Open Surgical Treatment of Acute Iliofemoral and Inferior Vena Cava Thrombosis Bo Eklöf 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. Surgical Thrombectomy The first thrombectomy for an iliofemoral venous thrombosis was performed by Läwen in 1937. Surgery today is performed under general intubation anesthesia with 10 cm H2O positive end-expiratory pressure (PEEP) added during manipulation of the thrombus to prevent a perioperative PE. The involved leg, contralateral groin, and abdomen are prepared. A cell-saver is used to minimize the need for nonautologous blood transfusions. A longitudinal incision is made in the groin to expose the great saphenous vein (GSV), which is followed to its confluence with the common femoral vein (CFV), which is dissected up to the inguinal ligament. The superficial femoral artery is cleared 3 to 4 cm below the femoral bifurcation for later construction of an arteriovenous fistula. In treating a primary iliofemoral thrombus, where the thrombus originates in the iliac vein with subsequent distal progression of the clot, a longitudinal venotomy is made in the CFV and a venous Fogarty thromboembolectomy catheter is passed upward through the thrombus into the IVC. The balloon is inflated and withdrawn, these maneuvers being repeated until no more thrombotic material can be extracted. With the balloon left inflated in the common iliac vein, a suction catheter is introduced to the level of the internal iliac vein to evacuate thrombi from this vein. Backflow is not a reliable sign of thrombus clearance because of a proximal valve in 25% of external iliac veins that would prevent retrograde flow in a cleared vein. On the other hand, backflow can be excellent from the internal iliac vein and its tributaries despite a remaining occlusion of the common iliac vein. Therefore, an intraoperative completion venogram is mandatory. An alternative is the use of an angioscope, which enables removal of residual thrombus material under direct vision, or intravascular ultrasound (IVUS). In early interventions, the distal thrombus is usually readily extruded through the venotomy by manual massage of the leg distally, starting at the foot. The Fogarty venous catheter, with a soft flexible tip, can sometimes be advanced in retrograde fashion without significant trauma to the vein and its valves. The aim is to remove all fresh thrombi from the leg. The venotomy is closed with continuous suture and an arteriovenous fistula is created using the saphenous vein, anastomosing it end-to-side to the superficial femoral artery. An intraoperative venogram is performed through a catheter inserted in a branch of the fistula. After a satisfactory completion venogram, the wound is closed in layers and a closed suction drain is placed in the wound to evacuate blood and lymphatic fluid that accumulates postoperatively. In the case of an iliofemoral vein thrombosis secondary to ascending thrombosis from the calf, the thrombus in the femoral vein may be old and adherent to the venous wall. In such cases, the chance of preserving valve function has already been lost, and the opportunity to restore patency is significantly diminished. A femoral segment without functioning valves will lead to distal valve dysfunction in time, much as will failure to achieve proximal patency. However, a patent iliac venous outflow plus a competent profunda collateral system most of the time can achieve normal venous function. If iliac patency is established but the thrombus in the femoral vein is too old to remove, it is preferable to ligate the femoral vein. If normal flow in the femoral vein cannot be reestablished, we recommend extending the incision distally and exploring the orifices of the deep femoral branches. These are isolated, and venous flow is restored with a small Fogarty catheter. The femoral vein is then ligated distal to the profunda branches. In a 13-year follow-up after femoral vein ligation in this setting, Masuda and colleagues found excellent clinical and physiologic results without PTS. Finally, if there is evidence of iliac vein compression on the completion venogram, which occurs in about 50% of left-sided iliofemoral thrombosis, we recommend intraoperative endovenous iliac angioplasty and stenting. If phlegmasia cerulea dolens, with its threat of impending venous gangrene, is the indication for an intervention, the operation is started with fasciotomy of the calf compartments to release the pressure and improve the circulation immediately. If there is extension of the thrombus into the IVC, the cava is approached transperitoneally through a subcostal incision. The IVC is exposed by deflecting the ascending colon and duodenum medially. Depending upon the venographic findings relative to the top of the thrombus, the IVC is controlled, usually just below the renal veins. The IVC is opened and the thrombus is removed by massage, especially of the iliac venous system. Then if the femoral segment is involved, the operation is continued in the groin as described earlier. As an alternative to open thrombectomy, a retrievable caval filter can be introduced before the thrombectomy to protect against a fatal PE. Heparin is continued at least 5 days postoperatively, and warfarin is started the first postoperative day and continued routinely for 6 months. The patient begins ambulating the day after the operation wearing a compression stocking and is usually discharged after a week, to return after 6 weeks for closure of the fistula. The objectives of a temporary arteriovenous fistula are to increase blood flow in the thrombectomized iliac segment to prevent immediate rethrombosis, to allow time for healing of the endothelium, and to promote development of collaterals in case of incomplete clearance or immediate rethrombosis of the iliac segment. Usually the fistula is created between the saphenous vein and the superficial femoral artery. More distally placed fistulas have not functioned well in the author’s experience. A new percutaneous technique for fistula closure was developed by Endrys in Kuwait. Through a puncture of the contralateral femoral artery, a catheter is inserted and positioned at the fistula level. Before the fistula is occluded with a coil, an arteriovenogram can be performed to evaluate the patency of the iliac and caval veins, which is of prognostic value. More than 10% of patients have been shown to have remaining significant stenosis of the iliac vein despite initially successful surgery. In the case of remaining stenosis, a percutaneous transvenous angioplasty and stenting can be performed under the protection of the fistula, which is then closed 4 weeks later. Only gold members can continue reading. 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Open Surgical Treatment of Acute Iliofemoral and Inferior Vena Cava Thrombosis Bo Eklöf 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. Surgical Thrombectomy The first thrombectomy for an iliofemoral venous thrombosis was performed by Läwen in 1937. Surgery today is performed under general intubation anesthesia with 10 cm H2O positive end-expiratory pressure (PEEP) added during manipulation of the thrombus to prevent a perioperative PE. The involved leg, contralateral groin, and abdomen are prepared. A cell-saver is used to minimize the need for nonautologous blood transfusions. A longitudinal incision is made in the groin to expose the great saphenous vein (GSV), which is followed to its confluence with the common femoral vein (CFV), which is dissected up to the inguinal ligament. The superficial femoral artery is cleared 3 to 4 cm below the femoral bifurcation for later construction of an arteriovenous fistula. In treating a primary iliofemoral thrombus, where the thrombus originates in the iliac vein with subsequent distal progression of the clot, a longitudinal venotomy is made in the CFV and a venous Fogarty thromboembolectomy catheter is passed upward through the thrombus into the IVC. The balloon is inflated and withdrawn, these maneuvers being repeated until no more thrombotic material can be extracted. With the balloon left inflated in the common iliac vein, a suction catheter is introduced to the level of the internal iliac vein to evacuate thrombi from this vein. Backflow is not a reliable sign of thrombus clearance because of a proximal valve in 25% of external iliac veins that would prevent retrograde flow in a cleared vein. On the other hand, backflow can be excellent from the internal iliac vein and its tributaries despite a remaining occlusion of the common iliac vein. Therefore, an intraoperative completion venogram is mandatory. An alternative is the use of an angioscope, which enables removal of residual thrombus material under direct vision, or intravascular ultrasound (IVUS). In early interventions, the distal thrombus is usually readily extruded through the venotomy by manual massage of the leg distally, starting at the foot. The Fogarty venous catheter, with a soft flexible tip, can sometimes be advanced in retrograde fashion without significant trauma to the vein and its valves. The aim is to remove all fresh thrombi from the leg. The venotomy is closed with continuous suture and an arteriovenous fistula is created using the saphenous vein, anastomosing it end-to-side to the superficial femoral artery. An intraoperative venogram is performed through a catheter inserted in a branch of the fistula. After a satisfactory completion venogram, the wound is closed in layers and a closed suction drain is placed in the wound to evacuate blood and lymphatic fluid that accumulates postoperatively. In the case of an iliofemoral vein thrombosis secondary to ascending thrombosis from the calf, the thrombus in the femoral vein may be old and adherent to the venous wall. In such cases, the chance of preserving valve function has already been lost, and the opportunity to restore patency is significantly diminished. A femoral segment without functioning valves will lead to distal valve dysfunction in time, much as will failure to achieve proximal patency. However, a patent iliac venous outflow plus a competent profunda collateral system most of the time can achieve normal venous function. If iliac patency is established but the thrombus in the femoral vein is too old to remove, it is preferable to ligate the femoral vein. If normal flow in the femoral vein cannot be reestablished, we recommend extending the incision distally and exploring the orifices of the deep femoral branches. These are isolated, and venous flow is restored with a small Fogarty catheter. The femoral vein is then ligated distal to the profunda branches. In a 13-year follow-up after femoral vein ligation in this setting, Masuda and colleagues found excellent clinical and physiologic results without PTS. Finally, if there is evidence of iliac vein compression on the completion venogram, which occurs in about 50% of left-sided iliofemoral thrombosis, we recommend intraoperative endovenous iliac angioplasty and stenting. If phlegmasia cerulea dolens, with its threat of impending venous gangrene, is the indication for an intervention, the operation is started with fasciotomy of the calf compartments to release the pressure and improve the circulation immediately. If there is extension of the thrombus into the IVC, the cava is approached transperitoneally through a subcostal incision. The IVC is exposed by deflecting the ascending colon and duodenum medially. Depending upon the venographic findings relative to the top of the thrombus, the IVC is controlled, usually just below the renal veins. The IVC is opened and the thrombus is removed by massage, especially of the iliac venous system. Then if the femoral segment is involved, the operation is continued in the groin as described earlier. As an alternative to open thrombectomy, a retrievable caval filter can be introduced before the thrombectomy to protect against a fatal PE. Heparin is continued at least 5 days postoperatively, and warfarin is started the first postoperative day and continued routinely for 6 months. The patient begins ambulating the day after the operation wearing a compression stocking and is usually discharged after a week, to return after 6 weeks for closure of the fistula. The objectives of a temporary arteriovenous fistula are to increase blood flow in the thrombectomized iliac segment to prevent immediate rethrombosis, to allow time for healing of the endothelium, and to promote development of collaterals in case of incomplete clearance or immediate rethrombosis of the iliac segment. Usually the fistula is created between the saphenous vein and the superficial femoral artery. More distally placed fistulas have not functioned well in the author’s experience. A new percutaneous technique for fistula closure was developed by Endrys in Kuwait. Through a puncture of the contralateral femoral artery, a catheter is inserted and positioned at the fistula level. Before the fistula is occluded with a coil, an arteriovenogram can be performed to evaluate the patency of the iliac and caval veins, which is of prognostic value. More than 10% of patients have been shown to have remaining significant stenosis of the iliac vein despite initially successful surgery. In the case of remaining stenosis, a percutaneous transvenous angioplasty and stenting can be performed under the protection of the fistula, which is then closed 4 weeks later. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Dyslipidemia and Hypertriglyceridemia Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join
