Technique of contemporary iliofemoral and infrainguinal venous thrombectomy

Abstract

Patients with acute deep vein thrombosis involving the iliofemoral venous system experience the most severe postthrombotic sequelae. Treatment designed to reduce or eliminate the postthrombotic syndrome must necessarily remove thrombus to eliminate obstruction. Unfortunately, currently published guidelines do not recommend venous thrombectomy and actually recommend against its use because of the poor results initially reported. However, recent reports of venous thrombectomy and the long-term results of a large randomized trial confirm the significant benefit compared with anticoagulation alone. The technique of contemporary venous thrombectomy follows basic vascular surgical principles and offers patients the opportunity for complete or nearly complete thrombus extraction, thereby avoiding the significant morbidity of their anticipated postthrombotic syndrome. The techniques described herein represent the authors' approach to patients with few alternatives to clear the venous system. Because the patient benefit is well established, vascular surgeons should include contemporary venous thrombectomy as part of their routine operative armamentarium, offering this procedure to patients with extensive deep vein thrombosis involving the iliofemoral venous system, especially if other options are not available or have failed.

Quantitative estimation of results of treatment of inferior vena cava thrombosis

“…Не пе-реконують авторів у неефективності антикоагулянтної терапії навіть результати консервативного лікування ТГВ: через 5 років у 95 % пацієнтів спостерігали веноз-ну гіпертензію [8,10], у 90 % -виражений венозний рефлюкс [8,10], у 50 % -порушення функції м'язово-венозної помпи гомілки [8], у 15 % -трофічні виразки [8,10] та у 15-50 % -переміжну венозну кульгавість [8][9][10]. А повідомлення в літературі про значну частоту післяопераційного рецидиву ТГВ взагалі відштовхують хірургів від хірургічного лікування цих пацієнтів [3,6]. Хоча B. Geier і співавтори (2009) наводять дані про збе-реження прохідності реканалізованих ділянок глибоких вен через 5 років після відкритої тромбектомії у 75 % пацієнтів та наявність ознак посттромбофлебітичного синдрому лише у 20 % випадків [7].…”

Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

“…7) Surgical treatment of acute lower extremity DVT Anticoagulation therapy is the main treatment option for acute femoropopliteal DVT, but anticoagulation only in extensive iliofemoral DVT is not sufficient to prevent later development of chronic venous insufficiency and postphlebitic syndrome [125,148,194]. Therefore, early thrombus removal is necessary [195,196]. However, surgical venous thrombectomy is an invasive treatment with possible complications of anesthesia, bleeding, or PE.…”

“…Important contemporar y techniques include the following: preoperative imaging to define the proximal extent of the thrombus, intraoperative use of positive end-expiratory pressure to reduce the risk of PE, intraoperative completion venography to ensure patency of the iliac vein, stenting of iliac vein stenosis, use of temporary arteriovenous fistula to reduce early thrombosis, and postoperative anticoagulation with careful monitoring [195,196]. The most common complication of DVT is PTS, which affects 25% to 60% of acute lower extremity DVT patients [207].…”

Management of Ilio-Femoral Deep Vein Thrombosis: A Hybrid Approach

“…An AVF can be constructed by end-to-side anastomosis using the end of proximal saphenous vein or preferably a large proximal branch of the saphenous vein anastomosed to the side of the proximal superficial femoral artery or profunda femoris with the anastomosis limited to 3.5 to 4.0mm in diameter [49]. Then, a wrap of polyethylene or silastic can be placed around the saphenous AVF.…”

“…While some researchers have reported closure of the AVF by percutaneous balloon occlusion [50][51][52], most patients do not require closure as flow through the small AVF diminishes with time because of neo-intimal fibroplasia [49]. If closure of the AVF is necessary, it is commonly performed after 4-8 weeks [46,47].…”