A strategy of aggressive regional therapy for acute iliofemoral venous thrombosis with contemporary venous thrombectomy or catheter-directed thrombolysis  Anthony J. Comerota, MD, Samuel C. Aldridge, MD, Gary Cohen, MD, David S. Ball, DO, Mark Pliskin, MD, John V. White, MD  Journal of Vascular Surgery  Volume 20, Issue 2, Pages 244-254 (August 1994) DOI: 10.1016/0741-5214(94)90012-4 Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 1 Algorithm for treating iliofemoral venous thrombosis. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 2 Example of catheter-directed thrombolysis for acute iliofemoral venous thrombosis extending to popliteal vein in 40-year-old man presenting 9 days after total colectomy for ulcerative colitis. A, Iliocavagram (anteroposterior and oblique views) demonstrates thrombus extending from left iliac vein partially occluding distal vena cava. B, Bird's Nest vena caval filter was placed above thrombus, and two multi-side-hole catheters were inserted into clot, one from right jugular vein and one from contralateral femoral vein. Bolus rt-PA and continuous infusion of urokinase was given through both catheters to restore venous patency. C, After 72 hours, patency was restored with excellent clinical response. Note embolus trapped by caval filter (arrow). At 1 year superficial femoral veins and iliofemoral veins remained patent. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 2 Example of catheter-directed thrombolysis for acute iliofemoral venous thrombosis extending to popliteal vein in 40-year-old man presenting 9 days after total colectomy for ulcerative colitis. A, Iliocavagram (anteroposterior and oblique views) demonstrates thrombus extending from left iliac vein partially occluding distal vena cava. B, Bird's Nest vena caval filter was placed above thrombus, and two multi-side-hole catheters were inserted into clot, one from right jugular vein and one from contralateral femoral vein. Bolus rt-PA and continuous infusion of urokinase was given through both catheters to restore venous patency. C, After 72 hours, patency was restored with excellent clinical response. Note embolus trapped by caval filter (arrow). At 1 year superficial femoral veins and iliofemoral veins remained patent. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 2 Example of catheter-directed thrombolysis for acute iliofemoral venous thrombosis extending to popliteal vein in 40-year-old man presenting 9 days after total colectomy for ulcerative colitis. A, Iliocavagram (anteroposterior and oblique views) demonstrates thrombus extending from left iliac vein partially occluding distal vena cava. B, Bird's Nest vena caval filter was placed above thrombus, and two multi-side-hole catheters were inserted into clot, one from right jugular vein and one from contralateral femoral vein. Bolus rt-PA and continuous infusion of urokinase was given through both catheters to restore venous patency. C, After 72 hours, patency was restored with excellent clinical response. Note embolus trapped by caval filter (arrow). At 1 year superficial femoral veins and iliofemoral veins remained patent. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 3 Technique of venous thrombectomy and AVF. A, Preoperative ascending phlebogram of 38-year-old woman with development of early phlegmasia cerulea dolens 6 days after spine reconstruction for scoliosis. All named veins, from her foot to vena cava are thrombosed. B, Through longitudinal femoral incision, common femoral, saphenous, and superficial femoral veins are exposed. Transverse venotomy is made in common femoral vein, (arrow), which is packed with thrombus (Left). Within short time, thrombus begins to extrude from venotomy, (double arrow) because of high venous pressure (Right).C, Leg is raised and rubber bandage is wrapped tightly from foot to upper thigh, to remove as much clot as possible from infrainguinal venous system (Top). After passage of no. 10 venous thrombectomy catheter proximally, one can appreciate extensive amount of thrombus retrieved (Bottom).D, Completion venogram demonstrates patent iliofemoral venous system without residual thrombus or obstruction (Left). Small (4 mm) AVF (arrow) is created, sewing end of transsected saphenous vein (or large proximal branch) to side of superficial femoral artery (Right). Proximal saphenous vein frequently requires thrombectomy before creating A-V fistula. Small cuff of 5 mm PTFE graft around proximal saphenous vein segment is now used routinely. E, Photograph taken at 3-year follow-up visit. Patient has only mild intermittent swelling, controlled with low-pressure gradient compression stockings. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 3 Technique of venous thrombectomy and AVF. A, Preoperative ascending phlebogram of 38-year-old woman with development of early phlegmasia cerulea dolens 6 days after spine reconstruction for scoliosis. All named veins, from her foot to vena cava are thrombosed. B, Through longitudinal femoral incision, common femoral, saphenous, and superficial femoral veins are exposed. Transverse venotomy is made in common femoral vein, (arrow), which is packed with thrombus (Left). Within short time, thrombus begins to extrude from venotomy, (double arrow) because of high venous pressure (Right).C, Leg is raised and rubber bandage is wrapped tightly from foot to upper thigh, to remove as much clot as possible from infrainguinal venous system (Top). After passage of no. 10 venous thrombectomy catheter proximally, one can appreciate extensive amount of thrombus retrieved (Bottom).D, Completion venogram demonstrates patent iliofemoral venous system without residual thrombus or obstruction (Left). Small (4 mm) AVF (arrow) is created, sewing end of transsected saphenous vein (or large proximal branch) to side of superficial femoral artery (Right). Proximal saphenous vein frequently requires thrombectomy before creating A-V fistula. Small cuff of 5 mm PTFE graft around proximal saphenous vein segment is now used routinely. E, Photograph taken at 3-year follow-up visit. Patient has only mild intermittent swelling, controlled with low-pressure gradient compression stockings. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 3 Technique of venous thrombectomy and AVF. A, Preoperative ascending phlebogram of 38-year-old woman with development of early phlegmasia cerulea dolens 6 days after spine reconstruction for scoliosis. All named veins, from her foot to vena cava are thrombosed. B, Through longitudinal femoral incision, common femoral, saphenous, and superficial femoral veins are exposed. Transverse venotomy is made in common femoral vein, (arrow), which is packed with thrombus (Left). Within short time, thrombus begins to extrude from venotomy, (double arrow) because of high venous pressure (Right).C, Leg is raised and rubber bandage is wrapped tightly from foot to upper thigh, to remove as much clot as possible from infrainguinal venous system (Top). After passage of no. 10 venous thrombectomy catheter proximally, one can appreciate extensive amount of thrombus retrieved (Bottom).D, Completion venogram demonstrates patent iliofemoral venous system without residual thrombus or obstruction (Left). Small (4 mm) AVF (arrow) is created, sewing end of transsected saphenous vein (or large proximal branch) to side of superficial femoral artery (Right). Proximal saphenous vein frequently requires thrombectomy before creating A-V fistula. Small cuff of 5 mm PTFE graft around proximal saphenous vein segment is now used routinely. E, Photograph taken at 3-year follow-up visit. Patient has only mild intermittent swelling, controlled with low-pressure gradient compression stockings. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 3 Technique of venous thrombectomy and AVF. A, Preoperative ascending phlebogram of 38-year-old woman with development of early phlegmasia cerulea dolens 6 days after spine reconstruction for scoliosis. All named veins, from her foot to vena cava are thrombosed. B, Through longitudinal femoral incision, common femoral, saphenous, and superficial femoral veins are exposed. Transverse venotomy is made in common femoral vein, (arrow), which is packed with thrombus (Left). Within short time, thrombus begins to extrude from venotomy, (double arrow) because of high venous pressure (Right).C, Leg is raised and rubber bandage is wrapped tightly from foot to upper thigh, to remove as much clot as possible from infrainguinal venous system (Top). After passage of no. 10 venous thrombectomy catheter proximally, one can appreciate extensive amount of thrombus retrieved (Bottom).D, Completion venogram demonstrates patent iliofemoral venous system without residual thrombus or obstruction (Left). Small (4 mm) AVF (arrow) is created, sewing end of transsected saphenous vein (or large proximal branch) to side of superficial femoral artery (Right). Proximal saphenous vein frequently requires thrombectomy before creating A-V fistula. Small cuff of 5 mm PTFE graft around proximal saphenous vein segment is now used routinely. E, Photograph taken at 3-year follow-up visit. Patient has only mild intermittent swelling, controlled with low-pressure gradient compression stockings. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 3 Technique of venous thrombectomy and AVF. A, Preoperative ascending phlebogram of 38-year-old woman with development of early phlegmasia cerulea dolens 6 days after spine reconstruction for scoliosis. All named veins, from her foot to vena cava are thrombosed. B, Through longitudinal femoral incision, common femoral, saphenous, and superficial femoral veins are exposed. Transverse venotomy is made in common femoral vein, (arrow), which is packed with thrombus (Left). Within short time, thrombus begins to extrude from venotomy, (double arrow) because of high venous pressure (Right).C, Leg is raised and rubber bandage is wrapped tightly from foot to upper thigh, to remove as much clot as possible from infrainguinal venous system (Top). After passage of no. 10 venous thrombectomy catheter proximally, one can appreciate extensive amount of thrombus retrieved (Bottom).D, Completion venogram demonstrates patent iliofemoral venous system without residual thrombus or obstruction (Left). Small (4 mm) AVF (arrow) is created, sewing end of transsected saphenous vein (or large proximal branch) to side of superficial femoral artery (Right). Proximal saphenous vein frequently requires thrombectomy before creating A-V fistula. Small cuff of 5 mm PTFE graft around proximal saphenous vein segment is now used routinely. E, Photograph taken at 3-year follow-up visit. Patient has only mild intermittent swelling, controlled with low-pressure gradient compression stockings. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 4 This patient is example of combination therapy with catheter-directed intraarterial thrombolysis, venous thrombectomy, and cross-pubic venous bypass. A, Ascending phlebography in patient with advanced phlegmasia cerulea dolens and impending venous gangrene demonstrates thrombosis of every named vein of his right lower extremity. Left iliofemoral venous system and vena cava were patent and free of thrombus. Arteriogram was obtained to evaluate arterial inflow because of impending gangrene. There was no occlusive disease, however, because of severe venous hypertension, no contrast was visualized distal to popliteal artery despite delayed imaging. Catheter was left in place, and urokinase was infused into common femoral artery at 4000 U/min. B, Graph of patient's venous pressure recorded via dorsal foot vein, indicates severe venous hypertension initially. Drop in pressure was rapid in response to urokinase infusion, which plateaued at 78 cm H2O. Although patient's pain resolved, swelling persisted. After 16 hours without additional improvement, urokinase was discontinued and patient was taken to operating room for venous thrombectomy. No thrombus was extracted from veins below inguinal ligament. Although thrombus was removed from iliofemoral venous system, persistent pelvic venous obstruction was appreciated, therefore cross-pubic bypass was performed. Patient's venous pressure returned to normal after operation and patient was given anticoagulants. C, Predischarge phlebogram demonstrates patent deep venous system with multiple functional valves in superficial femoral vein and patent cross-pubic bypass (arrows). Although there was some degree of residual venous obstruction of popliteal vein, patient's noninvasive physiologic study results were normal, without evidence of venous insufficiency. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 4 This patient is example of combination therapy with catheter-directed intraarterial thrombolysis, venous thrombectomy, and cross-pubic venous bypass. A, Ascending phlebography in patient with advanced phlegmasia cerulea dolens and impending venous gangrene demonstrates thrombosis of every named vein of his right lower extremity. Left iliofemoral venous system and vena cava were patent and free of thrombus. Arteriogram was obtained to evaluate arterial inflow because of impending gangrene. There was no occlusive disease, however, because of severe venous hypertension, no contrast was visualized distal to popliteal artery despite delayed imaging. Catheter was left in place, and urokinase was infused into common femoral artery at 4000 U/min. B, Graph of patient's venous pressure recorded via dorsal foot vein, indicates severe venous hypertension initially. Drop in pressure was rapid in response to urokinase infusion, which plateaued at 78 cm H2O. Although patient's pain resolved, swelling persisted. After 16 hours without additional improvement, urokinase was discontinued and patient was taken to operating room for venous thrombectomy. No thrombus was extracted from veins below inguinal ligament. Although thrombus was removed from iliofemoral venous system, persistent pelvic venous obstruction was appreciated, therefore cross-pubic bypass was performed. Patient's venous pressure returned to normal after operation and patient was given anticoagulants. C, Predischarge phlebogram demonstrates patent deep venous system with multiple functional valves in superficial femoral vein and patent cross-pubic bypass (arrows). Although there was some degree of residual venous obstruction of popliteal vein, patient's noninvasive physiologic study results were normal, without evidence of venous insufficiency. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions

Fig. 5 Schematic of preferred method of cross-pubic venous bypass with 8 or 10 mm externally supported PTFE graft. Note small AVF (≤4 mm) to superficial femoral artery. Journal of Vascular Surgery 1994 20, 244-254DOI: (10.1016/0741-5214(94)90012-4) Copyright © 1994 Society for Vascular Surgery and International Society for Cariovascular Surgery, North Amercian Chapter Terms and Conditions