Iliofemoral Venous Thrombosis Research Articles

High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: successful use of low molecular weight heparin with antibiotics

Injecting drug use, mainly of heroin, currently represents a major public health issue in the North East of Scotland. The recent tendency of the committed injecting drug user to inject...

Advances in Therapy and the Management of Antithrombotic Drugs for Venous Thromboembolism.

This review focuses on antithrombotic therapy for venous thromboembolism and covers a diverse range of topics including a discussion of emerging anticoagulant drugs, a renewed focus on thrombolytic agents for selected patients, and an analysis of the factors leading to adverse events in patients on warfarin, and how to optimize therapy. In Section I Dr. Weitz discusses new anticoagulant drugs focusing on those that are in the advanced stages of development. These will include drugs that (a) target factor VIIa/tissue factor, including tissue factor pathway inhibitor and NAPc2; (b) block factor Xa, including the synthetic pentasaccharide and DX9065a; (c) inhibit factors Va and VIIIa, i.e., activated protein C; and (d) block thrombin, including hirudin, argatroban, bivalirudin and H376/95. Oral formulations of heparin will also be reviewed. In Section II, Dr. Comerota will discuss the use of thrombolysis for selected patients with venous thromboembolism. Fibrinolytic therapy, which has suffered from a high risk/benefit ratio for routine deep venous thrombosis, may have an important role to play in patients with iliofemoral venous thrombosis. Dr. Comerota presents his own results with catheter-directed thrombolytic therapy and the results from a large national registry showing long-term outcomes and the impact on quality of life. In Section III, Dr. Ansell presents a critical analysis of the factors responsible for adverse events with oral anticoagulants and the optimum means of improving outcomes. The poor status of present day anticoagulant management is reviewed and the importance of achieving a high rate of "time in therapeutic range," is emphasized. Models of care to optimize outcomes are described, with an emphasis on models that utilize patient self-testing and patient self-management of oral anticoagulation which are considered to be the ultimate in anticoagulation care. The treatment of venous and arterial thromboembolism is undergoing rapid change with respect to the development of new antithrombotic agents, an expanding list of new indications, and new methods of drug delivery and management. In spite of these changes, many of the traditional therapeutics are still with us and continue to play a vital role in the treatment of thromboembolic disease. The following discussion touches on a wide range of therapeutic interventions, from old to new, exploring the status of anticoagulant drug development, describing a new intervention for iliofemoral venous thrombosis, and analyzing the critical factors for safe and effective therapy with oral anticoagulants.

Advances in Therapy and the Management of Antithrombotic Drugs for Venous Thromboembolism

AbstractThis review focuses on antithrombotic therapy for venous thromboembolism and covers a diverse range of topics including a discussion of emerging anticoagulant drugs, a renewed focus on thrombolytic agents for selected patients, and an analysis of the factors leading to adverse events in patients on warfarin, and how to optimize therapy. In Section I Dr. Weitz discusses new anticoagulant drugs focusing on those that are in the advanced stages of development. These will include drugs that (a) target factor VIIa/tissue factor, including tissue factor pathway inhibitor and NAPc2; (b) block factor Xa, including the synthetic pentasaccharide and DX9065a; (c) inhibit factors Va and VIIIa, i.e., activated protein C; and (d) block thrombin, including hirudin, argatroban, bivalirudin and H376/95. Oral formulations of heparin will also be reviewed.In Section II, Dr. Comerota will discuss the use of thrombolysis for selected patients with venous thromboembolism. Fibrinolytic therapy, which has suffered from a high risk/benefit ratio for routine deep venous thrombosis, may have an important role to play in patients with iliofemoral venous thrombosis. Dr. Comerota presents his own results with catheter-directed thrombolytic therapy and the results from a large national registry showing long-term outcomes and the impact on quality of life.In Section III, Dr. Ansell presents a critical analysis of the factors responsible for adverse events with oral anticoagulants and the optimum means of improving outcomes. The poor status of present day anticoagulant management is reviewed and the importance of achieving a high rate of “time in therapeutic range,” is emphasized. Models of care to optimize outcomes are described, with an emphasis on models that utilize patient self-testing and patient self-management of oral anticoagulation which are considered to be the ultimate in anticoagulation care. The treatment of venous and arterial thromboembolism is undergoing rapid change with respect to the development of new antithrombotic agents, an expanding list of new indications, and new methods of drug delivery and management. In spite of these changes, many of the traditional therapeutics are still with us and continue to play a vital role in the treatment of thromboembolic disease. The following discussion touches on a wide range of therapeutic interventions, from old to new, exploring the status of anticoagulant drug development, describing a new intervention for iliofemoral venous thrombosis, and analyzing the critical factors for safe and effective therapy with oral anticoagulants.

Advances in Therapy and the Management of Antithrombotic Drugs for Venous Thromboembolism

This review focuses on antithrombotic therapy for venous thromboembolism and covers a diverse range of topics including a discussion of emerging anticoagulant drugs, a renewed focus on thrombolytic agents for selected patients, and an analysis of the factors leading to adverse events in patients on warfarin, and how to optimize therapy. In Section I Dr. Weitz discusses new anticoagulant drugs focusing on those that are in the advanced stages of development. These will include drugs that (a) target factor VIIa/tissue factor, including tissue factor pathway inhibitor and NAPc2; (b) block factor Xa, including the synthetic pentasaccharide and DX9065a; (c) inhibit factors Va and VIIIa, i.e., activated protein C; and (d) block thrombin, including hirudin, argatroban, bivalirudin and H376/95. Oral formulations of heparin will also be reviewed.In Section II, Dr. Comerota will discuss the use of thrombolysis for selected patients with venous thromboembolism. Fibrinolytic therapy, which has suffered from a high risk/benefit ratio for routine deep venous thrombosis, may have an important role to play in patients with iliofemoral venous thrombosis. Dr. Comerota presents his own results with catheter-directed thrombolytic therapy and the results from a large national registry showing long-term outcomes and the impact on quality of life.In Section III, Dr. Ansell presents a critical analysis of the factors responsible for adverse events with oral anticoagulants and the optimum means of improving outcomes. The poor status of present day anticoagulant management is reviewed and the importance of achieving a high rate of “time in therapeutic range,” is emphasized. Models of care to optimize outcomes are described, with an emphasis on models that utilize patient self-testing and patient self-management of oral anticoagulation which are considered to be the ultimate in anticoagulation care. The treatment of venous and arterial thromboembolism is undergoing rapid change with respect to the development of new antithrombotic agents, an expanding list of new indications, and new methods of drug delivery and management. In spite of these changes, many of the traditional therapeutics are still with us and continue to play a vital role in the treatment of thromboembolic disease. The following discussion touches on a wide range of therapeutic interventions, from old to new, exploring the status of anticoagulant drug development, describing a new intervention for iliofemoral venous thrombosis, and analyzing the critical factors for safe and effective therapy with oral anticoagulants.

Safety and efficacy of catheter-directed thrombolysis for iliofemoral venous thrombosis.

Safety and efficacy of catheter-directed thrombolysis for iliofemoral venous thrombosis.C Grossman and S McPhersonAudio Available | Share

Contemporary Treatment of Iliofemoral Deep Vein Thrombosis

The standard treatment for acute iliofemoral venous thrombosis has been hospital admission with bedrest, leg elevation, and anticoagulation using unfractionated heparin IV and warfarin. With the recent release from the FDA of low molecular weight heparin we can anticipate a rapid embrace of this drug for ambulatory treatment. Based on level I studies from mainly Canada and Europe, low molecular weight heparin has been proven to be highly effective in the initial treatment of established deep vein thrombosis. We will argue that the long term sequels of low molecular weight heparin treatment is not known. Early and quick removal of the thrombus is indicated to avoid the late postthrombotic syndrome. We suggest that catheter-directed intrathrombus thrombolysis with or without adjunct procedures such as angioplasty and stenting should be the first line of treatment. When there are contraindications or failure of thrombolysis, thrombectomy with a temporary arteriovenous fistula is a valid alternative, with bot...

Urokinase: Past, present, and future

Discovered in 1947, the plasminogen activator urokinase (UK) was found to have major safety advantages over streptokinase (SK) as a thrombolytic drug. In 1978, it received Food and Drug Administration (FDA) approval for the systemic treatment of pulmonary embolism, and in 1983 as catheter-directed treatment of acute myocardial infarction, with studies showing a significantly lower rate of bleeding complications in patients treated with UK than in patients treated with SK. Approval was granted in 1984 for restoration of patency in occluded intravenous catheters, including central venous catheters, obviating the need for catheter removal and replacement in most patients treated. While not FDA-approved, the most common use of UK has been catheter-directed intra-arterial treatment of peripheral arterial occlusion of the leg, with more than 100,000 procedures performed annually in the United States. It is also widely used for the treatment of iliofemoral venous thrombosis and as an adjunct to angioplasty for acute occlusions of aortocoronary bypass grafts. Other limited uses include the treatment of superior vena cava syndrome, occluded prosthetic heart valves, stroke, and loculated pleural effusions; it is also used adjunctively with percutaneous transluminal angioplasty in patients with flow restriction due to thrombus accumulation or complex coronary narrowings. Novel forms of UK currently under development are recombinant urokinase and prourokinase. Produced by genetic engineering, recombinant urokinase is purer, more homogeneous, and more fully active than previously available forms of UK. Prourokinase, a single-chain UK with the same molecular weight as the double-chain UK but greater clot specificity, activates fibrin-bound plasminogen preferentially and therefore induces relatively fibrin-specific clot lysis. Discovered in 1947, the plasminogen activator urokinase (UK) was found to have major safety advantages over streptokinase (SK) as a thrombolytic drug. In 1978, it received Food and Drug Administration (FDA) approval for the systemic treatment of pulmonary embolism, and in 1983 as catheter-directed treatment of acute myocardial infarction, with studies showing a significantly lower rate of bleeding complications in patients treated with UK than in patients treated with SK. Approval was granted in 1984 for restoration of patency in occluded intravenous catheters, including central venous catheters, obviating the need for catheter removal and replacement in most patients treated. While not FDA-approved, the most common use of UK has been catheter-directed intra-arterial treatment of peripheral arterial occlusion of the leg, with more than 100,000 procedures performed annually in the United States. It is also widely used for the treatment of iliofemoral venous thrombosis and as an adjunct to angioplasty for acute occlusions of aortocoronary bypass grafts. Other limited uses include the treatment of superior vena cava syndrome, occluded prosthetic heart valves, stroke, and loculated pleural effusions; it is also used adjunctively with percutaneous transluminal angioplasty in patients with flow restriction due to thrombus accumulation or complex coronary narrowings. Novel forms of UK currently under development are recombinant urokinase and prourokinase. Produced by genetic engineering, recombinant urokinase is purer, more homogeneous, and more fully active than previously available forms of UK. Prourokinase, a single-chain UK with the same molecular weight as the double-chain UK but greater clot specificity, activates fibrin-bound plasminogen preferentially and therefore induces relatively fibrin-specific clot lysis.

Catheter-directed Thrombolysis in Acute, Infected Iliofemoral Venous Thrombosis

Catheter-directed Thrombolysis in Acute, Infected Iliofemoral Venous Thrombosis

Left iliac venous thrombosis caused by venous spur: Treatment with thrombectomy and stent implantation

Purpose: To determine the frequency of iliac venous spurs in left iliofemoral venous thrombosis and to report the results of interventional management of venous spurs after transfemoral venous thrombectomy. Methods: From 1990 through 1996, 77 patients with acute iliac venous thrombosis (61 left and 16 right) underwent surgical treatment. Patients with malignant disease were excluded from this series. All patients had transfemoral venous thrombectomy with construction of an inguinal arteriovenous fistula and perioperative anticoagulation with heparin with a switch to warfarin sodium for at least 12 postoperative months. Immediate results of thrombectomy were documented by means of intraoperative completion venography. Arteriovenous fistulas were ligated 3 months after control arteriovenography. Since 1995 venous spurs eventually detected during thrombectomy were treated immediately by means of stent implantation. Results: Among 61 patients with left-sided thrombosis, intraoperative phlebography revealed common iliac venous obstruction suggestive of venous spurs in 30 patients (49%). In 16 of 22 patients (73%) with untreated spurs, postoperative rethrombosis of the iliac vein was documented despite adequate anticoagulation. Only one of eight patients (13%) with stented spurs had reocclusion (χ 2 test P < .01). Conclusion: Venous spurs are found among about half of patients with left-sided iliac venous thrombosis. As long as the underlying venous pathologic process is left untreated, thrombectomy will not restore patency. Stent implantation is a simple and safe means to correct central venous strictures and provides excellent long-term results. (J Vasc Surg 1998;28:492-7.)

Iliofemoral Venous Thrombosis Caused by Compression of an Internal Iliac Artery Aneurysm: A Minimally Invasive Treatment

To report the success of a minimally invasive treatment for phlegmasia cerulea dolens without gangrene caused by compression from an internal iliac artery aneurysm. An 81-year-old male with a 1-month history of paralysis owing to a hemorrhagic stroke presented with massive edema and skin mottling of the right lower extremity. Imaging confirmed right iliofemoral deep vein thrombosis caused by compression from a 4-cm internal iliac artery aneurysm. With thrombolysis ruled out, a minimally invasive treatment plan was undertaken, featuring percutaneous coil embolization of the aneurysm and surgical venous thrombectomy with proximal arteriovenous fistula creation and iliac vein stent placement. Failure of the coils to embolize the iliac aneurysm prompted the use of an endovascular graft to exclude the aneurysm. The patient's symptoms subsided, and he has a patent right iliofemoral venous system and internal iliac artery at his latest (16-month) follow-up. This case demonstrates that minimally invasive endovascular and open techniques can be combined to achieve an optimum outcome in patients at high risk for standard surgical approaches.

Impact of endovascular treatment on relationships between vascular surgeons and interventional radiologists

Currently available endovascular techniques include PTA and the use of lytic agents, caval filters, and intravascular occluding devices, such as coils. To date, these endovascular treatments can be applied to some, but not all, patients who have a valid rial thromboembolism, iliofemoral venous thrombosis, arteriovenous malformations, and some visceral artery aneurysms. Some of these lesions can now be treated effectively with percutaneous transluminal angioplasty (PTA), catheter-directed lytic drugs and aspiration, intracaval filters, or coil embolization. All these techniques have in common the use of endovascular pathways accessed from remote sites to treat the offending vascular lesion, usually under fluoroscopic guidance. Because these endovascular techniques have proven to be a simpler, safer way to treat some vascular disease patients, they have been embraced and used increasingly by vascular surgeons and others. In some cases, these catheterbased treatments have been used directly by the vascular surgeon; in other circumstances management has been by referral to a collaborating interventional radiologist or other interventional specialist. Because these endovascular techniques are increasingly gaining acceptance and because their less invasive nature renders them attractive to referring physicians and patients alike, it is reasonable to ask how they have affected and will affect the practices of vascular surgery and interventional radiology. The purposes of the present article are to examine some of the effects endovascular technology has already had on vascular disease management, to speculate on its future impact, and to Endovascular treatments are those administered through and within blood vessels. These treatments are catheter guidewire-based and use fluoroscopic or ultrasonic imaging modalities for localization and control within the vascular system. These endovascular treatments include local drug delivery systems and, more importantly, a variety of new technologies that permit mechanical correction of mural and intraluminal pathological lesions within the vascular system. Access to the vascular tree for these endovascular manipulative treatments can be gained via percutaneous puncture utilizing Seldinger wire-cathetersheath technology or, less commonly, by open exposure and arteriotomy or venotomy. Because of innovations in endovascular technology, the treatment of arterial and venous disease has changed over the last 20 years and will change even more dramatically in the years to come. Catheter guidewire-based techniques have already made significant contributions to the manipulative and surgical management of aortoiliac, femoropopliteal, tibial, and renal artery lesions, arteGefasschirurgie (1998) 3:199–204 © Springer-Verlag 1998 EDITORIAL

Management of venous thromboembolism

SummaryThe therapy of deep venous thrombosis consists of several elements and depends on the localization, the age and the extent of the thrombus. In addition, the patient’s age and the life expectancy may influence the modality of treatment. The present overview discusses various types of initial therapy and long-term treatment of venous thromboembolism and also reviews future perspectives of pharmacological treatment. The initial treatment regimens comprise thrombolysis, thrombectomy, inferior vena cava filters and the anticoagulation with either unfractionated heparin or low molecular weight heparins. Thrombolysis is only effective in the initial phase of acute thromboembolic disorders, and the potential benefits must be balanced against the risk of hemorrhage. In the case of totally occlusive venous thrombosis, a successful outcome is more likely if the thrombolytic agent is infused into the thrombus via catheter directed thrombolysis. Thrombectomy should be considered in patients with acute iliofemoral venous thrombosis of less than seven days duration and a life expectancy of more than ten years. A filter device should be inserted in the inferior vena cava in patients with venous thrombosis above the knee when anticoagulation is contraindicated or when adequate anticoagulation fails to prevent recurrent embolism. The intravenous administration of unfractionated heparin has been the modality of choice for initial treatment of venous thromboembolism during several decades, however, this type of therapy requires an aPTT-adjusted dosing due to a broad interindividual variation of laboratory results. Numerous clinical trials have provided firm evidence that low molecular weight heparins given subcutaneously are significantly superior to intravenous, unfractionated heparin with regard to thrombus regression and reductions of severe hemorrhages, mortality and recurrent thromboembolism. Thus, these preparations may become the treatment of choice in the near future. Pulmonary embolism may be treated with low molecular weight heparins as well.Long-term treatment of venous thromboembolism is usually performed with oral anticoagulants. The recommended therapeutic range is an INR of 2.0 to 3.0, however the optimal duration of oral anticoagulant therapy for patients with acute proximal deep venous thrombosis is uncertain.Various thrômbin-inhibitors have been tested for initial treatment of thrombosis, however further investigations of their efficacy, safety and cost-effectiveness will have to provide firm evidence on their superiority when compared to unfractionated or low molecular weight heparins.

Venous Thrombectomy in Pregnancy: A Follow-up Study

Objective: To evaluate women who have been treated by venous thrombectomy in pregnancy because of iliofemoral venous thrombosis, reporting the outcome of their pregnancy and frequency of objectively measured venous insufficiency. Design: A retrospective study. The patients were assessed by questionnaire, clinical examination, tests of venous function and ultrasonography. Setting: Department of Vascular Surgery, Gentofte Hospital, University of Copenhagen. Patients: Nineteen women treated previously by venous thrombectomy during pregnancy, with a subsequent pregnancy. Results: None of the women had complications during subsequent pregnancies or deliveries, 47% had an occluded iliac segment and 53% had dilated or varicose veins. None had ulcers or skin changes. None of the women showed signs of of re-thrombosis. Conclusion: Women who have been treated for deep venous thrombosis in pregnancy by thrombectomy and arteriovenous fistula followed by anticoagulant therapy may undergo further pregnancies with a very low risk of obstetric complications and a low risk of developing re-thrombosis or chronic venous insufficiency.

Venous thrombectomy for lliofemoral vein thrombosis — 10-year results of a prospective randomised study

To study if venous thrombectomy prevents late post-thrombotic sequelae, venous obstruction reflux, and improves venous physiology following an acute iliofemoral venous thrombosis. Prospective randomised controlled study. Thirty patients returned for follow-up 10 years after an acute iliofemoral venous thrombosis initially treated with conventional anticoagulation treatment (medical group, n = 17) or with thrombectomy combined with a temporary arteriovenous fistula and anticoagulation (surgical group, n = 13). Clinical assessment, radionuclide angiography, duplex ultrasound and venous physiology tests were performed. Leg swelling was recorded in 12 (71%) and leg ulcers in three (18%) of the medical patients and in, respectively, six (46%) and one (8%) of the surgical patients. The surgical patients had less severe sequelae (class 0-2). Radionuclide angiography demonstrated that the iliac vein was more commonly occluded following medical (59%) than following surgical (17%) treatment (p < 0.05). Duplex examination demonstrated slightly (n.s.) more reflux in the femoral and popliteal veins in the medical group. Venous physiology (occlusion plethysmography, foot volumetry, and foot vein pressures) did not show any significant differences, although the medical group tended to have a more severe pathology. Venous thrombectomy improves venous patency and possibly reduces venous reflux and post-thrombotic sequelae as compared to anticoagulation treatment.

Case #3: Acute Iliofemoral Venous Thrombosis with Pulmonary Embolism

Case #3: Acute Iliofemoral Venous Thrombosis with Pulmonary Embolism

Late results of iliofemoral venous thrombectomy.

Although anticoagulation therapy for iliofemoral venous thrombosis prevents pulmonary embolism, it is not designed to avoid the postthrombotic syndrome. Mechanical removal of the thrombus in the form of venous thrombectomy should yield better long-term results. The purpose of our study was to analyze the clinical outcome and venous valvular function of limbs 5 to 13 years after iliofemoral venous thrombectomy. Seventy-seven lower extremities underwent venous thrombectomy for acute iliofemoral venous thrombosis and were monitored for a mean follow-up of 8 1/2 years (range, 5 to 13 years). Patency of the iliofemoral venous system, competence of the femoral popliteal valves, and clinical signs and symptoms of chronic venous insufficiency were evaluated in each case. Subsequent to early perioperative failure, patency remained stable over time at 84%. Valvular competence was preserved in 80% at 5 years; however, it decreased to 56% at 10 years. It is important that more than 90% of the limbs had no symptoms or mild symptoms of chronic venous insufficiency. Venous thrombectomy should be considered for primary treatment in selected cases of early iliofemoral venous thrombosis.

The long-term outcome of proximal vein thrombosis during pregnancy is not improved by the addition of surgical thrombectomy to anticoagulant treatment

To compare the long-term outcome for pregnant/puerperal women with iliofemoral venous thrombosis treated either with thrombectomy and additional anticoagulants or with anticoagulants alone. Retrospective study of two treatment methods. Thirty women with iliofemoral venous thrombosis during pregnancy or puerperium were treated with thrombectomy and additional anticoagulants. Twenty-five women, with the same condition, treated with anticoagulants only were obtained from a registry. The mean follow-up time for both groups was 9 years. The patients of the two groups were well matched, had the same risk factor score and were comparable except for duration of symptoms before treatment. The follow-up comprised history and clinical examination, colour Duplex ultrasound and venous strain-gauge plethysmography. Patency of iliac veins, symptoms of chronic venous disease, venous emptying and venous reflux did not differ between the groups. A significant reduction of outflow was found in 20% of the surgically treated patients and 16% of the controls. Impaired muscle pump function was seen in less than half of the patients in both groups. Surgical thrombectomy does not offer any advantage over anticoagulation treatment alone in the long-term outcome for patients with iliofemoral venous thrombosis during pregnancy or puerperium.

Spontaneous Spinal Epidural Hematoma After Combined Urokinase and Heparin Thrombolytic Therapy for Deep Venous Thrombosis

The literature clearly supports the view that all anticoagulation therapy is associated with a significant risk of hemorrhagic complications. Combining anticoagulation and fibrinolytic therapy further adds to this risk. Moreover, in the treatment of deep venous thrombosis the combined use of heparin and fibrinolytic therapy is not necessarily associated with a better outcome. Close monitoring of the clotting profile has not eliminated the risks since a correlation between laboratory parameters and bleeding complications has not been demonstrated. Furthermore, the appropriate total dose and duration of therapy remain unclear. The authors report an especially devastating complication of spinal epidural hematoma with resultant paraplegia after combined use of heparin and urokinase for iliofemoral venous thrombosis in an otherwise healthy young woman. The dramatic nature of the complications illustrates the need for continued analysis of this therapeutic strategy.

Morphological changes in the skin microlymphatics in recently injured paraplegic patients with ilio-femoral venous thrombosis.

Based on morphological features of the lymphatic microcirculation of the skin from healthy subjects, and from paraplegic patients who had no evidence of ilio-femoral venous thrombosis (thromboembolic disease: TED), the leg terminal lymphatic vessels from skin biopsies of five male paraplegic patients with acute traumatic spinal cord lesions and with documented TED were studied. Paraplegic patients with TED had lymph vessels with a dilated lumen surrounded by a rarefacted perivascular connective tissue characterized by dissociation and disruption of collagen and elastic fibres. The lymphatic wall was generally attenuated and some open junctions and channels delimited by endothelial protrusions were observed. The venous outflow obstruction caused by deep venous thrombosis accompanied by the absence of ambulatory venous pressure in the paretic leg determines skin microlymphatic dilatation, lymph stasis and changes in the interstitial connective tissues. These alterations may be considered to be the morphological aspect of the dystrophic alterations seen in the skin of legs from paraplegic patients with TED. The results are discussed in view of the correct rehabilitative medical treatment necessary, and adequate prophylaxis of TED.

A strategy of aggressive regional therapy for acute iliofemoral venous thrombosis with contemporary venous thrombectomy or catheter-directed thrombolysis

Purpose: Occlusive iliofemoral venous thrombosis is associated with morbid short- and long-term consequences. Having been disappointed with standard anticoagulant therapy and systemic fibrinolysis, we embarked on an aggressive multidisciplinary regional approach to treat these patients, with the goals of therapy being (1) to eliminate iliofemoral venous thrombus, (2) to provide unobstructed venous drainage from the affected limb, and (3) to prevent recurrent thrombosis.Methods: Twelve consecutive patients were treated for extensive iliofemoral venous thrombosis. Each had thrombus from their infrapopliteal veins through their iliofemoral system, and four had vena caval involvement. The conditions of 11 patients failed to improve when the patients were given anticoagulants, and prior systemic fibrinolysis failed in five patients. The treatment strategy includes catheter-directed thrombolysis with intrathrombus infusion of the plasminogen activator or operative thrombectomy or venous bypass with a permanent 4 mm arteriovenous fistula (AVF).Results: Nine of 12 patients had a good or excellent clinical outcome (mean follow-up 25 months), which correlated with restored unobstructed venous drainage from the affected limb. Seven patients had catheter-directed lytic therapy attempted. In five patients the catheters were appropriately positioned, and lysis was successful. Five of the eight patients who underwent operations had successful procedures. Two of the three patients with poor operative outcomes had residual thrombus in their iliac veins or vena cava after thrombectomy (without bypass). The third patient, in whom anticoagulation was contraindicated, had an initially successful thrombectomy and AVF; however, vena caval thrombosis developed 2 months after operation. No patient had symptomatic pulmonary emboli, and routine posttreatment ventilation/perfusion lung scanning was not performed.Conclusions: An aggressive multidisciplinary regional approach to patients with obliterative iliofemoral venous thrombosis, designed to remove thrombus and provide unobstructed venous drainage, offers substantially better clinical outcome compared with systemic fibrinolysis and standard anticoagulation. Catheter-directed thrombolysis is successful if the catheter is appropriately positioned within the thrombus. Contemporary venous thrombectomy, which includes thrombus removal, completion phlebography, AVF, and cross-pubic bypass when necessary, is associated with high success rates. Failures can be anticipated and avoided in most patients.