Deep vein thrombosis surgery

Editors-in-Chief: C. Michael Gibson, M.S., M.D. Associate Editor-In-Chief: Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org]

Overview
Percutaneous transcatheter treatment of patients with deep venous thrombosis (DVT) includes:
 * Thrombus removal with catheter-directed thrombolysis,
 * Mechanical thrombectomy,
 * Angioplasty,
 * Stenting of venous obstructions

Fibrinolysis
In many patients of arterial and venous thrombosis, fibrinolysis alone is the main mode of treatment. It should not be used in following conditions:
 * In patient who have undergone recent surgery or trauma involving central nervous system.
 * In patient with extensive or bulk thrombosis.

Mechanical thrombectomy
It should be considered in patients with proximal occlusive DVT, which is associated with significant swelling and symptoms or phlegmasia cerulea dolens. This procedure must be carried out carefully to avoid dislodging the clot or breaking it into small fragments because it may lead to pulmonary embolus.

Inferior vena cava filter
Inferior vena cava filter reduces pulmonary embolism and is an option for patients with an absolute contraindication to anticoagulant treatment (e.g., cerebral hemorrhage) or those rare patients who have objectively documented recurrent PEs while on anticoagulation, an inferior vena cava filter (also referred to as a Greenfield filter) may prevent pulmonary embolisation of the leg clot. However these filters are themselves potential foci of thrombosis, IVC filters are viewed as a temporary measure for preventing life-threatening pulmonary embolism.

ACCP Guidelines Catheter-directed Thrombolysis of Acute DVT of the Leg (DO NOT EDIT)
1. In selected patients with extensive acute proximal DVT (eg, iliofemoral DVT, symptoms for <14 days, good functional status, life expectancy of >1 year) who have a low risk of bleeding, we suggest that catheter-directed thrombolysis (CDT) may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B).

2. After successful CDT in patients with acute DVT, we suggest correction of underlying venous lesions using balloon angioplasty and stents (Grade 2C).

3. We suggest pharmacomechanical thrombolysis (eg, with inclusion of thrombus fragmentation and/or aspiration) in preference to CDT alone to shorten treatment time if appropriate expertise and resources are available (Grade 2C).

4. After successful CDT in patients with acute DVT, we recommend the same intensity and duration of anticoagulant therapy as for comparable patients who do not undergo CDT (Grade 1C).

Recommendation for systemic Thrombolytic therapy
1. In selected patients with extensive proximal DVT (eg, symptoms for < 14 days, good functional status, life expectancy of > 1 year) who have a low risk of bleeding, we suggest that systemic thrombolytic therapy may be used to reduce acute symptoms and postthrombotic morbidity if CDT is not available (Grade 2C).

Recommendation for percutaneous venous Thrombectomy
1. In patients with acute DVT, we suggest that they should not be treated with percutaneous mechanical thrombectomy alone (Grade 2C).

Recommendation for operative venous Thrombectomy
1. In selected patients with acute iliofemoral DVT (eg, symptoms for < 7 days, good functional status, and life expectancy of > 1 year), we suggest that operative venous thrombectomy may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B). If such patients do not have a high risk of bleeding, we suggest that catheter-directed thrombolysis is usually preferable to operative venous thrombectomy (Grade 2C).

2. In patients who undergo operative venous thrombectomy, we recommend the same intensity and duration of anticoagulant therapy afterwards as for comparable patients who do not undergo venous thrombectomy (Grade 1C).

Recommendation for vena caval Filters
1. For patients with DVT, we recommend against the routine use of a vena cava filter in addition to anticoagulants (Grade 1A).

2. For patients with acute proximal DVT, if anticoagulant therapy is not possible because of the risk of bleeding, we recommend placement of an inferior vena cava (IVC) filter (Grade 1C).

3. For patients with acute DVT who have an IVC filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C).

Recommendation for Immobilization for the Treatment of Acute DVT
1. In patients with acute DVT, we recommend early ambulation in preference to initial bed rest when this is feasible (Grade 1A).

Guidelines Resources

 * Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)