References

 1. Prandoni P, Lensing AW, Buller HR, et al. Deep-vein thrombosis and the incidence of subsequent symptomatic cancer. N Engl J Med. 1992;327:1128-1133.

 2. Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345:1326-1330.

 3. Froehlich JB, Prince MR, Greenfield LJ, Downing LJ, Shah NL, Wakefield TW. “Bull´s-eye” sign on gadolinium-enhanced magnetic resonance venography determines thrombus presence and age: a preliminary study. J Vasc Surg. 1997;26:809-816.

 4. Gallus A, Jackaman J, Tillett J, Mills W, Wycherley A. Safety and efficacy of warfarin started early after submassive venous thrombosis or pulmonary embolism. Lancet. 1986;2:1293-1296.

 5. Semba CP, Dake MD. Catheter-directed thrombolysis for iliofemoral venous thrombosis. Semin Vasc Surg. 1996;9:26-33.

 6. Verhaeghe R, Stockx L, Lacroix H, Vermylen J, Baert AL. Catheter-directed lysis of iliofemoral vein thrombosis with use of rt-PA. Eur Radiol. 1997;7:996-1001.

 7. Patel NH, Plorde JJ, Meissner M. Catheter-directed thrombolysis in the treatment of phlegmasia cerulea dolens. Ann Vasc Surg. 1998;12:471-475.

 8. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999;211:39-49.

 9. Grossman C, McPherson S. Safety and efficacy of catheter-directed thrombolysis for iliofemoral venous thrombosis. Am J Roentgenol. 1999;172:667-672.

10.Silver D, Sabiston DC Jr. The role of vena caval interruption in the management of pulmonary embolism. Surgery. 1975;77:3-10.

11.Magnant JG, Walsh DB, Juravsky LI, Cronenwett JL. Current use of inferior vena cava filters. J Vasc Surg. 1992;16:701-706.

12.Torngren S, Hjertberg R, Rosfors S, Bremme K, Eriksson M, Swedenborg J. The long-term outcome of proximal vein thrombosis during pregnancy is not improved by the addition of surgical thrombectomy to anticoagulant treatment. Eur J Vasc Endovasc Surg. 1996;12:31-36.

13.Röder OC, Lorentzen JE, Hansen HJB. Venous thrombectomy for iliofemoral thrombosis. Early and long-term results in 46 consecutive cases. Acta Chir Scand. 1984;150:31-34.

14.Hood DB, Weaver FA, Modrall JG, Yellin AE. Advances in the treatment of phlegmasia cerulea dolens. Am J Surg. 1993;166:206-210.

15.Perkins JM, Magee TR, Galland RB. Phlegmasia caerulea dolens and venous gangrene. Br J Surg. 1996;83:19-23.

16.Eklöf B, Kistner RL. Is there a role for thrombectomy in iliofemoral venous thrombosis? Semin Vasc Surg. 1996;9:34-45.

17.Plate G, Eklöf B, Norgren L, Ohlin P, Dahlström JA. Venous thrombectomy for iliofemoral vein thrombosis – 10-year results of a prospective randomised study. Eur J Vasc Endovasc Surg. 1997;14:367-374.

18.PatelKR,PaidasCN.Phlegmasiaceruleadolens:theroleofnon-operativetherapy.Cardiovasc Surg. 1993;1:518-523.

19.Alimi YS, Dimauro P, Fabre D, Juhan C. Iliac vein reconstructions to treat acute and chronic venous occlusive disease. J Vasc Surg. 1997;25:673-681.

20.Hood DB, Alexander JQ. Endovascular management of iliofemoral venous occlusive disease. Surg Clin North Am. 2004;84:1381-1396. viii.

Anthony J. Comerota

A24-year-oldfemalewhowas32weekspregnantpresentedtotheemergencydepart- ment at 7 pm with a swollen, painful left lower extremity. Her left leg had become progressively more symptomatic during the past 48 h. During the past 24 h, she began feeling lethargic, had slight shortness of breath, and began to experience right chest discomfort with deep breathing.

Upon physical examination, her heart rate was 106/min, respiratory rate was 18/ min, and blood pressure was 112/70. Her lungs were clear, and her abdomen was appropriate for her gestational age.

Shehadaswollenleftlegfromthefoottotheinguinalligament,whichhadabluishhue. Shehadpainuponpalpationoftheleftfemoralvein.Herarterialexaminationwasnormal.

A venous duplex was ordered and scheduled to be performed in approximately 3 h.

Question 1

At this point, what would be your next course of action?

A.  Obtain an immediate ventilation/perfusion lung scan. B.  Perform a venogram.

C.  Start intravenous heparin at 100 mg/kg bolus followed by a continuous infusion at 15 mg/kg/h; or, an injection of subcutaneous enoxaparin at 1 mg/kg.

D.  Maintain the patient at bed rest until the duplex is completed. If the duplex confirms deep vein thrombosis (DVT), begin treatment with heparin.

E.  Perform an echocardiogram.

The patient had an intravenous line started and a bolus of unfractionated heparin was given, followed by a continuous infusion. Four hours later, the venous duplex examination demonstrated venous thrombosis in the posterior tibial vein, popliteal vein, femoral vein, proximal great saphenous vein, common femoral vein, and external iliac vein to the visible limit of the examination. The veins of the right lower extremity were normal. The patient asks, “What can I expect if treated with continued anticoagulation?”

A.J. Comerota

Department of Surgery, Temple University Hospital, Philadelphia PA, USA

Question 2

You tell the patient that she has iliofemoral and infrainguinal deep vein thrombosis, and with continued anticoagulation

A.  She will do much better following delivery if she remains anticoagulated for 1 year. B.  She faces a 15–40% likelihood of venous claudication at 5 years.

C.  She faces a 90% likelihood of venous insufficiency and 15% likelihood of venous ulceration.

D.  It is difficult to predict the natural consequences of her disease.

Question 3

This patient’s father has long suffered with post-thrombotic chronic venous insufficiency, and she expresses a strong desire to avoid post-thrombotic complications.

However, she does not want to accept the risks of bleeding associated with thrombolytic therapy; therefore, she asks for your treatment recommendation. Your best recommendation to this patient would be

A.  Intravenous heparin for 5 days, followed by oral anticoagulation with a warfarin compound.

B.  Heparin (unfractionated or low-molecular-weight) until the delivery, followed by warfarin anticoagulation.

C.  Rheolytic thrombectomy.

D.  Catheter-directed thrombolysis. E.  Operative venous thrombectomy.

Because of her painful lower extremity and her concern for post-thrombotic complications, the patientrequested thatthe thrombus beremoved. She wasreluctant to accept the potential bleeding complications of catheter-directed thrombolysis, and the attending radiologist was reluctant to treat with catheter-directed lysis. Therefore, venous thrombectomy was planned

Question 4

The next appropriate step is

A.  Obtain a ventilation/perfusion scan or spiral CT scan of the chest to evaluate for suspected pulmonary embolism.

B.  Obtain a contralateral iliocavagram prior to taking the patient to the operating room. C.  Take the patient directly to the operating room and perform the procedure in order to

avoid progressive deterioration.

D.  Anticoagulate overnight and proceed with operative thrombectomy the next day.

Thepatientwasanticoagulatedwithintravenousheparinovernight.Thenextmorningacontralateral iliocavagram wasperformed (Fig. 52.1)prior to takingthe patient to theoperating room. A large volume of nonocclusive thrombus was found throughout the infrarenal vena cava.

Fig. 52.1  A contralateral iliocavagram demonstrates a large volume of nonocclusive thrombus in the vena cava. Note fetal skeleton in normal position

Question 5

In light of the findings on the cavagram, what is the best next step?

A.  Abandon operative venous thrombectomy and anticoagulate.

B.  Perform an AngioJet mechanical thrombectomy of the vena cava and iliofemoral venous system.

C.  Perform a pulmonary arteriogram to confirm/exclude pulmonary embolism. D.  Obtain an echocardiogram.

E.  Insert asuprarenal vena cavalfilterand proceed withvenous thrombectomyunder fluoroscopic guidance.

The patient was presumed to have had a pulmonary embolism. A echocardiogram failed to show right ventricular dysfunction, an enlarged right ventricle, tricuspid insufficiency, or elevated pulmonary artery pressures. Because of the potential risk of dislodging nonocclusive thrombus during the venous thrombectomy, a removable suprarenal vena caval filter was inserted (Fig. 52.2).

Question 6

Important considerations during thrombectomy include

A.  Shield the fetus from all X-ray exposure.

B.  Perform the venous thrombectomy under fluoroscopic guidance. C.  Monitor the fetus throughout the procedure.

D.  Let the nonocclusive thrombus in the vena cava remain undisturbed and perform a thrombectomy of the iliofemoral venous system only.

The patient was taken to the operating room for a venous thrombectomy with fluoroscopic guidance and fetal monitoring. A cut-down was performed on the left common femoral and femoral veins, with exposure of the saphenofemoral junction. A longitudinal venotomy was