Open Surgical Treatment of Acute Iliofemoral and Inferior Vena Cava Thrombosis

The options for early removal of an acute thrombus in the proximal veins of the leg are catheter-directed thrombolysis, percutaneous pharmacomechanical thrombectomy, and surgical thrombectomy. If either of the first two fail or are contraindicated, then surgical thrombectomy is a valid alternative, primarily in acute iliofemoral deep vein thrombosis (DVT).

When a DVT occurs, the goals of therapy are to prevent the extension or recurrence and a fatal pulmonary embolism (PE) and to minimize the early and late sequelae of DVT. Antithrombotic therapy can accomplish the former, but it contributes little to the second goal. A progressive swelling of the leg, especially with a proximal DVT, can lead to phlegmasia cerulea dolens and to increased compartmental pressure that can result in venous gangrene and limb loss. Later, the development of severe postthrombotic syndrome (PTS) can result from persistent obstruction of the venous outflow and/or loss of valvular competence, and PE can lead to chronic pulmonary hypertension.

Indications for Intervention

Early clot removal has clear benefit in two categories of patients with iliofemoral DVT falling at each end of the clinical spectrum: in active healthy patients with good longevity to prevent or mitigate potentially severe late PTS and in those with massive swelling and phlegmasia cerulea dolens to mitigate early morbidity and prevent progression to venous gangrene. Patients with significant intercurrent disease and serious comorbidities, who are unlikely to be active and live a long life, or those with distal thrombosis should be treated conservatively. Late PTS is not likely to be an issue with them. However, even these patients, if faced with the threat of venous gangrene, can deserve prompt clot removal.

In terms of the choice of method of clot removal, catheter-directed thrombolysis is an appropriate choice by removing obstructing thrombus and thereby preserving valve function, though the latter has been presumed rather than proved. If such therapy cannot be achieved, clot removal or dissolution is unsuccessful or does not progress satisfactorily, or the concomitant anticoagulation is contraindicated (e.g., iliofemoral DVT in young women in the peripartum period or in certain postoperative or trauma patients) then a surgical thrombectomy or pharmacomechanical thrombectomy is an appropriate choice.

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