1. Ambulatory Venous Hypertension Components Obstruction Valve incompetence Obstruction Valve incompetence Obstruction and valve incompetence …Highest venous pressure …Most severe morbidity …Highest venous pressure …Most severe morbidity

2. Iliofemoral DVT Contraindication to Lysis Yes No Surgical Thrombectomy + AVF Surgical Thrombectomy + AVF Anticoagulation Catheter-directed Thrombolysis Catheter-directed Thrombolysis Success Yes No

3. 63 patients: iliofemoral DVT Thrombectomy + AVF vs. Anticoagulation Follow-up: 6 mos, 5 yrs, 10 yrs Patency –Valve function –Venous hemodynamics –Clinical evaluation 63 patients: iliofemoral DVT Thrombectomy + AVF vs. Anticoagulation Follow-up: 6 mos, 5 yrs, 10 yrs Patency –Valve function –Venous hemodynamics –Clinical evaluation Plate G et al, J Vasc Surg 1984 Venous Thrombectomy vs. Anticoagulation Randomized Trial

4. Anticoag. Thrombectomy 60 mmHg 43 mmHg AVP 27% 11% Severe CVI 18% 37% Asymptomatic 37% 7% Reflux + obstruction 6% 40% N Valve fct. (fempop) 50% 78% Patent iliac* Plate G et al, Eur J Vasc Endovasc Surg 1990 Plate G et al, Eur J Vasc Endovasc Surg 1990 Venous Thrombectomy vs. Anticoagulation Results: 5 years (n=41) *radionuclide phlebography

5. Acute DVT “…There is no evidence that supports the use of thrombolytic agents for the initial treatment of DVT….” Thrombolytic Therapy: ACCP 2004 Buller H, et al Chest 2004;126:401S Buller H, et al Chest 2004;126:401S Recommend against the routine use of catheter- directed thrombolysis (Grade 1C) …Treatment..[with lytic Rx].. Be confined to patients requiring limb salvage. (Grade 2C)

6. Catheter-Directed Lysis Iliofemoral DVT Significantly better QOL with lysis Physical functionStigma Health distressPost thromb Sx Successful lysis correlated w/QOL Lytic failures and heparin Rx similar Significantly better QOL with lysis Physical functionStigma Health distressPost thromb Sx Successful lysis correlated w/QOL Lytic failures and heparin Rx similar Improvement in Quality of Life Comerota AJ et al J Vasc Surg 2000 Comerota AJ et al J Vasc Surg 2000

7. 35 consecutive patients Iliofemoral DVT Randomized Follow-up 1week/6mos –Clot lysis –Venous reflux 35 consecutive patients Iliofemoral DVT Randomized Follow-up 1week/6mos –Clot lysis –Venous reflux Cath-dir SK (pulse spray) vs. Anticoagulation alone Cath-dir SK (pulse spray) vs. Anticoagulation alone Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 Catheter-Directed Lysis Iliofemoral DVT Improvement in Quality of Life

8. Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 0.4 7d 6d LOS 0.04 11% 41%* Reflux <0.001 72% 12% Patency P-valve Lysis (n=18) Lysis (n=18) Anticoag (n=17) Anticoag (n=17) *Underestimate 2 0 occlusion Catheter-Directed Lysis Iliofemoral DVT Randomized Trial: Outcome at 6 months

9. Postthrombotic Syndrome Elastic Stockings (30-40 mmHg) Lancet 1997;349:759 <.01 51% 24% 49% <.01 55% 21% 47% P-value RRR Stocking Control Postthrombotic Syndrome Brandjes DP Prandoni P (n=194) (n=170) Patho Hemst Thromb 2002;32(suppl 2):72

10. A Strategy of Thrombus Removal for Venous Thromboembolism: We Owe it to Our Patients