From the Guidelines
Thrombectomy is recommended for proximal iliofemoral deep vein thromboses (DVTs) that are acute, causing significant symptoms or complications, and have a low bleeding risk, as evidenced by the most recent study 1.
Key Considerations
- Proximal iliofemoral DVTs, involving the iliac veins and/or common femoral vein, are primary candidates for thrombectomy, especially when causing severe swelling, pain, or limb-threatening ischemia.
- Phlegmasia cerulea dolens, a severe form of DVT characterized by massive swelling, cyanosis, and arterial compromise, almost always requires urgent thrombectomy.
- DVTs with free-floating thrombi that pose high risk for pulmonary embolism may also benefit from thrombectomy.
- The procedure is most effective when performed within 14 days of symptom onset, as older clots become more organized and adherent to vessel walls.
- Patients who are good surgical candidates with low bleeding risk and long life expectancy are preferred for thrombectomy.
Rationale
- The rationale for thrombectomy in these cases is to rapidly restore venous flow, reduce acute symptoms, prevent post-thrombotic syndrome, and preserve valve function.
- Most patients will still require anticoagulation therapy after thrombectomy, typically with heparin initially, followed by oral anticoagulants for at least 3-6 months, as supported by 1 and 1.
Important Factors
- The choice of regimen for thrombolysis should be made based on institutional expertise/preferences in conjunction with interventional radiology or vascular surgery colleagues, as noted in 1.
- Appropriate candidates for catheter-directed therapies include patients at risk for limb loss, patients with central thrombus propagation despite anticoagulation, and those with severely symptomatic proximal DVT, as stated in 1 and 1.
From the Research
Types of Deep Vein Thromboses (DVTs) Requiring Thrombectomy
- Proximal iliofemoral DVT, particularly those with an elevated Villalta score, may require thrombectomy as anticoagulation therapy alone may not be sufficient 2
- Iliofemoral DVT, which has a high risk of postthrombotic syndrome (PTS) and pulmonary embolism, may benefit from early clot removal through thrombectomy 3, 4
- Acute iliofemoral or central DVT may be treated with aspiration thrombectomy, which has shown technical success in resolving thrombus without the need for catheter-directed thrombolysis (CDT) 5
- Surgical thrombectomy may be considered for iliofemoral DVT, with studies showing excellent patency rates and good clinical outcomes after 8.5 years 6
Characteristics of DVTs Requiring Thrombectomy
- Location: Iliofemoral, iliocaval, or central DVT
- Severity: Elevated Villalta score, high risk of PTS and pulmonary embolism
- Acuteness: Acute iliofemoral or central DVT
- Underlying conditions: May-Thurner syndrome, stent thrombosis, or extrinsic narrowing of the inferior vena cava (IVC)