Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3727_Библиотеки_им_академика_М_И_Перельмана

Standard of care based on clinical guidelines in the United States have long recommended the use of LMWH for treat­ment of cancer-associated VTE. Recent trials have shown that multiple DOACs, including apixaban, rivaroxaban, and edoxaban, have shown similar efcacy in treating and preventing recurrent VTE.

Patients diagnosed with acute iliofemoral venous thrombo­sis should undergo careful evaluation of history, physical examination, and laboratory studies if use of lytic therapy is to be undertaken. There are multiple relative and abso­lute contraindications to lytic therapy due to the risk of hemorrhagic complications related to TPA administration, and these should be discerned preoperatively (Table20.1). Among the most signicant of these include head trauma, subarachnoid hemorrhage, or prior stroke in the previous 3 months; recent intracranial, intraspinal, or intra-abdom­inal surgery; intracranial neoplasm, arteriovenous malfor­mation, or aneurysm; recent (<14 days) arterial puncture at a noncompressible site; uncontrolled hypertension; active internal bleeding; ongoing bleeding diathesis; and intracar­diac thrombus. Each of these and other contraindications described in the instructions for use change the risk:benet ratio for the use of TPA in a condition like acute venous thrombosis, which in most cases is a lifestyle-altering condi­tion and not a limb-threatening condition. In patients with these contraindications, consideration should be given to the use of percutaneous thrombectomy as an alternative to catheter-directed therapy in order to minimize or eliminate the use of TPA. Physical exam should supplement the his­tory taking to assess for these contraindications, as well as to determine baseline exam features, which include severity of pain or swelling, and assessment for signs of limb-threat due to PCD. In the latter case, the urgency of thrombus removal may again dictate percutaneous mechanical thrombectomy, or even open venous thrombectomy, because the duration of treatment required to achieve the desired thrombus

Venous access in acute iliofemoral DVT is typically obtained in antegrade fashion via the popliteal vein using ultrasound guidance and the patient in the prone position. Alternative sites can be chosen based on the distribution of involved venous segments, including a posterior tibial vein at the ankle when the popliteal vein is involved or the common femoral vein in the case of isolated iliac or iliocaval involve­ment. Diagnostic venograms are then obtained to delin­eate the extent of thrombus and plan a treatment strategy (Figure 20.1). For patients presenting within a week of developing an acute DVT, a single-session clearance of the thrombus with pharmacomechanical thrombectomy (PMT) can often be achieved. A detailed description of various mechanical thrombectomy platforms will be discussed in a separate chapter. For patients with a longer interval between initial symptom onset and treatment, we have noted more organized thrombus and less success with single-session thrombus clearance attempts and therefore tend to rely on multiday ongoing thrombolytic therapy with CDT.