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• W2100348082 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. 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. Patients with acute deep vein thrombosis (DVT) involving the iliofemoral venous system experience the most severe postthrombotic sequelae. 1Hill S.L. Martin D. Evans P. Massive venous thrombosis of the extremities.Am J Surg. 1989; 158: 131-135Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 2Akesson H. Brudin L. Dahlstrom J.A. 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: 43-48Abstract Full Text PDF PubMed Scopus (251) Google Scholar, 3Delis K.T. Bountouroglou D. Mansfield A.O. Venous claudication in iliofemoral thrombosis long-term effects on venous hemodynamics, clinical status, and quality of life.Ann Surg. 2004; 239: 118-126Crossref PubMed Scopus (294) Google Scholar After 5 years, 95% of patients treated with anticoagulation alone demonstrate venous insufficiency, 15% have already progressed to venous ulceration, and another 15% complain of symptoms of venous claudication. 2Akesson H. Brudin L. Dahlstrom J.A. 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: 43-48Abstract Full Text PDF PubMed Scopus (251) Google Scholar When patients are exercised under supervision, up to 40% have been shown to have symptoms of venous claudication. 3Delis K.T. Bountouroglou D. Mansfield A.O. Venous claudication in iliofemoral thrombosis long-term effects on venous hemodynamics, clinical status, and quality of life.Ann Surg. 2004; 239: 118-126Crossref PubMed Scopus (294) Google Scholar Persistent venous obstruction is an important component of severe postthrombotic sequelae. 4Shull K.C. Nicolaides A.N. Fernandes e Fernandes J. Miles C. Horner J. Needham T. et al.Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration.Arch Surg. 1979; 114: 1304-1306Crossref PubMed Scopus (234) Google Scholar, 5Johnson B.F. Manzo R.A. Bergelin R.O. Strandness Jr, D.E. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis a one- to six-year follow-up.J Vasc Surg. 1995; 21: 307-312Abstract Full Text Full Text PDF PubMed Scopus (345) Google Scholar Therefore, 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 6Buller H.R. Agnelli G. Hull R.D. Hyers T.M. Prins M.H. Raskob G.E. Antithrombotic therapy for venous thromboembolic disease the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.Chest. 2004; 126: 401S-428SCrossref PubMed Scopus (1308) Google Scholar because of the poor results initially reported. However, this was the consequence of inadequate venous thrombectomy procedures that failed to adhere to basic principles of vascular surgery. 7Lansing A.M. Davis W.M. Five-year follow-up study of iliofemoral venous thrombectomy.Ann Surg. 1968; 168: 620-628Crossref PubMed Scopus (96) Google Scholar The procedure performed in these early reports did not routinely evaluate patients with preoperative phlebography or operative fluoroscopy, did not correct underlying venous lesions, did not incorporate an adjunctive arteriovenous fistula (AVF), failed to address infrainguinal DVT, and demonstrated no evidence that anticoagulation was used to avoid rethrombosis. Data from a contemporary randomized trial compared venous thrombectomy plus AVF with anticoagulation alone in patients with iliofemoral DVT. 8Plate G. Einarsson E. Ohlin P. Jensen R. Qvarfordt P. Eklof B. Thrombectomy with temporary arteriovenous fistula the treatment of choice in acute iliofemoral venous thrombosis.J Vasc Surg. 1984; 1: 867-876Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 9Plate 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: 483-489Abstract Full Text PDF PubMed Scopus (176) Google Scholar, 10Plate G. Eklof B. Norgren L. Ohlin P. Dahlstrom J.A. Venous thrombectomy for iliofemoral vein thrombosis—10-year results of a prospective randomised study.Eur J Vasc Endovasc Surg. 1997; 14: 367-374Abstract Full Text PDF PubMed Scopus (208) Google Scholar Six-month, 5-year, and 10-year follow-up consistently showed benefit in patients who were treated with venous thrombectomy. In addition to the results of the randomized trial, nonrandomized reports have shown the benefit of operative thrombus removal. 11Juhan C. Alimi Y. Di M.P. Hartung O. Surgical venous thrombectomy.Cardiovasc Surg. 1999; 7: 586-590Crossref PubMed Scopus (23) Google Scholar, 12Torngren S. Swedenborg J. Thrombectomy and temporary arterio-venous fistula for ilio-femoral venous thrombosis.Int Angiol. 1988; 7: 14-18PubMed Google Scholar, 13Eklof B. Kistner R.L. Is there a role for thrombectomy in iliofemoral venous thrombosis?.Semin Vasc Surg. 1996; 9: 34-45PubMed Google Scholar, 14Endrys J. Eklof B. Neglen P. Zyka I. Peregrin J. Percutaneous balloon occlusion of surgical arteriovenous fistulae following venous thrombectomy.Cardiovasc Intervent Radiol. 1989; 12: 226-229Crossref PubMed Scopus (19) Google Scholar, 15Neglen P. al-Hassan H.K. Endrys J. Nazzal M.M. Christenson J.T. Eklof B. Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula.Surgery. 1991; 110: 493-499PubMed Google Scholar, 16Eklof B. Arteriovenous fistulas as an adjunct to venous surgery.Semin Vasc Surg. 2000; 13: 20-26PubMed Google Scholar, 17Eklof B. Rutherford R.B. Surgical thrombectomy for acute deep vein thrombosis.in: Rutherford R.B. Vascular surgery. 6th ed. Elsevier Saunders, Philadelphia2005: 2188-2198Google Scholar The rationale for operative venous thrombectomy is based on (1) randomized trial data of venous thrombectomy vs standard anticoagulation, 8Plate G. Einarsson E. Ohlin P. Jensen R. Qvarfordt P. Eklof B. Thrombectomy with temporary arteriovenous fistula the treatment of choice in acute iliofemoral venous thrombosis.J Vasc Surg. 1984; 1: 867-876Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 9Plate 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: 483-489Abstract Full Text PDF PubMed Scopus (176) Google Scholar, 10Plate G. Eklof B. Norgren L. Ohlin P. Dahlstrom J.A. Venous thrombectomy for iliofemoral vein thrombosis—10-year results of a prospective randomised study.Eur J Vasc Endovasc Surg. 1997; 14: 367-374Abstract Full Text PDF PubMed Scopus (208) Google Scholar, 11Juhan C. Alimi Y. Di M.P. Hartung O. Surgical venous thrombectomy.Cardiovasc Surg. 1999; 7: 586-590Crossref PubMed Scopus (23) Google Scholar, 12Torngren S. Swedenborg J. Thrombectomy and temporary arterio-venous fistula for ilio-femoral venous thrombosis.Int Angiol. 1988; 7: 14-18PubMed Google Scholar, 13Eklof B. Kistner R.L. Is there a role for thrombectomy in iliofemoral venous thrombosis?.Semin Vasc Surg. 1996; 9: 34-45PubMed Google Scholar, 14Endrys J. Eklof B. Neglen P. Zyka I. Peregrin J. Percutaneous balloon occlusion of surgical arteriovenous fistulae following venous thrombectomy.Cardiovasc Intervent Radiol. 1989; 12: 226-229Crossref PubMed Scopus (19) Google Scholar, 15Neglen P. al-Hassan H.K. Endrys J. Nazzal M.M. Christenson J.T. Eklof B. Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula.Surgery. 1991; 110: 493-499PubMed Google Scholar, 16Eklof B. Arteriovenous fistulas as an adjunct to venous surgery.Semin Vasc Surg. 2000; 13: 20-26PubMed Google Scholar, 17Eklof B. Rutherford R.B. Surgical thrombectomy for acute deep vein thrombosis.in: Rutherford R.B. Vascular surgery. 6th ed. Elsevier Saunders, Philadelphia2005: 2188-2198Google Scholar (2) the authors’ contemporary experience of iliofemoral venous thrombectomy plus the experience of others, 11Juhan C. Alimi Y. Di M.P. Hartung O. Surgical venous thrombectomy.Cardiovasc Surg. 1999; 7: 586-590Crossref PubMed Scopus (23) Google Scholar, 12Torngren S. Swedenborg J. Thrombectomy and temporary arterio-venous fistula for ilio-femoral venous thrombosis.Int Angiol. 1988; 7: 14-18PubMed Google Scholar, 13Eklof B. Kistner R.L. Is there a role for thrombectomy in iliofemoral venous thrombosis?.Semin Vasc Surg. 1996; 9: 34-45PubMed Google Scholar, 15Neglen P. al-Hassan H.K. Endrys J. Nazzal M.M. Christenson J.T. Eklof B. Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula.Surgery. 1991; 110: 493-499PubMed Google Scholar (3) knowledge of the natural history of acute iliofemoral DVT treated with anticoagulation alone, 1Hill S.L. Martin D. Evans P. Massive venous thrombosis of the extremities.Am J Surg. 1989; 158: 131-135Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 2Akesson H. Brudin L. Dahlstrom J.A. 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: 43-48Abstract Full Text PDF PubMed Scopus (251) Google Scholar, 3Delis K.T. Bountouroglou D. Mansfield A.O. Venous claudication in iliofemoral thrombosis long-term effects on venous hemodynamics, clinical status, and quality of life.Ann Surg. 2004; 239: 118-126Crossref PubMed Scopus (294) Google Scholar, 4Shull K.C. Nicolaides A.N. Fernandes e Fernandes J. Miles C. Horner J. Needham T. et al.Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration.Arch Surg. 1979; 114: 1304-1306Crossref PubMed Scopus (234) Google Scholar, 5Johnson B.F. Manzo R.A. Bergelin R.O. Strandness Jr, D.E. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis a one- to six-year follow-up.J Vasc Surg. 1995; 21: 307-312Abstract Full Text Full Text PDF PubMed Scopus (345) Google Scholar and (4) an understanding of the underlying pathophysiology of the postthrombotic syndrome. 4Shull K.C. Nicolaides A.N. Fernandes e Fernandes J. Miles C. Horner J. Needham T. et al.Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration.Arch Surg. 1979; 114: 1304-1306Crossref PubMed Scopus (234) Google Scholar, 5Johnson B.F. Manzo R.A. Bergelin R.O. Strandness Jr, D.E. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis a one- to six-year follow-up.J Vasc Surg. 1995; 21: 307-312Abstract Full Text Full Text PDF PubMed Scopus (345) Google Scholar Intrathrombus catheter-directed thrombolysis or combined pharmacomechanical thrombectomy is the preferred treatment for most patients with extensive DVT. However, some patients are not candidates, and operative venous thrombectomy will be their only alternative for clearing thrombus and avoiding severe postthrombotic consequences. Because the benefit of venous thrombectomy is directly related to the success of the procedure and because the success of the procedure is related to the details of the technique, it is appropriate that the details of the technique be reviewed. This article describes the senior author’s operative approach to patients with extensive DVT. Because this technique has evolved, the opinions and suggestions of others have been incorporated and, whenever possible, directly referenced. Blood is sent for a full thrombophilia evaluation. Because most patients do not develop this severity of extensive disease, the likelihood of identifying an underlying thrombophilia is high. If the patient has already undergone anticoagulation treatment, then blood is sent for evaluation of antiphospholipid antibody, factor V Leiden, prothrombin gene mutation, and homocysteine, which are reliable in patients who have already undergone anticoagulation treatment. A type and cross match is also performed. The full extent of thrombus should be defined before surgery, and particular attention should be given to the status of the vena cava. A contralateral iliocavogram frequently is performed to assess the vena cava. However, magnetic resonance venography with gadolinium or spiral computerized tomography (CT) with contrast may obviate the cavagram in many patients. Our preference is spiral CT with contrast, because a rapid CT scan of the chest is routinely performed to evaluate for pulmonary emboli and thoracic pathology. A subsequent abdominal and pelvic CT scan during the same contrast infusion identifies the proximal extent of thrombus and any intra-abdominal or pelvic pathology that may be etiologically associated with the DVT. Therapeutic anticoagulation with heparin is initiated after the blood samples are drawn for the thrombophilia evaluation and is continued throughout the procedure and after surgery. Vena caval filtration is generally not required. An exception may be the patient with a nonocclusive thrombus in the vena cava. The recently introduced retrievable vena caval filters have been used, with plans for their early postoperative retrieval. These patients also can be protected from intraoperative pulmonary emboli by balloon occlusion of the proximal vena cava at the time of operative thrombectomy (Fig 1). The vena caval balloon can be positioned from the contralateral femoral vein by using fluoroscopic guidance during preoperative iliocavography. After positioning, the balloon remains deflated until thrombus extraction. The operating room is prepared for fluoroscopy, radiography, or both, and an autotransfusion device is made available during the procedure. General anesthesia is preferred for most patients. A longitudinal inguinal incision is made with exposure and control of the common femoral vein, femoral vein, saphenofemoral junction, and profunda femoris vein. A venotomy (longitudinal or transverse) is made at approximately the level of the saphenofemoral junction. The precise location of the venotomy depends on the extent and location of the thrombosis. Because the femoral vein is large and often distended, a longitudinal venotomy is preferred and can be closed primarily without compromising the vein lumen. The infrainguinal venous thrombectomy is usually performed first, after the femoral venotomy. The leg is elevated and wrapped tightly with a rubber bandage. The foot is dorsiflexed and the leg milked to remove the clot from below. If these maneuvers are unsuccessful and the infrainguinal clot persists, then the distal posterior tibial vein is exposed to perform the infrainguinal venous thrombectomy. A No. 3 or No. 4 Fogarty balloon catheter is passed proximally from below to exit the common femoral venotomy. The stem of a large silastic intravenous (IV) catheter (14 gauge) is cut from its hub and slid halfway onto the Fogarty balloon catheter passed from below, and a No. 4 Fogarty balloon catheter is placed into the other end (proximal end) of the silastic sheath (Fig 2). Pressure is applied to the two balloons (this firmly secures the catheters inside of the sheath), and the balloon catheters from above are guided distally through the venous valves and clotted veins to exit at the level of the posterior tibial venotomy. The operating surgeon applies pressure to both syringes and guides both catheters to ensure smooth, unencumbered passage. The infrainguinal venous thrombectomy is then performed with a No. 4 and No. 5 Fogarty balloon catheter if necessary; catheter passage is repeated as required until no further thrombus is extracted. After the infrainguinal balloon catheter thrombectomy, the infrainguinal venous system is vigorously flushed with a heparin saline solution to hydraulically force residual thrombus (which can be considerable) from the deep venous system by placing a No. 14 to 16 red rubber catheter into the proximal posterior tibial vein and flushing with a bulb syringe (Fig 3). A vascular clamp is then applied below the femoral venotomy, and the infrainguinal venous system is filled with a dilute plasminogen-activator solution: approximately 500,000 U of urokinase or 3 to 5 mg of recombinant tissue plasminogen activator in 150 to 200 mL of saline is used. If the infrainguinal venous thrombectomy is not successful as a result of chronic thrombus in the femoral vein, then the femoral vein is ligated and divided below the profunda. 13Eklof B. Kistner R.L. Is there a role for thrombectomy in iliofemoral venous thrombosis?.Semin Vasc Surg. 1996; 9: 34-45PubMed Google Scholar The patency of the profunda must be ensured before ligation of the femoral vein. The proximal thrombectomy is performed by passing a No. 8 or 10 venous thrombectomy catheter partway into the iliac vein for several passes to remove most of the iliac vein thrombus before advancing into the vena cava. The proximal thrombectomy is performed under fluoroscopy by using contrast to expand the balloon, especially if a caval filter is present, if there is clot in the vena cava, or if resistance to catheter passage or balloon thrombectomy is encountered. The anesthesiologist should apply positive end-expiratory pressure during the iliocaval thrombectomy. After completion of the iliofemoral thrombectomy, the iliofemoral venous system is examined with intraoperative phlebography/fluoroscopy to ensure unobstructed venous drainage into the vena cava. Any underlying iliac vein stenosis is corrected with balloon angioplasty (Fig 4), and a stent is used to maintain the desired luminal diameter if venous recoil occurs. After closure of the venotomy with fine monofilament suture, an end-to-side AVF is constructed by anastomosing the end of the transected proximal saphenous vein or a large proximal branch of the saphenous vein to the side of the proximal superficial femoral artery. The anastomosis should be no greater than 3.5 to 4.0 mm in diameter. Frequently the proximal saphenous vein is thrombosed and requires thrombectomy before the AVF. A wrap of polytetrafluoroethylene or silastic encircles saphenous AVF, and a large permanent monofilament suture is looped around the wrapped vein and clipped, leaving approximately 1 inch in the subcutaneous tissue. This will guide future dissection in the event that operative closure of the AVF becomes necessary. Others have viewed the AVF as temporary and reported closure of it by percutaneous balloon occlusion. 14Endrys J. Eklof B. Neglen P. Zyka I. Peregrin J. Percutaneous balloon occlusion of surgical arteriovenous fistulae following venous thrombectomy.Cardiovasc Intervent Radiol. 1989; 12: 226-229Crossref PubMed Scopus (19) Google Scholar, 15Neglen P. al-Hassan H.K. Endrys J. Nazzal M.M. Christenson J.T. Eklof B. Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula.Surgery. 1991; 110: 493-499PubMed Google Scholar, 16Eklof B. Arteriovenous fistulas as an adjunct to venous surgery.Semin Vasc Surg. 2000; 13: 20-26PubMed Google Scholar Because most patients tolerate the AVF well and because flow through the small AVF diminishes with time because of neointimal fibroplasia, most do not require closure. The common femoral vein pressure is measured before and after the AVF is opened; it should not change. If the femoral vein pressure increases when the AVF is opened, then the proximal iliac vein should be re-evaluated for residual stenosis or obstruction, and the proximal lesion should be corrected. If the pressure remains increased, then the AVF is constricted to decrease flow and normalize pressure. If there seems to be notable serous fluid in the wound, then a careful search for transected lymphatics is performed, and they are ligated or cauterized. A No. 7 Jackson-Pratt drain (or other similar closed suction drain) is placed in the wound to evacuate blood and serous fluid that may accumulate after surgery. The drain exits through a separate puncture site adjacent to the incision. The wound is closed with multilayered, running absorbable sutures to obliterate dead space and achieve a hemostatic and lymphostatic wound closure. Before the distal incision is closed, the distal posterior tibial vein is ligated. An infusion catheter (pediatric nasogastric tube) is brought into the wound via a separate stab incision in the skin and is inserted and fixed in the proximal posterior tibial vein (Fig 5). This catheter is used for postoperative therapeutic anticoagulation with a continuous infusion of unfractionated heparin and a follow-up phlebogram before discharge. This ensures maximal heparin concentration into the affected venous segment. A 2-0 monofilament suture is looped around the posterior tibial vein (and catheter), and both ends exit the skin adjacent to the wound. The ends of the suture are passed through the holes of a sterile button, which is secured snugly to the skin when the catheter is removed after therapeutic oral anticoagulation. This obliterates the proximal posterior tibial vein and eliminates the risk of bleeding after catheter removal. The patient’s leg is wrapped snugly from the base of the toes to the inguinal area with double- or triple-layer elastic bandages. Full anticoagulation is continued after surgery; unfractionated heparin is infused through the catheter secured in the posterior tibial vein. The heparin solution and pump are attached to an IV pole with wheels, and the patient is allowed (in fact, encouraged) to ambulate. Oral anticoagulation is begun when the patient resumes oral intake. The heparin infusion is continued for a minimum of 4 to 5 days, and the international normalized ratio reaches 2.0 to 3.0. Intermittent pneumatic compression garments are used on both legs during the postoperative period when the patient is not ambulating. Before removal of the posterior tibial vein catheter, a predischarge ascending phlebogram is obtained to evaluate patency. The femoropopliteal veins are easy to see; however, the iliofemoral segment may not be adequately visualized because of dilution of contrast by the AVF. Alternative techniques such as an arteriogram or CT scan with IV contrast can be used if postoperative iliocaval imaging is indicated. Any significant stenosis or occlusion in the iliofemoral segment should be treated to maintain unobstructed venous drainage into the vena cava. Oral anticoagulation is continued for an extended period of time—for at least 1 year in all patients and indefinitely in many. The AVF is considered permanent. With time, neointimal fibroplasia develops in most patients, and flow naturally decreases. Elastic compression stockings with a 30 to 40 mm Hg ankle gradient are used in all patients to further reduce postthrombotic complications. 18Brandjes D.P. Buller H.R. Heijboer H. Huisman M.V. de Rijk M. Jagt H. et al.Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.Lancet. 1997; 349: 759-762Abstract Full Text Full Text PDF PubMed Scopus (837) Google Scholar, 19Prandoni P. Lensing A.W. Prins M.H. 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: 249-256Crossref PubMed Scopus (588) Google Scholar Contemporary venous thrombectomy has substantially improved early and long-term results compared with the initial reports. Recent reports of those performing venous thrombectomy and the long-term results of a large randomized trial confirm the significant benefit compared with anticoagulation alone. The senior author has performed 28 venous thrombectomy procedures during the past 20 years—an indication that it is infrequently required. However, when it is properly performed, patients have a remarkably good clinical outcome. Early failures occurred in three patients. One patient had chronic thrombus (3 to 4 months), and one was treated early in this experience but did not have the underlying iliac vein stenosis corrected. The third patient could not be anticoagulated because of an intracranial malignancy and developed vena caval thrombosis 4 months after surgery. This is the only patient who required closure of the AVF. Wound complications are associated with lymphatic drainage. This occurred transiently in one successfully treated patient, and prolonged lymphatic drainage occurred in one unsuccessfully treated patient. 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. Critical is the avoidance of rethrombosis of the thrombectomized veins. The techniques described herein represent the authors’ approach to patients with few alternatives to clear the venous system. Although each element of the procedure may not be required in every patient (eg, AVF), each step is designed to provide incremental benefit. Catheter-directed postoperative anticoagulation is a new addition after infrainguinal venous thrombectomy. Although it is difficult to quantitate its benefit compared with routine IV (arm) heparin infusion or subcutaneous low-molecular-weight heparin, the high heparin concentration where it is needed most is intuitively attractive. With the leg wrapped snugly with elastic compression (toes to inguinal area) and early ambulation encouraged, this has not compromised patient recovery, and we believe that it has helped to avoid early rethrombosis in the five patients in whom it has been used. Compression and early ambulation have been shown to be beneficial even in patients treated with anticoagulation alone. 20Partsch H. Immediate ambulation and leg compression in the treatment of deep vein thrombosis.Dis Mon. 2005; 51: 135-140Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As in all patient care, good clinical judgment is most important for the proper application of any technique. Specific application of the details described in this article will, of course, depend on the extent and distribution of thrombosis in the patient being treated. 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 DVT that involves the iliofemoral venous system, especially if other options are not available or have failed. CorrectionJournal of Vascular SurgeryVol. 43Issue 4PreviewFor the article “Technique of contemporary iliofemoral and infrainguinal venous thrombectomy”, published in J Vasc Surg 2006:43;185-191, we are reprinting Figs 1-5 in higher quality. Full-Text PDF Open Archive" @default.
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