Discussion

Based upon the available literature, patients with iliofemoral DVT routinely should be considered for a management strategy designed to remove thrombus from the iliofemoral system in order to reduce postthrombotic sequelae. Many patients are now treated as outpatients for acute DVT. However, when common femoral vein thrombosis with occlusion is identified by venous duplex, we would recommend that the patient be hospitalized and the strategy that is summarized in Figure 45.10 adopted. If the patient is not a candidate for catheter-directed thrombolysis, the recommendation for venous thrombectomy (Grade 1B) should be followed.

Successful thrombus removal results in improved quality of life and fewer postthrombotic sequelae.16-18,23 A randomized trial of catheter-directed thrombolysis versus anticoagulation has shown better patency and preserved valve function in those treated with thrombolytic therapy.24 Patients who have iliofemoral DVT and contraindications to lytic

TABLE 45.4 Venous Thrombectomy: Comparison of Old and Contemporary Techniques

Technique

Old

Contemporary

Pretreatment phlebography/CT scan

Occasionally

Always

Venous thrombectomy catheter

No

Yes

Operative fluoroscopy/phlebography

No

Yes

Correct iliac vein stenosis

No

Yes

Arteriovenous fistula

No

Yes

Infrainguinal thrombectomy

No

Yes

Full post op anticoagulation

Occasionally

Yes

Catheter-directed anticoagulation

No

Yes

IPC post op

No

Yes

IPC, intermittent pneumatic compression. Adapted from Reference 29. Used with permission.

IPC, intermittent pneumatic compression. Adapted from Reference 29. Used with permission.

therapy should be considered for venous thrombectomy if they present within 10 days of the onset of their DVT.

Aggressive anticoagulation combined with leg compres-sion21,22 is the preferred treatment for patients who have a contraindication to thrombolysis, are poor operative candidates, have a prolonged duration of venous thrombosis, or are critically ill or bedridden.

Contemporary venous thrombectomy has substantially improved the early and long-term results of patients with extensive DVT compared to the initial reports. The major technical differences between the initial and contemporary procedures are listed in Table 45.4. Recent reports of those performing venous thrombectomy and the long-term results of a large Scandinavian randomized trial confirm significant benefit compared to anticoagulation alone. Therefore, vascular surgeons should include contemporary venous throm-bectomy as part of their routine operative armamentarium.

References

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