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Then an intravenous bolus of heparin is given and a 1.5 cm long venotomy is
performed at the inferior and lateral side of the sapheno–femoral junction. At this moment,
the anesthesiologists are asked to use a PEEP of 10 cm H
2
O during the whole thrombectomy
time in order to prevent from pulmonary embolism.
A large Fogarty catheter is then introduced cephalad between the venous wall and
the clot to the IVC. It should be inserted easily to 40 cm long to avoid ascending lumbar
vein catheterization. Then the balloon is inflated and the catheter is cautiously withdrawn
(Fig. 2B) to remove the clot (Fig. 3A). When performed on the left side it can need
deflation at 20 cm in order to pass under the right common iliac artery in cases of May-
Thurner syndrome. The Fogarty catheter should be used until no more clot is retrieved.
Then the catheter is passed through a large Vollmar ring before their introduction
into the CFV and is inflated into the iliocaval junction. The Vollmar ring is used to unstick
the adherent clot (Fig. 2C). Moreover a suction canula is inserted to remove the clot at the
internal iliac vein ostium (Fig. 2D). Then the catheter can be retrieved and the tape is
tightened around the common femoral vein after infusion of heparined serum.
Limb, popliteal and femoral veins thrombectomy is then performed without using
any endovenous instrumentation. All the tapes are tightened and sturdy massage of the
limb is performed, starting at the foot to unstick the clot. The tapes are briefly untightened
to release the clot (Fig. 3B) and the maneuver is repeated until no more clot is retrieved.
Blood loss must be controlled during this time. Then an Esmarch bandage is put around the
limb from the ankle to the thigh for one or two minutes before a last flush. The great
saphenous vein must be thrombectomised also.
The venotomy is then closed using a 6/0 polypropylene running suture which is tied
only after unclamping all the veins to prevent stricture.
The great saphenous vein is sectioned at 10 cm from the sapheno–femoral junction
in order to be used for construction of an AVF. A 7F sheath is inserted through it and
completion ilio-cavography is performed. If it shows persisting clot or venous stenosis,
angioplasty and stenting should be performed at this time. The AVF is performed with a
latero-terminal anastomosis between the superficial femoral artery and the saphenous vein
using a 7/0 polypropylene running suture. The site of the anastomosis is chosen while the
Figure 3 Operative view of the thrombus after venous thrombectomy: (A) iliac thrombus;
(B) femoro-popliteal thrombus. (See color insert.)
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saphenous vein is under tension and the retractor is removed (Fig. 4A). In case of an
unsuitable saphenous vein, a short 5 mm Plolytetrafluoro ethylene graft can be used.
A good thrill must be felt on the AVF and common femoral vein on completion (Fig. 4B).
Before wound closure, the AVF is located in order to facilitate its surgical closure
after six weeks. A PTFE patch (Fig. 4D) or a silastic loop (Fig. 4C) is put around it and
closed with metallic clips, its extremity lying in the subcutaneous plane. A suction drain
must be applied next to the CFV.
Inferior Vena Cava Thrombectomy
Thrombectomy is performed through a direct approach to the IVC. It preferentially uses a
right transperitoneal subcostal route deflecting the duodenum and the ascending colon
medially. The IVC can be exposed for 8 cm caudally to the renocaval confluence. Two
tapes are put around the IVC, one just under the renal veins and another one 6 cm caudally.
Lumbar and genital veins must be controlled by threads. Two 6/0 polypropylene
stay sutures are placed on the IVC between the two tapes, at each extremity of the
planned cavotomy.
If the clot reaches the renal vein or is more extensive, a Fogarty catheter is introduced
cephalad in the IVC once a 2 mm cavotomy has been performed in the center of a purse
string suture (Fig. 5A,B). The balloon is inflated cephalad to the superior pole of the clot
and the cavotomy is extended (Fig. 5C). Then the Fogarty catheter is retrieved and the
superior tape is tightened once the catheter is down to it (Fig. 5D). Then the lower part of
the IVC is thrombectomized as previously described and the cavotomy is closed with a 6/0
polypropylene running suture.
If thrombosis does not reach the superior third of the infrarenal IVC, the cephalad
tape is tightened and the iliac clot is massaged in order to mobilized it. Then the cavotomy
is performed and the clot is removed with a large Fogarty catheter while taking great care
to limit blood loss (Fig. 5D).
A median laparotomy should be used only if abdominopelvic exploration is needed,
if there is a doubt about the age of the thrombosis or if an IVC filter is to be removed.
Figure 4 Confection of an arterio-venous fistula (AVF). (A) the implantation site of the saphenous
vein on the superficial femoral artery is chosen with the retractor released, (B) view after
performance of the AVF, (C) location of the AVF with a silastic tape, (D) or with a piece of PTFE.
(See color insert.)
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A suction drain is applied next to the IVC before closure. In cases of phlegmasia cerulea
dolens, the procedure should begin by fasciotomy.
Postoperative Period
Elastic stockings are on both limbs applied and an intravenous heparin infusion is
continued. As soon as the patient is awake, active mobilization must be performed. The
patient should be walking from day one.
Long-term anticoagulation with fluindion is started the first postoperative day for at
least six months, but the AVF should be closed at six weeks with performance of ilio-
cavography. This procedure can be performed through a surgical approach following the
locating device or by an endovascular procedure (detachable balloons, coils) (17).
Indications for Surgical Thrombectomy
This technique should be considered for recent and proximal (iliofemoral with or without
IVC involvement) DVT in patients with life expectation up to five years. This means that:
† the thrombosis should be less than seven days old. Dating is given by the first
onset of symptoms. Moreover, the characteristics of the thrombosis at Duplex
scan (hypoechogenic and nonadherent clot with dilatation of the vein) and CT
scan (hypodense clot with peripheral enhancement) can help to confirm this.
† the thrombosis should reach at least the common femoral vein (CFV), most of
them reaching the common iliac vein (CIV) or the inferior vena cava (IVC).
† patients should be in good health, less than 70 years old and should not have
cancer, infectious or inflammatory disease, and no severe cardiorespiratory
disease. Moreover, they should be able to walk the day after the procedure.
Pregnancy, postdelivery, and thrombolytic treatment failure are not contra
indications to venous thrombectomy. In pregnant women, thrombus extension can be
evaluated by Duplex scan or iliocavography, but no completion angiography is performed
even if a stenosis was felt while retrieving the Fogarty catheter. AVF closure should be
Figure 5 IVC thrombectomy. A, B, C: when the clot reach the renal veins, a purse-string is
performed on the infra-renal IVC and a Fogarty is inserted between the venous wall and the
clot then inflated above it (A). A cavotomy is performed and the Fogarty catheter is retrieved (B)
until it is below the superior tape which is used to clamp the distal IVC (C). (D): proximal IVC
thrombectomy.
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performed one to three months after delivery with angiography; significant residual
lesions should be stented at this time if needed (18,19).
Surgical thrombectomy can be also used in cases of femoral extension of great
saphenous vein thrombosis and in case of IVC thrombosis in presence of an IVC filter
or clip.
Adjunctive Techniques
IVC Clip and Filters
Their goal is to avoid PE. Since the introduction of PEEP, which avoids peroperative
severe PE, and of stenting for treatment of residual clot there are no more routine
indications for their use during venous thrombectomy.
Angioplasty and Stenting
Stenting is used to treat lesions that could compromise patency after thrombectomy
or thrombolysis. It is indicated in cases of May-Thurner syndrome after left CIV
thrombectomy (Fig. 6) but also in cases of residual clot, postthrombotic occlusive disease,
extrinsic stenosis (retroperitoneale fibrosis) (20). Indeed, Mickley (21) showed that if the
underlying lesions are left untreated, rethrombosis rate is 73% versus only 13% after
stenting. Stenting should be systematically performed because recoil is very important. If
not stented, the vein would restenose quickly and the benefit of the procedure would not
be durable.
After insertion of a sheath in the common femoral vein, catheterization is performed
with a Terumo guidewire. Angioplasty is performed, generally using a 12 mm diameter
balloon. Then stent(s) is(are) deployed. Self-expanding metallic and retrievable stents
(Wallstent) should be used because balloon expandable stents can be crushed (22). These
stents need to be stabilized otherwise jumping can occur (23). This is achieved by using
long stents leaning on both sides of the stenosis. Raju (24) has shown that the stent must lie
on the right flank of the IVC when treating May-Thurner syndrome. In such cases 16 mm
diameter and at least 60 mm long stents should be used. Table 1 reviews the experience of
stenting during surgical thrombectomy (18,21,25–29).
Figure 6 Iliocavography during surgical thrombectomy: (A) May-Thurner syndrome; associated
with residual clot into the common iliac vein. (B) After angioplasty and stenting, no residual
stenosis.
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Contraindications to stenting are septic condition and pregnancy. In this last
case, iterative thrombectomy and stenting should be considered only in case of early
rethrombosis (22).
Venous Bypass
Bypasses were previously used in cases of rethrombosis after venous thrombectomy or if
major occlusive lesions were found at preoperative ilio-cavography. The Palma procedure
was the technique of choice in cases of iliac lesions compromising its patency. It had to be
associated to the AVF.
At present stenting is the preferred technique and bypass should be reserved for cases
of stenting failure without correctable remaining lesions or in case of contraindication for
stenting. Since 1995, such a procedure was needed twice and both of them were performed
more than four months after the surgical thrombectomy (18).
Regional Thrombolysis
Bla
¨
tter (30) reported the combination of surgical thrombectomy with regional
thrombolysis. 50,0000–30,00,000 UI of urokinase are infused through a 12-gauge catheter
introduced in a foot vein at the beginning of the procedure. The aim is to allow the
thrombolytic drug to act during 30 minutes (approach of the CVF and iliac thrombectomy)
in order to facilitate the clearance of the clot in the limb.
Results
Mortality is very low in recent series reported by experienced groups. We had no death in
our department in our late experience (75 patients) (31) and no more deaths since the
introduction of stenting (20 patients) (18). Eklo
¨
f reported a 1% mortality rate on 203
consecutive patients (32); both deaths were not related to the thrombosis.
PE is also rarely severe. As Bla
¨
ttler (30), we (18,27) had no symptomatic
postoperative PE in our experience, but Plate (11) reported 45% of positive perfusion scan
at the admission and 20% of additional defects postoperatively, but none when an AVF
was constructed.
Table 1 Results of Interventional Therapy with Stenting of Underlying Iliocaval Lesions for
Femoroiliac Venous Thrombosis
Study Technique N
Technical
success PP at 1 year Late PP Late SP
O’Sullivan TL 19 93.1%
(stented)
Mewissen TL
Without stent 122 53%
With stent 99 74%
Vedantham TL 23 100%
Mickley ST 20 95% M60:72% M60:88%
Wohlgemuth ST 35 97% M48:69%
Schwarzbach ST 21 100% M21:80% M21:90%
Hartung ST 20 100% 76% M36:76% M36:81%
Abbreviations: PP, primary patency rate; SP, secondary patency rate; STCAVF, surgical thrombectomy and
arteriovenous fistula; TL, thrombolysis.
Source: From Refs. 6, 15–18.
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The main other complication is rethrombosis. It is commonly due to underlying
venous lesions like in May-Thurner syndrome, incomplete thrombectomy, inappropriate
indication, failure of the AVF or to inadequate anticoagulation. Use of an AVF has been
shown to reduce the rethrombosis rate: Hutschenreiter (33) had 83% of iliac patency with
AVF versus 54% without it. According to this technique, primary patency rate was 87%
at three months in a metaanalysis performed by Eklo
¨
f while reviewing 527 cases (28).
Residual lesions on the iliac veins and IVC represented a major cause for rethrombosis.
In our experience, it occurred in 7% of the cases in absence of stenosis, 26% in case of
mild stenosis and 56% in case of tight stenosis (31). Obstruction was treated by cross
pubic venous bypass until Mickley (21) showed that while leaving iliac lesions untreated
reocclusion rate was 73% versus 13% after stenting. Table 1 summarizes the results
of the published reports (18,21,25–29). In a group of 21 consecutive patients who
had surgical thrombectomy with stenting, our primary patency rate was 85.7% at one
month (18).
In a report with a mean follow up of more than eight years, we reported patency
and valvular competence rates of respectively 84% and 80% at five years and 84% and
56% at 13 years (Fig. 7) (31). These results are consistent with the literature review of
Eklo
¨
f (32).
The association of regional thrombolysis with surgical thrombectomy (26) gave
100% primary success without recurrence or deep venous reflux at one year. After a six to
10 years follow-up, 16 legs were asymptomatic without compression therapy.
Pillny (19) reported 97 cases of venous thrombectomy during pregnancy or after
delivery without maternal death and one postoperative fetal death. After a mean follow up
of six years, patency rate was 89.5%, and 56.3% of the patientshad no post-thrombotic
syndrome, while only 3.5% had leg ulceration.
Timing
It is generally agreed that the thrombosis should be less than seven days old. Despite this
some patients were operated on after larger delay, up to 16 days in our experience (31).
Figure 7 Cumulative iliofemoral vein patency after surgical thrombectomy and femoropopliteal
venous competence curve after successful iliofemoralvenous thrombectomy according to Juhan (31).
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We were unable to draw correlations between the age of the clot and the patency of the
iliofemoral vein. Nevertheless it does not seem advisable to recommend such delay
because the goal of the treatment is not only the iliac patency but also preservation of
valvular competence.
IVC INTERRUPTION AND FILTERS
The indications for such techniques are quite rare if strict indications are followed.
Techniques
This can be performed by different approaches, the endovascular being the only one
commonly used at present.
Surgical Techniques
The approach is commonly performed through a right transperitoneal subcostal route as
previously described. Once the IVC dissected free it can be ligated, plicated with
transfixion polypropylene sutures or an Adam-De Weese clip can be inserted around the
IVC (no longer available in France).
Endovascular Procedures
Since Greenfield’s report in 1973 (34), the use of IVC filters has became the gold standard
technique. Many filters are commercially available at present. Designs have been
improved, and most of them can be inserted percutaneously by femoral or jugular
approaches through 6 to 12 French sheaths. Moreover, temporary and retrievable filters are
available. Measurement of the IVC must be performed before filter deployment. Indeed,
only the Birds Nest filter (Cook) is suitable for IVC larger than 28 mm in diameter.
Moreover, venous anomalies must be identified before implantation (35).
Filter placement can be performed under fluoroscopic guidance after cavography to
visualize the level of the renal veins or by means of transabdominal duplex ultrasound (36)
or intravascular ultrasound (IVUS) guidance (37).
Indications
Categorical Indications
Documented DVT and/or PE with
† absolute contra indication to anticoagulation
† documented progression of DVT or recurrent PE while well anticoagulated
† complication of anticoagulation therapy requiring its termination
† massive PE.
Relative Indications
Documented DVT and/or PE with
† large free floating IVC/iliac vein thrombus (unless surgical thrombectomy is
performed)
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† limited cardiac reserve
† high risk of complications of anticoagulation.
Indications for surgical approaches were considerably decreased by percutaneous
filters. Remaining indications are the absence or impossibility of percutaneous access and
in case of surgical approach of the IVC for another reason.
Placement in the suprarenal IVC can be performed in case of thrombosis of the
infrarenal IVC, mostly if an infrarenal filter is thrombosed.
Results
The different devices are not free of secondary complications. The main ones are IVC
thrombosis and migration.
Two main articles have reviewed the results of IVC filters: one reports the
experience of one center on 1765 filters implanted over 26 years (38), and another
analyzes the published results (39). The PE rate was 5.6% including 3.7% of fatal PE and
no filter gave superior results compared to the others (38). According to Athanasoulis, the
filter migration rate is 0.1% but Streiff (39) reported a higher rate ranging from 2.2% with
the Simon filter to 12.8% with the Greenfield titanium filter. These migrations justify the
performance of abdominal radiography after implantation and in case of PE or cardiac
arrhythmia. The perforation rate ranged between 0 and 14.1% depending on the filter (39).
Thrombosis of the access site is very frequent (30%) (39) and depends on the size of the
sheath. Filter thrombosis is a more problematic complication which exposes the patient to
the risk of major PE. Its rate is ranging between 3.6% and 11.2% (39). Table 2 reviews
these complications. A randomized prospective study (42) showed at 8 years that filters
reduce the risk of pulmonary embolism but increase that of deep-vein thrombosis and had
no effect on survival.
Bedside placement under duplex scan guidance has been shown to be safe and cost-
effective (36) but inadequate imaging of the IVC is reported to be 8–13% mostly in
critically ill patients (36,40,41). IVUS placement technical success rate is about 92% (33)
and can be done with single-puncture venous access. The main potential drawback of these
techniques is missed venous anomalies.
ENDOVASCULAR TECHNIQUES
Percutaneous techniques have the theorical advantage of being less invasive than surgical
thrombectomy.
Table 2 Complication Rates Depending on the Model of Filter According to Streiff
Filter PE Lethal PE DVT IVCT PTS AST
Greenfield 2.6% 0.9% 5.9% 3.6% 19% 23%
Greenfield Ti 3.1% 1.7% 22.7% 6.5% 14.4% 28%
Bird nest 2.9% 0.9% 6% 3.9% 14% 23%
Simon 3.8% 1.9% 8.9% 7.7% 12.9% 31%
LGM 3.4% 0.3% 32% 11.2% 41% 36%
Abbreviations: Ti, titanium; PE, pulmonary embolism; DVT, deep venous thrombosis; IVCT, inferior vena cava
thrombosis; PTS, postthrombotic syndrome; AST, access site thrombosis.
Source: From Ref. 35.
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Thrombolysis
Indication
According to the Venous registry (28), thrombolysis should be performed for acute
(!10 days) or chronic (O10 days) femoro-popliteal or iliofemoral DVT.
More over, such patients should be healthy and active with a normal life expectancy (42).
Contraindications
In this study (28) patients were excluded with:
† contraindications to the use of anticoagulants and contrast media
† contraindications to thrombolytic agents: active internal bleeding, recent cerebro-
vascular accident,allergy to thrombolytic agents, recent major surgery, recent serious
gastrointestinal bleeding, recent serious trauma, severe hypertension, pregnancy,
bacterial endocarditis, possibility of intracardiac thrombus, coagulopathy.
Technique
Catheterization access approach can be performed on internal jugular vein, common
femoral vein, or popliteal vein, but this last vein has became the site of choice. It is
recommended to perform it under ultrasonographic guidance with a 21G needle in order to
reduce the risk of bleeding due to arterial puncture. Infusion is commonly performed
through a multiple-side-hole catheter embedded in the thrombus and lysis is monitored
at venography. The procedure should be ended when no additional lysis is achieved within
the last 12 hours. Intravenous heparin therapy must be administrated during and after the
procedure (100–500 IU/hr).
Adjunctive techniques can include angioplasty and stenting to treat underlying lesions
(9,27,28,43) and IVC filter placement to prevent from PE in case of recurrent PE despite
anticoagulation or free floating IVC or iliac thrombus (43).
Laboratory parameters of surveillance are hematocrit level, fibrinogen level,
prothrombin time, activated thromboplastin time and INR. The patients should be monitored
in an intensive care unit.
Results
Experimental studies have demonstrated that thrombolysis can restore venous patency
while preserving valvular competence (44,45).
Since the 1970s, this technique was used to treat acute DVT first via a systemic
route. Comerota pooled the results of 13 studies in 1993 (46). He showed that while
anticoagulation alone gave 82% of no thrombus clearing or worsening, 45% of significant
or complete clearing of the clot and 18% of partial clearing was obtained with
thrombolysis. But general thrombolysis was shown to have high complication rates mainly
due to bleeding and pulmonary embolism (47,48).
Catheter directed thrombolysis (CDT) was then introduced, and the first major report
was published in 1994 by Semba (9). Grossman (49) pointed out in a review in 1999
the lack of data from the literature on follow-up and the absence of control groups.
Technical venographic success was 84% and 4.9% of the patients needed transfusion for
bleeding (49).
The Venous Registry is the most important database reporting this treatment (28). It
reported the results on 303 limbs in 287 patients in 63 centers with 71% of iliofemoral
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DVT including 21% of IVC involvement. Mean infusion time was 53.4 hours (2–47 hours)
using a mean 7.8 million IU of urokinase. Stenting was needed in 33% of the limbs. Grade
III (complete) and grade II (50–99%) lysis were respectively achieved in 31% and 52% of
the patients [19% grade III in chronic patients (O10 days)]. Primary patency rates
were 64% for iliofemoral DVT at 12 months versus 47% for femoral-popliteal DVT.
The results were better if the DVT was acute, the patient had no history of previous
ipsilateral DVT, the thrombolysis was complete, the DVT involved the iliac veins and if
stenting was performed in iliac veins. Major bleeding occurred in 11% of the patients,
mostly at the puncture site (39%) and in the retroperitonal space (13%) and minor bleeding
in 16%. Mortality, PE and major neurologic complication rates were respectively 0.4%,
1% and 0.4%.
Quality of life after CDT was evaluated by Comerota (50). Patients receiving CDT
reported significantly better overall physical functioning, less stigma and fewer post-
thrombotic symptoms compared with patients who received anticoagulation alone.
Laiho (48) reported 44% of valve competence preservation with CDT versus 13%
with systemic thrombolysis with less deep (44% vs. 81%) and superficial (25% vs. 63%)
reflux but the clinical disability score did not differ significantly.
The Cochrane PVD group (51) reviewed all the publications describing randomized
controlled trials of thrombolysis versus anticoagulation for acute DVT. Complete clot
lysis and improvement in venous patency occurred significantly more often with
thrombolysis at early and late follow-up. Significantly less post-thrombotic syndrome and
less leg ulceration occurred in those receiving thrombolysis. Venous function was
improved at late follow up, but not significantly. Out of 668 patients, those receiving
thrombolysis had significantly more bleeding complications but their incidence reduced
over time with introduction of stricter selection criteria. There was no effect on mortality
but no conclusions can be drawn on PE and DVT recurrence rates.
Thrombolysis appears to offer advantages in terms of reducing post-thrombotic
syndrome and maintaining venous patency after DVT, but optimum drug dose (none has
the FDA approval in this indication) and route of administration have yet to be determined.
Moreover, multiple issues such as cost, safety, reporting standards, and practice guidelines
need to be studied.
Mechanical Thrombolysis
This technique was first reported for DVT by Uflacker (52). It has the potential advantages
of faster vein recanalization and relief of the symptoms with reduced bleeding
complication rates and cost. Main concerns are the potential risks of wall and valve
injury and haemolysis.
Devices
Many devices are available, and none is perfect. Moreover, while some have FDA
approval for hemodialysis graft thrombosis, none have it for DVT. The ideal device should
allow complete thrombus removal without causing venous wall and valve trauma and
without using thrombolytic agents. Moreover, it should prevent bleeding, hemolysis and
PE. The actually available catheters can be classified depending on two major properties:
complete vessel wall contact and possibility of thrombus aspiration (Table 3).
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