Lack of decent venous back bleeding indicates presence of significant thrombus in the infrainguinal venous system. To address this, medial incision is made in the lower leg to expose the posterior tibial vein. After obtaining proximal and distal control, a longitudinal venotomy is performed on the posterior tibial vein (Fig. 26.1c). A #3 Fogarty balloon is passed from the posterior tibial vein proximally to the common femoral vein and brought out through the proximal femoral vein venotomy (Fig. 26.1a). A silastic IV catheter is used to connect the #3 Fogarty to another #4 Fogarty balloon. Pressure is applied to both balloons to secure them in the silastic tubing, and both are passed distally to the posterior tibial vein venotomy. This allows for atraumatic passage through the valves and clotted vein (Fig. 26.1b). The #3 Fogarty and the silastic tubing are removed. The #4 Fogarty is inflated and utilized to complete the infrainguinal thrombectomy (Fig. 26.1d). The inflated Fogarty catheter is passed with the direction of flow in the vein to avoid getting stuck on valves, and the thrombus is removed from the femoral incision (Fig. 26.1e). This process can be repeated with a bigger Fogarty in the place of the #4 Fogarty until no further thrombus is extracted.

An alternative to the abovementioned technique is introducing over the wire Fogarty catheter from the posterior tibial vein. At its exit from common femoral vein, a guidewire is inserted into the tip of the catheter and advanced, till it comes out of the catheter’s hub (Fig. 26.2a). Now, the catheter can be removed and introduced over the wire, from the common femoral venotomy side and advanced till it exits the posterior tibial vein. The Fogarty catheter is then inflated and thrombus removed when the catheter is withdrawn from the common femoral venotomy site (Fig. 26.2b). This process can be repeated multiple times till good venous back bleeding is achieved.

Once infrainguinal thrombectomy is completed, a large diameter red rubber catheter is inserted into the posterior tibial vein and is flushed with a bulb syringe. This hydraulically removes any remaining thrombus from the deep venous system (Fig. 26.3). Infrainguinal deep venous system can now be instilled with dilute plasminogen activator solution. Comerota et al. recommend 4–6 mg recombinant tissue plasminogen activator in 200 mL of saline. This solution will remain in the infrainguinal veins until completion of the procedure. If infrainguinal thrombectomy is unsuccessful due to chronic thrombus in the femoral vein, the femoral vein is ligated below the level of the profunda femoris vein. The patency of the profunda femoris has to be ensured to allow for adequate inflow. Attention is then directed to the proximal thrombus. A #8 or #10 Fogarty catheter is passed several times into the iliac veins to remove the bulk of the thrombus. Then it is passed into the vena cava. This part of the procedure should be performed under fluoroscopy . Saline should be mixed with contrast to inflate the balloon. In cases in which caval clot exists, thrombectomy can be performed in the presence of a protective balloon. Another Fogarty balloon is inserted into the vena cava through the contralateral femoral vein and is inflated above the level of the clot to prevent pulmonary embolism. It is imperative that these steps be performed under fluoroscopic guidance. Once the iliofemoral venous thrombectomy is completed, fluoroscopy is used to evaluate the iliofemoral venous system to ensure drainage into the inferior vena cava. Any residual stenosis should be addressed with balloon angioplasty. If there is continued recoil, then an appropriately sized stent should be utilized. It is recommended to use at least a 12–14 mm stent for external iliac veins and 14–16 mm stent for common iliac veins. The common femoral venotomy is closed with a fine monofilament suture. Next an AV fistula is created between the superficial femoral artery and the end of the saphenous vein. A large branch of the saphenous vein can also be utilized for the fistula (Fig. 26.4a). The anastomosis of the fistula should be between 3.5 and 4 mm in diameter. The patency of the saphenous vein needs to be verified, and commonly thrombectomy needs to be performed. The AV fistula should be marked with suture with clips to guide future dissection if the AV fistula needs to be ligated in the future. The fistula can be closed using endovascular coils, and clips can be useful to determine the site of fistula under fluoroscopy. Most of these fistulas do not need future ligation. Some surgeons recommend using a piece of synthetic PTFE graft to encircle the fistula in order to facilitate later dissection and ligation.