Anthony J. Comerota, MD, Steven S. Gale, MD

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Presentation transcript:

Technique of contemporary iliofemoral and infrainguinal venous thrombectomy Anthony J. Comerota, MD, Steven S. Gale, MD Journal of Vascular Surgery Volume 43, Issue 1, Pages 185-191 (January 2006) DOI: 10.1016/j.jvs.2005.09.036 Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 1 A, Preoperative iliocavogram shows nonocclusive thrombus extending into the vena cava. B, A suprarenal balloon catheter was placed from the contralateral femoral vein and inserted under fluoroscopy. The balloon was inflated at the time of thrombectomy. C, Iliocaval thrombectomy is performed with the patient protected from pulmonary embolism. Journal of Vascular Surgery 2006 43, 185-191DOI: (10.1016/j.jvs.2005.09.036) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 2 The technique of infrainguinal balloon catheter venous thrombectomy begins with exposure of the common femoral, femoral, and profunda femoris veins, the saphenofemoral junction proximally, and the distal posterior tibial vein. A No. 3 or 4 balloon catheter is advanced from the posterior tibial vein proximally, exiting the femoral venotomy. A silastic intravenous sheath is placed halfway onto the catheter, and another No. 4 balloon catheter is inserted into the other end of the sheath. B, The balloons are inflated to fix the catheter tips inside of the sheath, and pressure is applied by a single individual guiding them distally through the clotted veins and venous valves. C, Catheters and sheath exit the posterior tibial venotomy. D, The thrombectomy catheter balloon is gently inflated as the catheter is pulled proximally (E) to exit the femoral venotomy, extracting thrombus. Journal of Vascular Surgery 2006 43, 185-191DOI: (10.1016/j.jvs.2005.09.036) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 3 A red rubber catheter (with the largest possible diameter) is placed into the posterior tibial vein and vigorously injected with a heparin-saline solution by using a bulb syringe to flush residual thrombus. After flushing, the femoral vein is clamped, and the leg veins are injected with 150 to 200 mL of a dilute urokinase or recombinant tissue plasminogen activator solution. The iliac vein thrombectomy is performed with a No. 8 to 10 venous thrombectomy catheter (Fig 1). Journal of Vascular Surgery 2006 43, 185-191DOI: (10.1016/j.jvs.2005.09.036) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 4 A, After iliac vein thrombectomy, a completion phlebogram of the right common iliac vein shows residual stenosis. B, After iliac vein venoplasty, the stenosis is corrected, thus restoring unobstructed venous drainage into the vena cava. Journal of Vascular Surgery 2006 43, 185-191DOI: (10.1016/j.jvs.2005.09.036) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 5 A, The venotomy is closed with fine monofilament suture, and a 3.5- to 4.0-mm arteriovenous fistula is constructed by sewing the transected end of the saphenous vein to the side of the superficial femoral artery. B, The distal posterior tibial vein is ligated. An infusion catheter (pediatric nasogastric tube) is brought into the wound through a separate stab wound in the skin and inserted and fixed in the proximal posterior tibial vein. The proximal posterior tibial vein and catheter are looped with No. 0 monofilament suture and fixed to the skin through a sterile button, which is used to snugly occlude the posterior tibial vein at the time of catheter removal. Journal of Vascular Surgery 2006 43, 185-191DOI: (10.1016/j.jvs.2005.09.036) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions