Introduction

Contemporary venous thrombectomy has the potential of offering patients with extensive iliofemoral and/or infrain-guinal deep vein thrombosis (DVT) an opportunity for rapid resolution with significant reduction in postthrombotic morbidity. It is both surprising and disappointing that vascular surgeons in the United States have not moved beyond the criticisms of the venous thrombectomy procedure performed over 40 years ago. In the most recent ACCP consensus conference section addressing the management of patients with venous thromboembolic disease, it is stated that "in patients with DVT, we recommend against the use of venous thrombectomy (Grade 1C)."1 They go on to say that "surgical thrombectomy is commonly complicated by a recurrence of thrombus formation." Unfortunately, the authors reference an anecdotal experience in patients treated over 40 years ago.2 The follow-up on these patients was incomplete and biased. Only 50% of the patients originally treated underwent follow-up and only 25% had follow-up phlebography.

The early experience with venous thrombectomy was enthusiastically received because of reports of excellent patency without severe postthrombotic sequelae. Mahorner et al.3 and Haller and Abrams4 reported excellent patency rates in patients operated upon early for iliofemoral venous thrombosis. Haller and Abrams reported an 85% patency rate with 81% of survivors having normal legs without postthrombotic swelling. However, a subsequent follow-up report indicated higher rates of rethrombosis with failure to prevent postthrombotic sequelae, despite a patent deep venous system, presumably due to valvular incompetence.2 This most damaging report was a five-year follow-up of patients originally described by Haller and Abrams. They reported that 94% of patients returning for follow-up had significant edema and skin changes, which required elastic stockings and leg elevation. Patients who underwent follow-up phlebography were found to have incompetent valves, although this represented only approximately 25% of the patients initially treated. Lansing and Davis2 brought attention to the fact that two of the three postoperative deaths (in the 34 patients initially operated) were from pulmonary embolism (PE) and that there was a 30% wound complication rate, an average transfusion requirement of 1000 ml, and a mean hospital stay of 12 days. Critics of operative venous thrombectomy frequently fail to mention that the early technique was unlike modern thrombectomy procedures, with patients undergoing cut-downs on their iliac veins, femoral veins, and vena cava, often with flush and irrigation procedures performed to clear the venous system of thrombus, whereas venous thrombectomy today is performed with balloon catheters, and autotransfusion devices are available to minimize the need for blood transfusion. Completion phlebograms were essentially nonexistent with no effort to either identify or correct underlying venous pathology. Arte-riovenous fistulae were not constructed and it is unclear to what degree patients were anticoagulated either during the procedure or postoperatively.

The report by Lansing and Davis suffered from a selection bias, since it is likely that the patients with the most severe postthrombotic sequelae were returning for follow-up and therefore the most heavily represented in their series. Furthermore, the patients reported represented only 50% of those initially operated upon, with phlebographic examination in far fewer. Another damaging report was that of Karp and Wylie,5 who reported uniform rethrombosis following iliofemoral venous thrombectomy. Although the patients' clinical symptoms appeared to be improved, the predischarge phlebographic documentation of rethrombosis led to further disinterest in venous thrombectomy.

Subsequent reports of successful thrombectomy from European centers,613 with success rates reported as high as 88% without mortality, were for the most part ignored by surgeons in the United States. However, a number of vascular centers have persisted in using thrombectomy,13,14 and with the ongoing experience and refinement of technique,15 the results have markedly improved.

Most notable among these technical improvements are the use of a venous thrombectomy catheter (large balloon), fluoroscopic-guided thrombectomy with completion intraoperative phlebography, correction of an underlying venous stenosis, construction of an AVF, and immediate and prolonged therapeutic anticoagulation, often catheter-directed.

The ACCP consensus guideline authors failed to reference a contemporary randomized trial of venous thrombec-tomy and AVF versus anticoagulation alone in patients with iliofemoral venous thrombosis.1618 These patients underwent systematic follow-up with routine venous imaging and physiologic measurements. Peer-reviewed reporting occurred at six months,16 five years,17 and 10 years18 of follow-up. Patients randomized to venous thrombectomy demonstrated improved patency (P < 0.05), lower venous pressures (P < 0.05), less leg swelling (P < 0.05), and fewer postthrombotic symptoms (P < 0.05) compared to anticoagulation.

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