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Current status of surgical therapy for deep vein thrombosis
Insights
Operative thrombectomy shows promise for acute deep vein thrombosis (DVT) management, alongside heparin and compression. However, its use without phlegmasia cerulea dolens requires further study for effective deep vein thrombosis treatment.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Venous Thromboembolism Management
Background:
- Acute deep vein thrombosis (DVT) management is evolving.
- Post-thrombotic syndrome and pulmonary embolism remain significant clinical challenges.
- Surgical and interventional techniques are being refined for venous thromboembolic disease.
Purpose of the Study:
- To review current and emerging surgical and interventional strategies for managing acute deep vein thrombosis (DVT).
- To discuss indications and outcomes for procedures addressing post-thrombotic syndrome and venous valvular incompetence.
- To evaluate advancements in preventing and treating pulmonary embolism.
Main Methods:
- Review of operative thrombectomy adjuncts including heparin infusion and pneumatic compression for acute DVT.
- Discussion of Palma femorofemoral bypass for iliac venous obstruction.
- Overview of techniques for venous valvular incompetence: valvuloplasty, transposition, and valve transplantation.
- Assessment of inferior vena cava filters (e.g., Greenfield filter) for pulmonary embolism prophylaxis.
Main Results:
- Operative thrombectomy indications for DVT, excluding phlegmasia cerulea dolens, are not fully established.
- Palma bypass is a recognized treatment for persistent unilateral iliac venous obstruction.
- Limited success reported for direct venous valvuloplasty, transposition, and autologous valve transplantation.
- Inferior vena cava filters demonstrate long-term patency and efficacy in preventing pulmonary embolism.
Conclusions:
- Further research is needed to define the precise indications for operative thrombectomy in acute DVT.
- Established surgical options exist for post-thrombotic syndrome and pulmonary embolism prevention.
- Venous valvular incompetence remains a complex condition with ongoing therapeutic challenges.
Abstract:
There is renewed interest in the use of operative thrombectomy in the management of acute DVT using the adjuncts of heparin infusion through an indwelling catheter and pneumatic segmental compression of the leg. In the absence of phlegmasia cerulea dolens, however, the indication for thrombectomy remains unresolved. For the postthrombotic syndrome, the most widely accepted procedure is the Palma femorofemoral cross-over bypass, which is indicated for relief of persistent unilateral iliac venous obstruction. Venous valvular incompetence is a much more challenging problem for which some limited success has been achieved by direct valvuloplasty, venous transposition, and autologous vein valve transplantation. For the most serious complication of venous thrombosis, pulmonary embolism, the evolution of mechanical devices has eliminated the need for direct approaches to the vena cava, and the long-term results with the Greenfield filter allow it to be placed in either an infrarenal or suprarenal position with assurance of long-term patency.