A STRATEGY OF AGGRESSIVE REGIONAL THERAPY FOR ACUTE ILIOFEMORAL VENOUS THROMBOSIS WITH CONTEMPORARY VENOUS THROMBECTOMY OR CATHETER-DIRECTED THROMBOLYSIS

Purpose: Occlusive iliofemoral venous thrombosis is associated with mo rbid short- and long-term consequences. Having been disappointed with standard anticoagulant therapy and systemic fibrinolysis, we embarked on an aggressive multidisciplinary regional approach to treat these pa tients, with the goals of therapy being (1) to eliminate iliofemoral v enous thrombus, (2) to provide unobstructed venous drainage from the a ffected limb, and (3) to prevent recurrent thrombosis. Methods: Twelve consecutive patients were treated for extensive iliofemoral venous th rombosis. Each had thrombus from their infrapopliteal veins through th eir iliofemoral system, and four had vena caval involvement. The condi tions of 11 patients failed to improve when the patients were given an ticoagulants, and prior systemic fibrinolysis failed in five patients. The treatment strategy includes catheter-directed thrombolysis with i ntrathrombus infusion of the plasminogen activator or operative thromb ectomy or venous bypass with a permanent 4 mm arteriovenous fistula (A VF). Results: Nine of 12 patients had a good or excellent clinical out come (mean follow-up 25 months), which correlated with restored unobst ructed venous drainage from the affected limb. Seven patients had cath eter-directed lytic therapy attempted. In five patients the catheters were appropriately positioned, and lysis was successful. five of the e ight patients who underwent operations had successful procedures. Two of the three patients with poor operative outcomes had residual thromb us in their iliac veins or vena cava after thrombectomy (without;bypas s). The third patient, in whom anticoagulation was contraindicated, ha d an initially successful thrombectomy and AVP; however, vena caval th rombosis developed 2 months after operation. No patient had symptomati c pulmonary emboli, and routine posttreatment ventilation/perfusion lu ng scanning was not performed. Conclusions: An aggressive multidiscipl inary regional approach to patients with obliterative iliofemoral veno us thrombosis, designed to remove thrombus and provide unobstructed ve nous drainage, offers substantially better clinical outcome compared w ith systemic fibrinolysis and standard anticoagulation. Catheter-direc ted thrombolysis is successful if the catheter is appropriately positi oned within the thrombus. Contemporary venous thrombectomy, which incl udes thrombus removal, completion phlebography, AVF, and cross-pubic b ypass when necessary, is associated with high success rates. Failures can be anticipated and avoided in most patients.