Anti-platelets and venous stents: Lessons from ARIVA and C-TRACT

This episode breaks down the newly published ARIVA trial (Circulation), a randomized study testing whether adding aspirin to rivaroxaban after post-thrombotic iliofemoral venous stenting actually improves stent patency or simply adds bleeding risk.Clinical Question: For years, endovascular specialists have reflexively prescribed dual therapy (anticoagulation + aspirin) after venous stenting, but ARIVA asks whether aspirin is actually improving outcomes in low-flow venous systems.Result: Primary patency at six months was nearly identical, 94.8% with rivaroxaban + aspirin versus 92.4% with rivaroxaban alone, suggesting no meaningful benefit to routinely adding aspirin.Bleeding Trade-Off: While major bleeding was absent in both groups, clinically relevant non-major bleeding was more than tripled with dual therapy (8.2% vs. 2.4%), with menorrhagia emerging as a major issue in this predominantly younger female cohort.Why This Matters: When synthesized with C-TRACT, ARIVA suggests we may be overtreating venous stent patients by applying arterial antiplatelet logic to fundamentally different venous biology.Caveat: ARIVA was stopped early and excluded patients with active cancer or poor medication adherence, meaning high-risk populations still require individualized decision-making.Bottom Line: For most standard post-thrombotic iliofemoral stenting cases with good inflow and optimized IVUS-guided deployment, full-dose rivaroxaban alone may be enough without the added bleeding burden of routine aspirin.Tune in to learn whether it is finally time to stop reflexively prescribing aspirin after venous stenting.This podcast is generated using an AI model that has been trained in the context of endovascular surgery and interventional radiology in addition context of the articles cited below. The content was reviewed and edited by multiple healthcare professionals in the field. Barco S, Jalaie H, Sebastian T, et al. Aspirin plus rivaroxaban versus rivaroxaban alone for the prevention of venous stent thrombosis among patients with post-thrombotic syndrome: the multicenter, multinational, randomized, open-label ARIVA trial. Circulation. 2025;151:835-846. https://doi.org/10.1161/CIRCULATIONAHA.124.073050Vedantham S, Kahn SR, Marston WA, et al. Endovascular therapy for post-thrombotic syndrome — a randomized trial. N Engl J Med. 2026. https://doi.org/10.1056/NEJMoa2519001