Venous Thrombectomy for Deep Vein Thrombosis

Deep vein thrombosis (DVT) is a blood clot in the deep veins, and when it fills the iliac and femoral veins (iliofemoral DVT) it can leave the leg chronically swollen and painful (post-thrombotic syndrome) or break off and travel to the lungs. Most DVT is treated with blood thinners alone or with catheter-based treatments done through a needle puncture. Open venous thrombectomy is used for selected patients with a large, fresh iliofemoral clot, for patients who cannot have clot-dissolving drugs, and for the most severe form, phlegmasia cerulea dolens, where the leg is so swollen and blue that it is at risk. This is a venous operation, which sets it apart from a femoral arterial embolectomy even though both are done through the groin with Fogarty balloon catheters. The surgeon opens the common femoral vein, sweeps clot out of the iliac veins and sometimes the vena cava, and pushes clot up out of the leg by squeezing or wrapping it. Because the clot can break loose toward the lungs, extra steps protect against pulmonary embolism: a blocking balloon in the vena cava when the clot reaches it, a high PEEP from the anesthesia team and a head-up tilt. A venogram checks the result, a stent may be placed in a narrowed iliac vein, and a small temporary arteriovenous fistula is often made to keep blood moving fast through the cleared vein. The case is often combined with endovascular work, so the room needs fluoroscopy, wires and stents. Wound infection and new clotting are the main risks afterward, and patients stay on blood thinners and compression stockings for months.