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




Pretreatment phlebography/CT scan



Venous thrombectomy catheter



Operative fluoroscopy/phlebography



Correct iliac vein stenosis



Arteriovenous fistula



Infrainguinal thrombectomy



Full post op anticoagulation



Catheter-directed anticoagulation



IPC post op



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.


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6. Piquet P. Traitement chirurgical des thromboses iliocaves: Exigences et resultats. In: Kieffer E, ed. Chirurgie de la Veine Cave Inferieure et de Ses Branches. 1985. Paris: Expansion Scientifique Francaise; 210-216.

7. Einarsson E, Albrechtsson U, Eklof B. Thrombectomy and temporary AV-fistula in iliofemoral vein thrombosis. Technical considerations and early results, Int Angiol. 1986. 5: 65-72.

8. Vollmar JF. Robert May memorial lecture: Advances in reconstructive venous surgery, Int Angiol. 1986. 5: 117-129.

9. Juhan C, Alimi Y, Di MP, Hartung O. Surgical venous thrombectomy, Cardiovasc Surg. 1999. 7: 586-590.

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11. Rasmussen A, Mogensen K, Nissen FH, Wadt J, Skibsted L. Acute iliofemoral venous thrombosis. 26 cases treated with thrombectomy, temporary arteriovenous fistula and anticoagulants, Ugeskr Laeger. 1990. 152: 2928-2930.

12. Neglen P, al-Hassan HK, Endrys J, Nazzal MM, Christenson JT, Eklof B. Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula, Surgery. 1991. 110: 493-499.

13. Eklof B, Kistner RL. Is there a role for thrombectomy in iliofemoral venous thrombosis? Semin Vasc Surg. 1996. 9: 34-45.

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15. Comerota AJ, Gale SS. Technique of contemporary iliofemoral and infrainguinal venous thrombectomy, J Vasc Surg. 2006. 43: 185.

16. Plate G, Einarsson E, Ohlin P, Jensen R, Qvarfordt P, Eklof B. Throm-bectomy with temporary arteriovenous fistula: The treatment of choice in acute iliofemoral venous thrombosis, J Vasc Surg. 1984. 1: 867876.

17. Plate G, Akesson H, Einarsson E, Ohlin P, Eklof B. Long-term results of venous thrombectomy combined with a temporary arterio-venous fistula, Eur J Vasc Surg. 1990. 4: 483-489.

18. Plate G, Eklof B, Norgren L, Ohlin P, Dahlstrom JA. Venous throm-bectomy for iliofemoral vein thrombosis—10-year results of a prospective randomised study, Eur J Vasc Endovasc Surg. 1997. 14: 367-374.

19. Eklof B, Juhan C. Revival of thrombectomy in the management of acute iliofemoral venous thrombosis, Contemp Surg. 1992. 40: 21.

20. Akesson H, Brudin L, Dahlstrom JA, Eklof B, Ohlin P, Plate G. Venous function assessed during a 5 year period after acute ilio-

femoral venous thrombosis treated with anticoagulation, Eur J Vasc Surg. 1990. 4: 43-48.

21. Brandjes DP, Buller HR, Heijboer H, Huisman MV, de RM, Jagt H et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis, Lancet. 1997. 349: 759762.

22. Prandoni P, Lensing AW, Prins MH, Frulla M, Marchiori A, Bernardi E et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: A randomized, controlled trial, Ann Intern Med. 2004. 141: 249-256.

23. Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life, J Vasc Surg. 2000. 32: 130137.

24. Elsharawy M, Elzayat E. Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis. A randomised clinical trial, Eur J Vasc Endovasc Surg. 2002. 24: 209-214.

25. Meissner AJ, Huszcza S. Surgical strategy for management of deep venous thrombosis of the lower extremities, World J Surg. 1996. 20: 1149-1155.

26. Pillny M, Sandmann W, Luther B, Muller BT, Tutschek B, Gerhardt A et al. Deep venous thrombosis during pregnancy and after delivery: Indications for and results of thrombectomy, J Vasc Surg. 2003. 37:

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