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234 Chapter 21 Percutaneous mechanical thrombectomy for treatment of acute iliofemoral deep vein thrombosis
https://t.me/med1917
dolens (grade 1A). The guidelines suggested pharmacomechanical thrombolysis over CDT if it was available.
16
pharmacomechanical or mechanical thrombolysis. Younger
patients with a prolonged life expectancy seem to benet
the most from aggressive management of iliofemoral DVT.
The rationale for aggressive strategy in these patients is to
21.4 CONCLUSION
prevent long-term sequelae of PTS by removal of physical
obstruction from the iliofemoral venous outow. MechanBased on the available evidence, in patients with acute
iliofemoral DVT, clinical judgment should be used to determine the best candidates for aggressive management with
ical thrombectomy with a low dose or no lytic drug use at
all has a promising future to treat patients with iliofemoral
DV T.
Guidelines and Statements 21.0 of the American Venous Forum on percutaneous mechanical thrombectomy for
treatment of acute iliofemoral deep vein thrombosis
No. Guideline Grade of
recommendation
21.1 In patients with phlegmasia cerulea dolens or venous gangrene due to acute
iliofemoral DVT, we recommend a strategy of thrombus removal.
21.2 In patients with a rst episode of iliofemoral DVT with onset <14 days with low
risk of bleeding, if the patient was ambulatory with good functional capacity
1
(strong)
2
(weak)
and an acceptable life expectancy, we suggest a strategy of thrombus removal.
21.3 For thrombus removal, we suggest pharmacomechanical thrombectomy
over catheter-directed thrombolysis.
2
(weak)
Consensus Statement
21.4 In patients with acute iliofemoral DVT, mechanical thrombectomy (with low-dose or no lytic therapy) is a safe technique for
thrombus removal. Long-term efcacy to prevent PTS needs conrmation.
Quality of evidence
B
(moderate)
C
(low to very low)
C
(low to very low
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acute subclavian vein thrombosis in
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jvsv.2023.05.011
CHAPTER
22
https://t.me/med1917
Open and hybrid surgical interventions
for the treatment of acute iliofemoral
deep vein thrombosis
Ahsan Zil-E-Ali, Kayla J. Krause, Faisal Aziz, and Peter Gloviczki
22.1 INTRODUCTION
Venous thromboembolism (VTE) is highly prevalent, with
signicant morbidity and mortality.
thrombosis is the most serious form of lower extremity
deep vein thrombosis (DVT). In the acute phase, it may
cause pulmonary embolism (PE) and pain and swelling
of the lower extremity, and in the long term, it can cause
post-thrombotic syndrome (PTS). Chapter 19 discusses
medical management with anticoagulation; Chapters 20
and 21 are devoted to percutaneous interventions including
catheter-directed thrombolysis (CDT), pharmacomechanical thrombectomy (PMT), and percutaneous mechanical
thrombectomy. While percutaneous techniques have taken
over from open surgery during the past two decades, there
is still need for open and hybrid procedures when expertise
for endovascular techniques is not available or has failed
to achieve its goal, when thrombolysis is contraindicated,
and when there is urgent threat of losing the limb or life of
the patient due to advanced DVT, such as phlegmasia cerulea dolens or venous gangrene (Figure22.1).
discusses indications, preoperative evaluation, techniques,
and results of open and hybrid surgical procedures for
thrombus removal in patients with acute iliofemoral DVT.
1
Iliofemoral venous
2
This chapter
Pharmacomechanical thrombectomy has been performed
most frequently, but there are absolute and relative contraindications to using a lytic agent because of the high risk
of bleeding. Absolute contraindications include active internal bleeding, recent head trauma or cerebral infarct, recent
neurosurgical or eye intervention, intracerebral tumor,
aneurysm, or vascular malformation. For a full list of absolute and relative contraindications to lytic agents, please
see Table 20.1. Mechanical thrombectomy has become a
good option in recent years, used with low-dose or no lytic
therapy at all, but expertise or device may not be available,
the procedure can fail, or the severity of the disease (phlegmasia cerulean dolens, venous gangrene) may warrant
immediate and complete thrombus removal. In addition
to limb-threatening ischemia combined with massive DVT,
the Society for Vascular Surgery/American Venous Forum
clinical practice guidelines also recommend strategies of
thrombus removal, including open venous thrombectomy,
for patients with acute iliofemoral venous thrombosis, in
those with a rst episode of DVT within 14 days after onset,
and in patients with a low risk of bleeding who are ambulatory with good functional capacity and an acceptable life
expectancy.
for expeditious treatment of massive iliofemoral and lower
extremity DVT, without the use of lytic therapy.
9
Open and hybrid techniques have been useful
3,4,10–14
22.2 INDICATIONS FOR OPEN
OR HYBRID VENOUS
THROMBECTOMY
Interventional treatments to manage iliofemoral DVT have
undergone an evolution over the course of the past two
decades, and open surgery
percutaneous catheter based interventions.
ment for patient selection has been important, and all of
the factors, including the severity and extent of DVT, the
patient’s age, life expectancy, lifestyle, underlying disease
like cancer, immobility, the age of the thrombus, and history
of previous and recurrent DVTs, must be taken into account
in order to make a decision to proceed with intervention.
DOI: 10.1201/9781003328971-25
3–6
has been largely replaced by
7,8
Clinical judg-
22.3 EVALUATION FOR VENOUS
THROMBECTOMY
After the diagnosis of acute DVT is established, all patients
should be placed on therapeutic anticoagulation therapy
immediately, followed by leg elevation and leg compression. After anticoagulation and compression, ambulation,
if possible, is encouraged. In patients with normal renal
function, a contrast-enhanced computed tomography (CT)
scan of the head, chest, abdomen, and pelvis is performed.
A prospective study by Partsch et al.
140 patients (46.4%) with suspected iliofemoral DVT
had PE at admission that was symptomatic in only 19
patients (13.6%). Although such emboli may not change
15
found that 65 of
237237
238 Chapter 22 Open and hybrid surgical interventions for the treatment of acute iliofemoral deep vein thrombosis
https://t.me/med1917
(e)
(a)
Tip of balloon catheter
Silastic sheath
(c)
(b)
(d)
22.1 Steps (a-e) of orthograde and retrograde open venous thrombectomy for femoro-popliteal and tibial venous thrombosis.
Source: Manunga, J.M and Gloviczki, P. Ischemic Venous Thrombosis: Phlegmasia Cerulea Dolens and Venous Gangrene. Haimovici’s Vascular Surgery,
6th Ed. E. Ascher, Editor. Pp.1213–1220, with permission.
the treatment plan, the value of establishing the diagnosis
is often not appreciated until 3–5 days later when pleuritic chest pain develops in up to 25% of asymptomatic
PE patients.
16
Without a previous diagnosis of PE, physicians might suspect that the result of pleuritic chest pain
represents a “treatment failure” or an embolic complication of either lytic therapy or venous thrombectomy, rather
than a delayed manifestation of a preexisting PE. The CT
scan is useful to detect any PE but also to diagnose other
unexpected thoracic, abdominal, or pelvic pathologies.
Imaging of the inferior vena cava (IVC) is important for
assessing the degree of vena cava involvement with thrombus. If offering catheter-based techniques, a vena cava lter is recommended by most interventionists for patients
with a free-oating, nonocclusive vena caval thrombus. If
open thrombectomy is performed, either proximal balloon
antithrombin, as these test results may impact future care
during pregnancy. Additionally, testing antiphospholipid
antibodies is also warranted.
After the extent of the disease has been established,
contraindications to either surgical or catheter-based
techniques should be reviewed. In general, most patients
with iliofemoral DVT are offered a strategy for thrombus
removal. Individuals with an occlusive thrombus of the
common femoral vein have effectively obliterated venous
drainage from the lower extremity and are candidates for
severe post-thrombotic morbidity. Although most patients
with acute DVT are treated as outpatients, those with occlusion of the common femoral vein and/or iliac vein should
be hospitalized for an appropriate procedure designed to
restore patency and provide unobstructed venous drainage
from their common femoral vein into their vena cava.
occlusion of the IVC or caval ltration is appropriate in
patients with free-oating thrombus. Most with iliofemoral DVT, however, do not require an IVC lter.
Testing for acquired thrombophilia is also warranted.
Aserious consequence of a negative thrombophilia evalua-
22.4 TECHNIQUE OF OPEN SURGICAL
VENOUS THROMBECTOMY
tion is physician underestimation of future thrombotic risk.
However, thrombophilia testing is important in rst-degree female relatives of childbearing potential, especially
for factor V Leiden, prothrombin, 20210 mutations, and
The technique of open thrombectomy with a temporary arteriovenous stula (AVF) has evolved during the
past several years; it was described in detail by Plate and
3,6
https://t.me/med1917
Eklof,
operation is best performed under general anesthesia. The
femoral vein is exposed through a vertical groin incision
and the common femoral, femoral, saphenous vein, and
profunda femoris vein or veins are encircled with vessel
loops. Atransverse or longitudinal venotomy is performed,
followed by thrombectomy using venous Fogarty balloon
catheters with or without uoroscopic control. A15 mmHg
positive end-expiratory pressure is applied by the ventilator to decrease the risk of PE. Because of the competent
vein valves below the inguinal ligament, the Fogarty catheter usually cannot be advanced from the common femoral vein distally more than a short distance. Sometimes,
when thrombosis is massive, the thrombus keeps the valves
from closing and the catheter can be advanced easier, more
distally. An option of performing a Fogarty thrombectomy
is to expose the posterior tibial vein at the ankle, cut the
hub of the catheter off, and use that end of the catheter
to thread it upwards through the posterior tibial vein all
the way up to the common femoral vein. By canulating
the cut end of the catheter with a blunt needle attached to
a uid-lled syringe, the balloon can be inated and used
to perform a thrombectomy from the ankle to the groin,
usually without difculties. Manual compression of the leg
is also applied to remove distal thrombi. An Eschmarch
bandage is used to remove as much thrombus as possible,
placing the bandage progressively around the limb from
the foot all the way up to the groin. At this point signicant
blood loss can occur, and rapid retransfusion of the lost
blood with a cell saver is most helpful.
The great saphenous vein (GSV) is divided 10cm from
the saphenofemoral junction, and an AVF is created by
by Comerota,4 and by Wagenhauser et al.17 The
Once thrombectomy is done, an AVF is constructed.
22.5 Technique of hybrid operative thrombectomy 239
anastomosing the cranial end of the saphenous vein to
the side of the supercial femoral artery. ANo. 5 French
infant-feeding tube is then introduced into the stula
through a saphenous vein tributary and left in place for
24hours for completion phlebography and control phlebography on the rst postoperative day. Asilastic sheath is
wrapped around the saphenous vein proximal to the anastomosis, and a 1/0 polypropylene suture is tied around the
vein loosely, without obstructing the ow, and a 2-cm portion is left subcutaneously, clipped for easy identication
later for closure of the AVF. The AVF is closed after 4–6
weeks under local anesthesia or, percutaneously, with an
Amplatz plug.
a diligent search for transected lymphatics is performed,
with careful ligation and coagulation. A closed suction
drain is generally placed in the wound to evacuate serosanguineous uid that may accumulate postoperatively. The
drain exits through a separate puncture site adjacent to
the incision. The wound is closed in three layers to achieve
hemostatic and lymphostatic wound closure and ensure
the elimination of dead space. The skin is then closed
with absorbable subcuticular suture. The patient’s leg is
wrapped with multilayered elastic bandages from the base
of the toes to the groin.
18
If serous wound accumulation is observed,
22.5 TECHNIQUE OF HYBRID
OPERATIVE THROMBECTOMY
The technique of hybrid repair was described in detail
by Rodriguez et al.
under general anesthesia; the common femoral profunda
13,14
The procedure is performed
22
(f) (g)(f) (g)
22.2 Open venous thrombectomy. f. ushing of the popliteal vein to remove thrombus. g. left iliac vein thrombectomy with embolic
protection using an occlusive vena cava balloon, placed through the right femoral vein.
240 Chapter 22 Open and hybrid surgical interventions for the treatment of acute iliofemoral deep vein thrombosis
https://t.me/med1917
femoris, femoral, and saphenous veins are exposed at the
groin. Under uoroscopic control, the common femoral
vein is punctured in a retrograde fashion, and a soft-tip
hydrophilic guidewire is placed through a 4F sheath and
advanced distally with the help of a soft angled glide catheter to pass it through the valves. A45-cm 7F sheath was
then passed over the wire and advanced to the tibial veins.
An ascending venography is performed, and an over-thewire size 4 Fogarty balloon catheter is advanced distally
from the femoral into the tibial vein and thrombectomy is
performed. Thrombus through the common femoral vein is
removed through a generous transverse venotomy. Manual
compression of the thigh and use of an Esmarque bandage
on the leg will help to achieve complete thrombus removal.
Next, the system is vigorously ushed with a heparinized
saline solution to hydraulically remove any remaining
thrombus, and completion venography is performed.
The proximal thrombectomy is performed under uoroscopic guidance, using a size 7 over-the-wire Fogarty balloon catheter, starting with the iliac segments and nishing
with the IVC. Iliocaval venogram and intravascular ultrasound (IVUS) are used to evaluate lesions in the iliac veins
that may need stenting to improve outow. Lesions causing
>50% stenosis are stented. After removal of catheters and
guidewires, the venotomy is closed with 6-0 monolament
suture. The groin is closed in a standard fashion.
22.6 POSTOPERATIVE CARE
Following operative management, the patient is continued
on anticoagulation via unfractionated heparin through
the saphenous vein catheter. Notably, rivaroxaban has
been shown to have similar effectiveness and complication
rates as standard low-molecular-weight heparin (LMWH)
bridging to vitamin K antagonists (VKAs) following early
thrombus removal and stent placement.
is continued, and the patient is encouraged to ambulate.
Avenogram is done before the removal of the saphenofemoral catheter, if it was placed When the patient resumes
appropriate oral intake, intravenous anticoagulation is
bridged to oral, with a target international normalized
ratio (INR) of between 2 and 3. Oral anticoagulation is
continued long-term, often exceeding 6 months.
For the period that the patient is not ambulating, intermittent pneumatic compression devices are used to prevent
deep vein blood clots during stasis. Prior to discharge, the
patient is tted for 30–40 mmHg ankle gradient belowknee compression stockings, and they are instructed to
wear them from waking to bedtime. Prandoni etal. have
shown an over 50% reduction in post-thrombotic morbidity when this compression is utilized.
however, that the Sox trial by Kahn et al.
rm the benet of stockings in preventing PTS after a rst
proximal DVT.
Once the patient has recovered, repeat venous duplex
and venous function studies are performed to evaluate vessel patency and venous valve function, which will act as the
patient’s new baseline for future studies.
19
Anticoagulation
20
It is noteworthy,
21
failed to con-
22.7 RESULTS OF CLINICAL STUDIES
Ten-year results of an RCT were reported by Plate et al.22
in 30 patients who underwent treatment of acute iliofemoral venous thrombosis with conventional anticoagulation
(n = 17) or with open surgical thrombectomy, temporary AVF, and anticoagulation (n=13). Leg swelling was
recorded in 12 (71%) and leg ulcers in 3 (18%) of the medical patients and in 6 (46%) and 1 (8%) of the surgical
patients, respectively. The surgical patients had less severe
PTS. The iliac vein was more commonly occluded following medical (59%) than following surgical (17%) treatment (p < .05). Duplex examination demonstrated slightly
(NS) more reux in the femoral and popliteal veins in the
medical group. The study concluded that venous thrombectomy improves patency and possibly reduces reux and
post-thrombotic sequelae as compared to anticoagulation
treatment.
Wegenhauser et al.
bectomy with a temporary AVF in 48 of 142 patients.
Those with associated IVC thrombosis, IVC agenesis, or
pregnancy were excluded. The immediate success rate was
100%; seven patients had early revision, six for recurrent
thrombosis. None of the three late deaths were related to
the procedure. Eight-year primary and secondary patency
rates were 81% and 97%. Eight-year freedom from PTS
in patients with a patent iliac vein was 80 + 12%. Results
of open surgery in this study were safe and effective; they
appeared the same as those achieved by other treatment
modalities. Similarly good results were reported by the
same team in patients who underwent either transfemoral
or transabdominal open thrombectomies for IVC throm-
23
bosis.
Casey et al.24 performed a systematic review and
meta-analysis of 15 studies to compare the efcacy of three
available treatments for acute iliofemoral DVT: systemic
anticoagulation, surgical thrombectomy, and CDT. When
compared to systemic anticoagulation, thrombectomy was
associated with a statistically signicant reduction in the
risk of developing PTS (RR, 0.67; 95% CI, 0.52–0.87),
venous reux (RR, 0.68; 95% CI, 0.46–0.99), and a
trend for reduction in the risk of venous obstruction (RR,
0.84; 95% CI, 0.60–1.19). When compared to systemic
anticoagulation, pharmacologic CDT was also associated
with a statistically signicant reduction in the risk of PTS
(RR, 0.19; 95% CI, 0.07–0.48), venous obstruction (RR,
0.38; 95% CI, 0.18–0.37), and a trend for reduction in
the risk of venous reux (RR, 0.39; 95% CI, 0.16–1.00).
Low-quality evidence suggested that surgical thrombectomy decreased the incidence of PTS and venous reux.
Catheter-directed pharmacologic thrombolysis decreased
the incidence of PTS and venous obstruction. There were
insufcient data to compare the outcomes of thrombectomy to CDT.
Lindow et al.
patients who underwent iliofemoral thrombectomies.
Immediate iliac vein stenting was performed if intraoperative venography conrmed iliac vein stenosis. There was
no early mortality or clinically detected PE. At a mean
17
analyzed results of open throm-
10
used a hybrid procedure in 22 of 83
References 241
https://t.me/med1917
of 60 months, approximately 75% of the treated venous
segments remained patent. Moderate PTS was present in
hybrid procedure to treat endovenous heat-induced thrombosis was also reported by Kwak et al.
26
20%, and no patient had severe PTS.
Among 21 patients who underwent open surgical
thrombectomy for iliofemoral DVT in a C-arm–equipped
operating room by Ockert et al.,
25
10 (47.6%) required
immediate stenting for iliac vein stenosis. Primary technical success was 100%, and three patients needed early
revision for thrombosis, for a 30-day secondary patency of
100%. During a median follow-up of 6years, 19 (90.5%)
presented with patent iliofemoral veins, and all were free
of symptoms for PTS.
Results of 40 hybrid thrombectomies for treatment
of acute iliofemoral venous thrombosis were reported by
Rodriguez etal.,
12
and data were compared to those of 31
patients who underwent percutaneous thrombolysis. Bleeding complications were signicantly more frequent after
thrombolysis, and the hybrid technique established early
thrombus removal in one operation in >80%. Hospitalization was also longer after thrombolysis. Two-year data
were similar in both groups. Hybrid treatment had clear
advantages over lytic therapy in terms of bleeding complications and extent of early thrombus removal. Asuccessful
22.8 CONCLUSION
Open surgical venous thrombectomy is infrequently performed today because of the effectiveness of CDT and
pharmacochemical thrombectomies. When lytic treatment
cannot be performed, percutaneous mechanical thrombectomy has been used with increasing frequency. Open and
hybrid thrombectomies, however, remain valuable treatment options in selected patients. Such patients include
those with multiple trauma and active bleeding and those
at high risk for bleeding into a critical site (intracranial and
intraocular). Open and hybrid surgery is safe and effective
and should be used if percutaneous procedures have failed
or the appropriate device or endovascular expertise is not
available. Since in almost half of the patients who undergo
open thrombectomy, an iliac vein stent is needed, open
venous thrombectomies should be performed in a C-arm–
equipped operating room, with endovascular expertise for
iliac vein imaging and stenting available.
Guidelines and Statements 22.0 of the American Venous Forum on open surgical and hybrid thrombectomy for treatment of acute iliofemoral deep vein thrombosis
No. Guideline Grade of
22.1 In patients with phlegmasia cerulea dolens or venous gangrene due to
acute iliofemoral DVT, we recommend a strategy of thrombus removal.
22.2 In patients with a rst episode of iliofemoral DVT with onset <14 days with
low risk of bleeding, if the patient was ambulatory with good functional
capacity and an acceptable life expectancy, we suggest a strategy of
thrombus removal.
22.3 For thrombus removal, we suggest pharmacomechanical or open surgical
thrombectomy.
Consensus Statement
22.4 In patients with acute iliofemoral DVT, hybrid thrombectomy using open and endovascular techniques to remove the thrombus and treat venous outow obstruction is safe and effective. Prospective studies in larger numbers of patients are needed
to conrm long-term prevention of PTS.
recommendation
1
(strong)
2
(weak)
2
(weak)
Quality of evidence
B
(moderate)
C
(low to very low)
C
(low to very low
22
REFERENCES
★ Systematic review and
meta-analysis
♦ Guidelines
1. Data and Statistics on Venous Thromboembolism. 2023. www.cdc.gov/ncbddd/
dvt/data.html
2. Manunga JM, Gloviczki P. Ischemic
venous thrombosis: Phlegmasia Cerulea
Dolens and venous gangrene. In: Ascher E,
ed. Haimovici’s Vascular Surgery, 6th ed.
Wiley-Blackwell; 2012:1213–20
3. Eklof B. Surgical thrombectomy for
iliofemoral venous thrombosis revisited.
J Vasc Surg. Sep 2011;54(3):897–900.
doi:10.1016/j.jvs.2011.04.027
4. Comerota AJ. The current role of
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2012;25(1):2–12. doi:10.1053/j.semvascsurg.2012.02.004
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P, Eklof B. Long-term results of venous
thrombectomy combined with a temporary arterio-venous stula. Eur J Vasc
Surg. Oct 1990;4(5):483–9. doi:10.1016/
s0950-821x(05)80788-1
6. Plate G, Einarsson E, Ohlin P, Jensen R,
Qvarfordt P, Eklof B. Thrombectomy
with temporary arteriovenous stula:
The treatment of choice in acute iliofemoral venous thrombosis. J Vasc Surg.
Nov 1984;1(6):867–76. doi:10.1067/
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7. Vedantham S, Goldhaber SZ, Julian
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NEJMoa1615066
8. Enden T, Haig Y, Klow NE, etal. Longterm outcome after additional catheter-directed thrombolysis versus standard
treatment for acute iliofemoral deep
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vein thrombosis (the CaVenT study):
Arandomised controlled trial. Lancet.
Jan 7 2012;379(9810):31–8. doi:10.1016/
S0140-6736(11)61753-4
♦9. Meissner MH, Gloviczki P, Comerota AJ,
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American Venous Forum. J Vasc Surg.
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10. Lindow C, Mumme A, Asciutto G, Strohmann B, Hummel T, Geier B. Long-term
results after transfemoral venous thrombectomy for iliofemoral deep venous
thrombosis. Eur J Vasc Endovasc Surg.
Jul 2010;40(1):134–8. doi:10.1016/j.
ejvs.2010.02.023
11. Holper P, Kotelis D, Attigah N,
Hyhlik-Durr A, Bockler D. Longterm
results after surgical thrombectomy
and simultaneous stenting for symptomatic iliofemoral venous thrombosis. Eur J Vasc Endovasc Surg. Mar
2010;39(3):349–55. doi:10.1016/j.
ejvs.2009.09.028
12. Rodriguez LE, Aboukheir-Aboukheir A,
Figueroa-Vicente R, etal. Hybrid operative thrombectomy is noninferior to percutaneous techniques for the treatment of
acute iliofemoral deep venous thrombosis.
J Vasc Surg Venous Lymphat Disord.
Mar 2017;5(2):177–84. doi:10.1016/j.
jvsv.2016.09.008
13. Rodriguez LE, Aponte-Rivera F, Figueroa
Vicente R, Martinez Trabal JL. Hybrid
operative thrombectomy for the treatment
of symptomatic iliofemoral deep venous
thrombosis: Initial experience and midterm results. J Vasc Surg Venous Lymphat
Disord. Jan 2015;3(1):131. doi:10.1016/j.
jvsv.2014.10.041
14. Rodriguez LE, Aponte-Rivera F,
Figueroa-Vicente R, Bolanos-Avila GE,
Martinez-Trabal JL. Symptomatic iliofemoral deep venous thrombosis treated
with hybrid operative thrombectomy.
J Vasc Surg Venous Lymphat Disord.
Oct 2015;3(4):438–41. doi:10.1016/j.
jvsv.2015.02.003
15. Partsch H, Kechavarz B, Mostbeck A,
Kohn H, Lipp C. Frequency of pulmonary
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with once- or twice-daily low-molecular-weight heparin. J Vasc Surg. Nov
1996;24(5):774–82. doi:10.1016/s07415214(96)70012-5
16. Dorfman GS, Cronan JJ, Tupper TB, Messersmith RN, Denny DF, Lee CH. Occult
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17. Wagenhäuser MU, Sadat H, Dueppers P,
Meyer-Janiszewski YK, Spin JM, Schelzig
H, Duran M. Open surgery for iliofemoral deep vein thrombosis with temporary
arteriovenous stula remains valuable.
Phlebology. Oct 2018/2017;33(9):600–9.
doi:10.1177/0268355517736437
18. Fahrni J, Gloviczki P. Percutaneous
closure of adjunctive arteriovenous
stulas after surgical reconstruction
of iliac veins. J Vasc Surg Cases Innov
Tech. 2016;2(3):66–7. doi:10.1016/j.
jvsc.2016.03.003
19. Kasirajan K, Gray B, Ouriel K. Percutaneous AngioJet thrombectomy in the
management of extensive deep venous
thrombosis. J Vasc Interv Radiol.
2001;12(2):179–85. doi:10.1016/S10510443(07)61823-5
20. Prandoni P, Lensing AWA, Prins MH,
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syndrome: Arandomized, controlled
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doi:10.7326/0003-4819-141-4200408170-00004
21. Kahn SR, Shapiro S, Wells PS,
etal. Compression stockings to
prevent post-thrombotic syndrome:
Arandomised placebo-controlled trial.
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doi:10.1016/S0140-6736(13)61902-9
22. Plate G, Eklof B, Norgren L, Ohlin P,
Dahlstrom JA. Venous thrombectomy
for iliofemoral vein thrombosis—10-year
results of a prospective randomised
study. Eur J Vasc Endovasc Surg. Nov
1997;14(5):367–74. doi:10.1016/
s1078-5884(97)80286-9
23. Wagenhauser MU, Dimopoulos C,
Antakyali K, etal. Clinical outcomes after
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May2019;7(3):333–43;e2. doi:10.1016/j.
jvsv.2018.11.005
★24. Casey ET, Murad MH, Zumaeta-Garcia
M, etal. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg.
May2012;55(5):1463–73. doi:10.1016/j.
jvs.2011.12.082
25. Ockert S, von Allmen M,
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26. Kwak JH, Min SI, Kim SY, etal. Delayed
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Specialist Int. Jun 2016;32(2):72–6.
doi:10.5758/vsi.2016.32.2.72
CHAPTER
23
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Endovascular and surgical management
of acute pulmonary embolism
Armin Farazdaghi and Randall R. DeMartino
23.1 INTRODUCTION
Venous thromboembolic events (VTEs) are clinically
important causes of morbidity and mortality, occurring
in 0.8–1 per 1000 person-years. This results in >250,000
admissions for a VTE annually in the United States. Athird
of these admissions will be for pulmonary embolism (PE)
at a rate of approximately 0.45 per 1000 person-years.
The morbidity of acute PE is signicant, and this diagnosis
confers a 15% 28-day mortality rate.
PE is classied by prognostic clinical factors (Table23.1),
with stratication into massive and submassive categories based on hemodynamics. For all groups, the initial
treatment for any PE is immediate anticoagulation with
unfractionated heparin or, preferentially, with low-molecular-weight heparin.
anticoagulation therapy alone.
are preferentially treated with thrombolysis, if not contraindicated.
modality of thrombolytic delivery: by peripheral systemic
or by catheter-directed approaches. Finally, the preferred
approach for the treatment of submassive PE with thrombolysis and/or the application of catheter-based treatment
(CBT) remains intensely debated. The goal of this discussion is to review the interventional approaches for acute PE
for use in clinical practice in massive and submassive PE.
4
However, there is debate regarding the optimal
3
Treatment of low-risk PE remains
1
To direct treatment,
4
Patients with massive PE
1,2
TABLE 23.1 Classication of acute pulmonary embolism
Risk Definition
Massive Sustained hypotension for >15 minutes or inotro-
pic support due to the PE
Pulselessness
Persistent profound bradycardia (<40 bpm) with
evidence of shock
Submassive No systemic hypotension, but either RV dysfunc-
tion or myocardial necrosis
RV dysfunction:
RV dilation (four-chamber RV diameter/LV diameter >0.9 by US or CT)
Elevated BNP (>90 pg/mL)
Elevated N-terminal proBNP (>500 pg/mL)
ECG changes
Myocardial necrosis:
Elevated troponin I (>0.4 ng/mL)
Elevated troponin T (>01 ng/mL)
Low risk No clinical markers for adverse prognosis used to
dene massive or submassive
Abbreviations: PE: Pulmonary embolism; bpm: beats per minute; RV: right
ventricle; LV: left ventricle; US: ultrasound; CT: computed tomography;
BNP: brain natriuretic peptide; ECG: electrocardiogram.
Source: Adapted from Jaff MR, McMurtry MS, Archer SL. Circulation
2011;16(123):1788–830.
23.2 PATHOPHYSIOLOGY
OF ACUTE PE
The hemodynamic response to acute PE will vary for each
patient based on several factors. In addition to the magnitude of the thromboembolic load, humoral factors, including serotonin, thrombin, and histamine release, contribute
to the potential for hemodynamic embarrassment. The
patient’s cardiopulmonary reserve also plays a large role
in the tolerance of an acute embolic event. Thus, a smaller
PE may result in cardiovascular collapse in a patient with
existing cardiopulmonary disease. Conversely, large thrombus burdens may be tolerated in healthy individuals. Therefore, a patient-specic approach based on the acute PE
stratication (Table23.1) is needed to guide appropriate
treatment.
DOI: 10.1201/9781003328971-26
5
Acute PE results in increased pulmonary vascular resistance due to two factors. Physical obstruction of the pulmonary vessels increases pulmonary artery (PA) pressures
proportional to the thrombus load. Additionally, the pulmonary vascular bed vasoconstricts in response to hypoxemia. The combination of these two factors results in a
high-pressure circuit. PA pressures are known to increase
when 25%–30% of the pulmonary vasculature is occluded
by thrombus.
classied as severe pulmonary hypertension. In a previously healthy individual, 40 mmHg may represent the
maximum pressure that the right ventricle (RV) can generate. However, preexisting RV hypertrophy may allow the
RV to overcome higher PA pressure.
The obstruction of blood ow through the pulmonary arteries results in increased dead space ventilation.
However, compensatory hyperventilation usually works
to remove CO
5,6
Mean PA pressures of 30–40 mmHg are
6
and can also increase PaO2. However,
2
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