertain.
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We studied 247 patients after iliofemoral venous stenting in 4 centers.
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Overall patency was similar with or without added antiplatelet therapy.
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A possible association in PTS patients with post-thrombotic syndrome requires confirmation in randomized trials.
1. Introduction
Chronic iliac vein obstruction, primarily caused by May-Thurner syndrome or post-thrombotic syndrome (PTS), is a significant source of morbidity, leading to persistent pain, swelling, and venous claudication that substantially impairs patients' quality of life [[1], [2], [3]]. Endovascular therapy, particularly percutaneous transluminal angioplasty followed by stent placement, has become a highly promising treatment option for symptomatic iliac vein obstruction [4]. By restoring venous outflow, stent implantation alleviates symptoms, accelerates ulcer healing, and improves quality of life [3,[5], [6], [7]]. Nevertheless, maintaining long-term stent patency remains a challenge. A previous systematic review reported a median primary patency rate of 75% (range, 38%-98%) across all patient groups [3]. In-stent restenosis and thrombosis are the principal causes of stent failure and the need for reintervention [8].
Antithrombotic therapy is widely used after iliofemoral venous stenting and is considered important for maintaining stent patency and reducing the risk of reocclusion and reintervention [[9], [10], [11]]. Unlike arterial interventions, where platelet-driven thrombosis predominates and antiplatelet therapy is the mainstay of treatment, venous thrombosis occurs in a low-shear environment and is characterized by fibrin-rich clot formation, making anticoagulation (AC) the cornerstone of treatment [6]. However, the optimal poststenting regimen remains unclear. In particular, whether antiplatelet agents should be added to AC continues to be debated. Current practices vary from AC alone, using vitamin K antagonists or direct oral anticoagulants (DOACs), to dual-pathway antithrombotic therapy, defined as anticoagulation plus antiplatelet therapy (AC+APT), but comparative data remain limited [12]. International guidelines and expert consensus statements provide no specific recommendations and have not reached a consensus on this issue [5,8,[13], [14], [15]].
The ARIVA study [16] compared AC+APT therapy with AC alone in patients with PTS undergoing iliofemoral venous stenting. Although similarly high short-term patency rates were observed in both groups over 6 months, evidence regarding mid- and long-term patency remains limited. Given that restenosis and stent occlusion may occur beyond the early postoperative period, further real-world data are needed to clarify the association between postprocedural antithrombotic strategy and longer-term venous stent outcomes. Therefore, this multicenter cohort study aimed to evaluate the association of dual-pathway antithrombotic therapy with primary patency after iliofemoral venous stenting.
2. Methods
2.1. Study design and setting
This multicenter, ambispective cohort study was conducted across 4 tertiary medical centers. Consecutive patients who underwent successful iliofemoral venous stent implantation between July 2019 and December 2024 were screened for eligibility. Baseline clinical and procedural data were retrospectively extracted from the electronic medical records, whereas follow-up data were prospectively collected through outpatient visits and supplemented by telephone follow-up when necessary. Follow-up continued until June 30, 2025, or the last available clinical contact.
This study was approved by the Ethics Committee of Zhongshan Hospital, Fudan University (approval number B2024-301R) and was conducted in accordance with the Declaration of Helsinki. Owing to the observational nature of the study and the use of deidentified data, the requirement for written informed consent was waived. This study was registered with the Chinese Clinical Trial Registry (ChiCTR2500102167).
2.2. Patient selection
Patients were included if they met the following criteria: (1) age ≥18 years; (2) diagnosis of iliac vein stenosis or occlusion, including nonthrombotic iliac vein lesions (NIVL), acute deep vein thrombosis (aDVT), and PTS, confirmed by imaging studies; (3) underwent successful iliofemoral venous stenting; and (4) had complete medical records available for review. aDVT was defined as symptomatic DVT with a symptom duration of ≤14 days before intervention. PTS was diagnosed based on a history of prior DVT with persistent chronic venous symptoms and imaging evidence of post-thrombotic changes. NIVL were defined as iliac vein compression or stenosis without prior thrombosis. Exclusion criteria included (1) lack of follow-up data or a follow-up duration of <6 months; (2) receipt of neither AC nor antiplatelet therapy postprocedurally, or receipt of antiplatelet therapy without concomitant AC.
2.3. Postprocedural antithrombotic regimens
Patients were categorized according to their postprocedural antithrombotic regimen into AC and AC+APT groups. AC consisted predominantly of DOACs, with a small minority of patients receiving vitamin K antagonists. In the AC+APT group, antiplatelet therapy was administered in combination with AC for 3 months, after which patients were transitioned to AC alone. Therapeutic-dose AC was defined according to standard dosing regimens for venous thromboembolism, whereas prophylactic dosing referred to reduced-intensity regimens at the discretion of the treating physician. Perioperative low-molecular-weight heparin (LMWH) was routinely administered during hospitalization and continued for several days postoperatively before transitioning to oral AC. The specific choice of anticoagulant agents, dosing intensity, and duration of LMWH therapy were determined by the treating physician based on individual patient risk profiles. In patients with aDVT, prestenting thrombus management strategies, including catheter-directed thrombolysis, mechanical thrombectomy, or AC alone, were performed at the discretion of the treating physician.
2.4. Outcome measures
The primary outcome was primary stent patency, defined as the absence of in-stent restenosis or stent occlusion without the need for target lesion reintervention during follow-up. Restenosis or occlusion was defined as ≥50% luminal narrowing or complete loss of patency within the stented segment as assessed by duplex ultrasound, computed tomography venography, or venography. The secondary outcome was bleeding events during follow-up. Major bleeding was defined according to the International Society on Thrombosis and Haemostasis criteria [17]. Clinically relevant nonmajor bleeding and minor bleeding were defined based on definitions used in the previous study [18]. Patients were scheduled for follow-up at 3, 6, and 12 months after the procedure, and annually thereafter. Follow-up assessments included clinical evaluation and imaging studies, primarily duplex ultrasound and computed tomography venography, with additional venography performed when clinically indicated. Outcome assessment was based on the most recent available follow-up data for each patient. The follow-up period concluded on June 30, 2025, or at the time of the last available follow-up data for each patient.
2.5. Data collection
Baseline clinical and procedural data were retrospectively extracted from the electronic medical record system, including demographic characteristics, comorbidities, prior thromboembolic events (DVT and pulmonary embolism), and lesion characteristics (stenotic or occlusive). Baseline laboratory parameters, including platelet count, serum creatinine, and coagulation profiles, were also recorded. Procedural details, including stent number, type, diameter, and brand, were collected. Follow-up data, including postprocedural antithrombotic regimens, bleeding events, and stent patency, were prospectively obtained through outpatient visits and supplemented by telephone follow-up when necessary.
2.6. Statistical analysis
Descriptive statistics were used to summarize baseline characteristics and clinical outcomes. Continuous variables were expressed as mean ± SD or median with IQR, as appropriate according to data distribution, and categorical variables were presented as counts and percentages. Comparisons between groups were performed using Student’s t-test or Mann–Whitney U-test for continuous variables and the chi-square test or the Fisher exact test for categorical variables, as appropriate. Kaplan–Meier analysis was used to estimate primary patency, and log-rank tests were used for group comparisons. Cox proportional hazards regression was performed to evaluate the association between antithrombotic regimen and loss of primary patency after adjustment for potential confounders. Hazard ratios (HRs) and 95% CIs were reported. Variables with a P < .10 in univariable analysis and clinically relevant covariates were considered for inclusion in multivariable models. Subgroup analyses were performed according to etiology (NIVL, aDVT, and PTS), and an interaction term between etiology and antithrombotic regimen was included to assess heterogeneity of association across etiologies. A 2-sided P value of <.05 was considered statistically significant. All statistical analyses were performed using R software (version 4.3.0; R Foundation for Statistical Computing, Vienna, Austria).
3. Results
3.1. Study population and baseline characteristics
A total of 326 consecutive patients who successfully underwent stent implantation were initially screened for eligibility, of whom 247 were ultimately included in the final analysis. Of these, 145 patients received AC+APT, whereas 102 patients received AC alone. The patient selection process is illustrated in Figure 1. Baseline characteristics are summarized in Table 1. Age, sex, body mass index, laboratory parameters, and comorbidities were generally similar between the 2 groups. The most notable descriptive difference was the distribution of clinical diagnoses, with PTS being more frequent in the AC+APT group and aDVT more frequent in the AC group. Baseline characteristics stratified by etiology are presented in Supplementary Table 1.
Figure 1.
Patient selection flow chart for iliofemoral venous stenting. AC, anticoagulation; AC+APT, anticoagulation plus antiplatelet therapy.
Table 1.
Baseline characteristics of patients in 2 antithrombotic therapy groups.
| Variablea | AC+APT group (n = 145) | AC group (n = 102) |
|---|---|---|
| Age (y) | 65 (58-71) | 66 (59-72) |
| BMI (kg/m2) | 24.98 (23.53-26.67) | 24.98 (23.27-26.57) |
| Sex (female) | 73 (50.3) | 49 (48.0) |
| Diagnosis | ||
| NIVL | 85 (58.6) | 52 (51.0) |
| aDVT | 23 (15.9) | 33 (32.4) |
| PTS | 37 (25.5) | 17 (16.7) |
| Classification by pathology | ||
| Stenosis | 113 (77.9) | 71 (69.6) |
| Occlusion | 32 (22.1) | 31 (30.4) |
| Laboratory tests | ||
| Platelet count (109/L)a | 205 (170-242) | 206 (165-243) |
| ALT (U/L) | 17 (13-27) | 17 (13-25) |
| AST (U/L) | 20 (17-27) | 20 (16-27) |
| eGFR (ml/min/1.73 m2) | 89 (79-96) | 89 (83-94) |
| Glucose (mmol/L) | 5.4 (5.0-6.3) | 5.4 (5.1-6.3) |
| Total cholesterol (mmol/L) | 4.60 (4.30-4.70) | 4.60 (4.40-4.97) |
| Triglycerides (mmol/L) | 1.40 (1.20-1.50) | 1.40 (1.30-1.90) |
| LDL-C (mmol/L) | 2.60 (2.40-2.70) | 2.60 (2.40-2.90) |
| HDL-C (mmol/L) | 1.12 (1.10-1.20) | 1.12 (1.10-1.20) |
| Prothrombin time (s) | 11.90 (11.30-12.50) | 11.70 (11.20-12.38) |
| INR | 1.00 (1.00-1.10) | 1.00 (0.90-1.00) |
| Fibrinogen (mg/dL) | 279 (239-322) | 295 (257-370) |
| D-dimer (mg/L) | 0.40 (0.20-0.80) | 0.40 (0.20-2.40) |
| History of thrombotic disease | ||
| Pulmonary embolism | 8 (5.5) | 4 (3.9) |
| Deep vein thrombosis | 36 (24.8) | 22 (21.6) |
| Coronary artery disease | 8 (5.5) | 5 (4.9) |
| Ischemic stroke | 6 (4.1) | 5 (4.9) |
| Peripheral artery disease | 6 (4.1) | 1 (1.0) |
| Atrial fibrillation | 3 (2.1) | 2 (2.0) |
| Comorbidities | ||
| Hypertension | 45 (31.0) | 34 (33.3) |
| Diabetes mellitus | 14 (9.7) | 18 (17.6) |
| Heart failure | 1 (0.8) | 0 (0.0) |
| Cancer | 9 (6.2) | 14 (13.7) |
| Renal insufficiency | 0 (0.0) | 1 (1.0) |
| Others | 11 (7.6) | 9 (8.8) |
ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; DVT, acute deep vein thrombosis; eGFR, estimated glomerular filtration rate; HDL-C, high-density lipoprotein cholesterol; INR, international normalized ratio; LDL-C, low-density lipoprotein cholesterol; NIVL, nonthrombotic iliac vein lesion; PTS, post-thrombotic syndrome.
Continuous variables are presented as the median and IQR, and categorical variables as counts and percentages.
3.2. Stent characteristics
The median number of implanted stents was 1 (IQR, 1-2). Most patients received a single stent (57.5%), followed by 2 stents (29.6%) and ≥3 stents (13.0%). Stents were predominantly placed on the left side (77.3%), and dedicated venous stents were used in 61.1% of patients. The median stent diameter was 14 (IQR, 12-14) mm, and 51.4% received stents ≥14 mm. Detailed stent characteristics are provided in Supplementary Table 2. Stent characteristics also varied across etiologies, with patients with PTS generally receiving a greater number of stents, whereas larger-diameter stents were more commonly used in patients with NIVL (Supplementary Table 3).
3.3. Medication regimens
Postoperatively, approximately 85% of patients received perioperative LMWH during hospitalization, followed by transition to oral AC. Oral AC in the overall cohort consisted predominantly of DOACs (239 of 247, 96.8%), including rivaroxaban and edoxaban. Antiplatelet therapy in the AC+APT group consisted mainly of aspirin (80%), with clopidogrel used as an alternative. Differences in anticoagulant dosing intensity were observed between groups. Therapeutic-dose AC predominated in the AC group (60%), whereas in the AC+APT group, prophylactic-dose AC (41%) was used nearly as frequently as therapeutic dosing (44%). Detailed treatment patterns are shown in Figure 2.
Figure 2.
Distribution of anticoagulation dosing strategies by clinical etiology and antithrombotic regimen. AC, anticoagulation; AC+APT, anticoagulation plus antiplatelet therapy; aDVT, acute deep vein thrombosis; NIVL, nonthrombotic iliac vein lesion; PTS, post-thrombotic syndrome.
3.4. Stent patency and predictors
The median follow-up duration was 24 months (IQR, 15-38 months). The overall primary patency rate was 91.1%, with no statistically significant difference between the AC+APT group (90.3%) and the AC group (92.2%; P = .66).
Kaplan–Meier analysis showed no significant difference in primary patency between the 2 treatment strategies (log-rank P = 1.00; Figure 3). In the multivariable Cox regression analysis, occlusive lesion morphology was the only independent predictor of patency loss (multivariable HR, 4.62; 95% CI; 1.55-13.81; P = .006). The univariable and multivariable analyses are presented in Table 2.
Figure 3.
Kaplan–Meier estimates of primary stent patency according to antithrombotic strategy in the overall cohort. The shaded areas represent 95% CIs, and the tick marks indicate censored observations. AC, anticoagulation; AC+APT, anticoagulation plus antiplatelet therapy; HR, hazard ratio.
Table 2.
Cox regression analysis of factors associated with primary stent patency loss in the overall cohort.
| Variable | Univariable analysis |
Multivariable analysis |
||
|---|---|---|---|---|
| HR (95% CI)a | P value | HR (95% CI)a | P value | |
| Diagnosis | ||||
| NIVL | Ref | Ref | ||
| aDVT | 3.83 (1.08-13.61) | .04 | 1.35 (0.29-6.22) | .70 |
| PTS | 7.62 (2.45-23.65) | <.001 | 2.61 (0.62-11.06) | .19 |
| Classification by pathology | ||||
| Stenosis | Ref | |||
| Occlusion | 7.31 (2.94-18.17) | <.001 | 4.62 (1.55-13.81) | .006 |
| Mean stent diameter (≥14 mm) | 0.28 (0.10-0.77) | .01 | 0.81 (0.25-2.68) | .73 |
| Total stent number | ||||
| 1 | Ref | Ref | ||
| 2 | 3.43 (1.25-9.45) | .02 | 1.90 (0.61-5.88) | .27 |
| ≥3 | 3.85 (1.23-12.01) | .02 | 1.20 (0.31-4.66) | .79 |
DVT, deep vein thrombosis; HR, hazard ratio; NIVL, nonthrombotic iliac vein lesion; PTS, post-thrombotic syndrome.
HR >1 indicates an increased hazard of primary patency loss.
3.5. Etiology-specific and subgroup analyses
Primary patency differed significantly across etiologies (P < .001). The incidence of restenosis or occlusion was highest in patients with PTS (22.1%), followed by aDVT (10.7%) and NIVL (2.9%). Compared with NIVL, both patients with aDVT (HR, 3.83; 95% CI, 1.08-13.61; P = .04) and patients with PTS (HR, 7.62; 95% CI, 2.45-23.65; P < .001) were associated with a higher risk of patency loss, whereas no significant difference was observed between PTS and aDVT (HR, 1.99; 95% CI, 0.74-5.32; P = .17) (Figure 4).
Figure 4.
Kaplan–Meier estimates of primary stent patency according to clinical etiology. The shaded areas represent 95% CIs, and the tick marks indicate censored observations. aDVT, acute deep vein thrombosis; HR, hazard ratio; NIVL, nonthrombotic iliac vein lesion; PTS, post-thrombotic syndrome.
No significant interaction was observed between antithrombotic regimen and etiology (P for interaction = .77). Etiology-specific Kaplan–Meier analyses comparing AC+APT with AC are shown in Supplementary Figures 1–3. In the PTS subgroup, occlusive lesions were independently associated with loss of stent patency (HR, 5.12; 95% CI, 1.28-20.54; P = .021). After adjustment for lesion morphology, AC alone was associated with a higher risk of patency loss than AC+APT (HR, 3.31; 95% CI, 1.02-10.74; P = .047). Because of the limited number of restenosis or occlusion events in the NIVL and aDVT subgroups, multivariable Cox regression analysis was not performed for these subgroups.
3.6. Bleeding events
The overall incidence of bleeding events did not differ significantly between the AC+APT and AC groups (4.8% vs 4.9%, P = 1.00), nor did it differ significantly across etiologic subgroups (P = .34). In the AC+APT group, major bleeding occurred in 2 patients (intracranial hemorrhage). Clinically relevant nonmajor bleeding occurred in 4 patients (hemoptysis, n = 3; melena, n = 1), whereas the remaining event (subcutaneous bleeding, n = 1) was classified as minor bleeding. In the AC group, no major bleeding events were observed. Clinically relevant nonmajor bleeding occurred in 4 patients, including hemoptysis (n = 1), combined hematuria with gum bleeding (n = 1), blood-tinged sputum (n = 1), and pharyngeal bleeding (n = 1), all of which required treatment modification. The remaining bleeding event (dental bleeding, n = 1) was classified as minor. No bleeding-related deaths were observed.
4. Discussion
In this multicenter real-world cohort, primary patency after iliofemoral venous stenting was high overall. AC+APT was not independently associated with improved primary patency in the overall cohort. In unadjusted analyses, primary patency differed across clinical etiologies, with the poorest outcomes observed in patients with PTS. Exploratory subgroup analysis suggested a possible association between AC+APT and improved patency in patients with PTS.
The optimal antithrombotic regimen after venous stenting—including the choice of agent, dosage, and duration—remains undefined. Although evidence is limited, existing studies confirm that anticoagulant therapy is the cornerstone of poststenting management and is closely associated with improved clinical outcomes [5,15,[19], [20], [21], [22]]. Moreover, there is a growing trend in both research and clinical practice to focus on DOACs [16,20,[23], [24], [25], [26]], to obtain more specific evidence regarding their application in patients after endovascular procedures, rather than relying on data extrapolated from studies involving venous patients who have not undergone such interventions [18]. In our study, nearly all patients received DOAC-based therapy, which differs from earlier studies in which warfarin was the predominant anticoagulant [26,27].
AC alone remains the most commonly used antithrombotic strategy after venous stenting [21]. A systematic review of 56 studies revealed that only 18% of the studies used a combination of anticoagulant and antiplatelet therapy as poststenting treatment [12]. Our previous survey [14] indicated that approximately 20% of physicians supported adding antiplatelet therapy to AC. An internationally registered study [21] further reported that 34% of patients with DVT received combined anticoagulant and antiplatelet therapy after venous stenting. Recently, the Chronic Venous Thrombosis: Relief with Adjunctive Catheter-Directed Therapy (C-TRACT) randomized trial [28] incorporated AC plus aspirin as part of the poststenting antithrombotic regimen for patients with PTS; the overall endovascular treatment strategy was associated with reduced PTS severity and improved health-related quality of life compared with standard care. In the present real-world cohort, the proportion of patients receiving combined therapy was higher than previously reported, with more than half receiving AC+APT. In addition, we observed that patients receiving AC+APT were more likely to receive lower-intensity AC.
The combination of AC with antiplatelet therapy has been proposed to provide a more comprehensive inhibition of thrombus formation by targeting both the coagulation cascade and platelet activation [29]. This strategy has been widely adopted in arterial interventions and has demonstrated clear benefits in preventing thrombotic complications [30]. In patients with chronic DVT who did not undergo stent implantation, the addition of antiplatelet agents to standard anticoagulant therapy may reduce recurrent venous thromboembolism [31]. It has been suggested that the addition of antiplatelet therapy to AC may improve stent patency in patients undergoing iliofemoral venous stenting. For example, a multicenter retrospective study [27] including 234 patients with acute and subacute DVT, with propensity score matching performed on 62 pairs, reported that AC+APT significantly improved stent patency compared with AC alone, with a nonsignificant increase in bleeding events. Similarly, in a retrospective study including 62 patients undergoing iliocaval venous stenting, Endo et al [32] reported that the use of antiplatelet therapy in addition to AC was independently associated with improved primary stent patency. However, the ARIVA trial [16], a multicenter, multinational randomized study including 162 patients with PTS, demonstrated no significant additional benefit of aspirin plus rivaroxaban compared with rivaroxaban alone in maintaining stent patency at 6 months. The discrepancy between observational studies and randomized trials may be related to differences in study populations and follow-up duration. Compared with randomized trials, our study included older patients and those with more complex clinical conditions, such as malignancy, which may confer a higher thrombotic risk and potentially influence the effectiveness of antithrombotic strategies [11,33,34].
Importantly, the observed association between dual-pathway antithrombotic therapy and improved patency appeared more pronounced among patients with PTS. This is clinically plausible, as PTS is often associated with chronic fibrotic change, a higher burden of occlusive lesions, and more complex venous reconstruction [35]. In the unadjusted analyses, primary patency differed across clinical etiologies, with poorer outcomes observed in thrombotic disease, particularly PTS. However, disease etiology itself was not an independent predictor in the multivariable model, while occlusive lesions were independently associated with patency loss. These findings indicate that anatomical characteristics may be more directly related to stent patency than etiologic diagnosis alone. This is supported by recent multicenter data showing that the anatomical extent of chronic venous obstruction independently predicts stent patency [2]. That study proposed a classification stratifying chronic venous obstruction according to the distal extent of disease and the involvement of the principal inflow veins, with 12-month primary patency decreasing from 94.9% in type 1 lesions to 39.4% in type 5 lesions. In our participating centers, patients with extensive obstruction involving the femoral and deep femoral inflow veins were less frequently selected for stenting, which may partly explain the relatively favorable overall patency observed. These anatomical considerations may also be relevant when interpreting the association between postprocedural antithrombotic therapy and stent patency. Patients with PTS and more complex thrombotic lesions may represent a subgroup warranting particular attention; however, whether intensified antithrombotic therapy can improve patency in such patients requires confirmation in adequately powered randomized controlled trials.
This study has several strengths. First, the multicenter design enhances the generalizability of the findings across different clinical settings. Second, this real-world observational cohort provides clinically relevant evidence on postprocedural antithrombotic management after iliofemoral venous stenting in routine practice. Third, the extended follow-up allowed assessment of mid- to long-term venous stent patency beyond the early postoperative period.
Nevertheless, several limitations should be acknowledged. First, the relatively small sample size limited the statistical power of subgroup analyses and precluded detailed stratification by etiology and antithrombotic regimen characteristics, such as treatment duration and dosing, making it difficult to determine whether the association between antithrombotic strategy and stent patency differed across patient subgroups. Second, some baseline variables were collected retrospectively, and certain clinical parameters were missing for a proportion of patients. For instance, laboratory indicators reflecting thrombophilia and other potential prognostic factors were not consistently available, which may have introduced bias into the analysis. However, previous studies [36,37] suggest that the presence of thrombophilia may not significantly impact venous stent patency. Third, although the PTS subgroup analysis showed a possible association between AC+APT and improved patency, the wide CI for the effect estimate underscores the need for cautious interpretation of this finding. Finally, the absence of baseline quality-of-life data prevented evaluation of the impact of antithrombotic strategies on patient-reported outcomes.
5. Conclusion
After iliofemoral venous stenting, similarly high primary patency and comparable bleeding risk were observed with dual-pathway antithrombotic therapy and AC alone in the overall cohort. An exploratory subgroup analysis suggested a possible association between AC+APT and improved patency in patients with PTS, but this finding requires cautious interpretation. Adequately powered randomized controlled trials with longer follow-up are warranted to evaluate the efficacy and safety of adding antiplatelet therapy to AC in this population.
Acknowledgments
We would like to express our sincere gratitude to associate researcher Li Yang from the Department of Nephrology, Zhongshan Hospital, Fudan University, for his valuable assistance with the statistical analysis.
Funding
This study is supported by the Shanghai Municipal Health Commission’s Health Youth Talent Training Program (No. 2022YQ13) and the Shanghai Oriental Talent Program Youth Project (No. QNWS2024026).
Author contributions
C.C. contributed to study conception and design, data analysis and interpretation, data collection, manuscript drafting, and critical revision. Z.G. contributed to data analysis and interpretation, manuscript drafting, and critical revision. J.T., Z.W., and G.L. contributed to data collection and critical revision of the manuscript. Z.S. contributed to data analysis and interpretation and critical revision. D.G., W.F., and Q.L. contributed to study conception and design and critical revision. B.G. contributed to study conception and design, data analysis and interpretation, data collection, statistical analysis, funding acquisition, and critical revision. All authors approved the final manuscript and agreed to be accountable for all aspects of the work.
Relationship Disclosure
There are no competing interests to disclose.
Declaration of AI and AI-assisted technologies in the writing process
During the preparation of this work the authors used ChatGPT in order to improve readability and language. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Data availability
The data supporting the findings of this study are available from the corresponding author upon reasonable request. No study materials or analysis code are publicly available.
Footnotes
Can Chen and Zhenyu Guo contributed equally to this work.
Handling Editor: Grigorios Gerotziafas
The online version contains supplementary material available at https://doi.org/10.1016/j.rpth.2026.106965.
Contributor Information
Qianzhou Lv, Email: lv.qianzhou@zs-hospital.sh.cn.
Baolei Guo, Email: guo.baolei@zs-hospital.sh.cn.
Supplementary material
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request. No study materials or analysis code are publicly available.