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Lower Extremity Veins and IVC Intervention
Brandt C. Wible, MD
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KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Synonyms

            • May-Thurner syndrome = Cockett syndrome, iliac vein or iliocaval compression syndrome
            • Femoral vein = superficial femoral vein
          • Definitions

            • Venous thromboembolism (VTE)
              • Includes deep vein thrombosis (DVT) & pulmonary embolism (PE)
              • Significant source of morbidity & mortality
              • Occurs in 1:1000 people yearly
            • Catheter-directed thrombolysis (CDT)
              • Delivery of fibrinolytic agent directly into thrombus via intravascular catheter
              • Allows increased dose of fibrinolytic into thrombus
              • Decreases fibrinolytic bypassing thrombus via collaterals
              • May decrease total fibrinolytic dose, treatment/hospitalization time
            • Pharmacomechanical thrombolysis (PMT)
              • Thrombolytic infusion + mechanical thrombus disruption
              • Increases contact area between fibrinolytic & thrombus
              • May improve thrombolytic action, further decreasing fibrinolytic dose & treatment/hospitalization time
            • Chronic venous insufficiency (CVI)
              • Venous reflux & ambulatory venous hypertension
              • Result of damaged, incompetent valves & venous obstruction
            • DVT: Formation of blood clot(s) in deep veins (usually lower extremities), often accompanied by inflammation (thrombophlebitis)
              • Anatomic distribution
                • Iliofemoral DVT: Includes any part of iliac vein &/or common femoral vein (CFV)
                  • High incidence of recurrent hospitalizations
                  • High incidence of postthrombotic venous ulceration
                • Femoropopliteal DVT: Involvement limited to popliteal, femoral, &/or deep femoral veins
                • Calf DVT: Involves any of paired deep calf veins
                  • Peroneal, anterior, &/or posterior tibial veins
                  • Calf DVT does not include popliteal vein
              • Duration of positive DVT symptoms/imaging tests
                • Acute DVT: < 14 days duration
                • Subacute DVT: 15-28 days duration
                • Chronic DVT: > 28 days duration
              • DVT involves left leg 3-5x more than right
                • Likely due to May-Thurner anatomy/syndrome
              • More severe initial symptoms with iliofemoral compression/occlusion than with more distal DVT
                • Much greater likelihood of developing postthrombotic syndrome (PTS)
              • Responsible for > 250,000 hospitalizations in USA/year
              • Risk factors: Acute medical illness, antiphospholipid syndrome, active cancer, inherited thrombophilia, later age, long-distance travel, major trauma, obesity, oral contraceptives/hormone replacement therapy, paralytic stroke or immobilization, pregnancy, previous VTE, recent surgery, varicose veins
            • PTS: Late DVT sequela
              • 20-40% of 1st-time, acute, iliofemoral DVT develop PTS within 2 years
                • 5-10% develop severe PTS
                • Recurrent ipsilateral DVT associated with 2-6x ↑ risk PTS
              • Result of chronic venous hypertension
                • Due to valvular reflux & venous obstruction
                  • Post-DVT valvular damage leads to reflux
                  • Thrombosed veins impair venous return
              • Villalta scale of PTS: Evaluate severity of PTS
                • Scoring with rating for each sign/symptom of 0 (none), 1 (mild), 2 (moderate), 3 (severe)
                  • < 5 = no PTS, 5-14 = mild/moderate PTS, ≥ 15 = severe PTS
                • Patient symptoms
                  • Pain (at rest or with ambulation), cramping, heaviness, itching, numbness
                • Clinical signs
                  • Redness, hyperpigmentation, skin induration, venous ectasia, pretibial edema
                • Additional signs/symptoms
                  • Venous claudication, skin lipodermatosclerosis & ulceration, worsening of symptoms with upright position/activity
            • May-Thurner anatomy: Incidental finding; no associated DVT
              • Left iliac vein compressed obliquely & anteriorly by right iliac artery
                • Right iliac artery compresses vein against spine
                • Occurs near iliac venous confluence into inferior vena cava (IVC)
              • Very common finding
                • Incidence: Female (41%) > male (27%)
                • Rarely symptomatic
            • May-Thurner syndrome: Symptomatic finding; DVT present
              • Left iliac vein compressed obliquely & anteriorly by right iliac artery
                • Right iliac artery compresses vein against spine
                • Occurs near iliac venous confluence into IVC
                • Produces endoluminal fibrous venous scar
                  • Well seen by intravascular ultrasound (IVUS)
                  • Termed venous "spur" by surgeons & pathologists
            • Phlegmasia alba dolens: Massive venous thrombosis-associated lower extremity swelling without cyanosis
            • Phlegmasia cerulea dolens: Massive venous thrombosis-associated lower extremity swelling with limb-threatening cyanosis of lower extremity
            • Proximal/distal thrombus: Society for Vascular Surgery (SVS) recommends use of precise anatomic terminology (e.g., iliofemoral, femoropopliteal, calf) over characterization of thrombus as proximal/distal
              • Include ± extension into IVC

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  • Society Guidelines

                    PROCEDURE

                    • Procedure-Specific Goals

                      • Patient Position/Location

                        • Procedure Steps

                          • Findings and Reporting

                            • Alternative Procedures/Therapies

                              POST PROCEDURE

                              • Things to Do

                                OUTCOMES

                                • Problems

                                  • Complications

                                    • Expected Outcomes

                                      Selected References

                                      1. Kearon C et al: Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 149(2):315-52, 2016
                                      2. Mousa AY et al: Catheter-directed thrombolysis versus full anticoagulation alone in treating proximal iliofemoral deep venous thrombosis. Vascular. ePub, 2016
                                      3. Birn J et al: May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med. 20(1):74-83, 2015
                                      4. Comerota AJ: Catheter-directed thrombolysis for iliofemoral deep vein thrombosis: helpful or hurtful? Expert Rev Hematol. 8(2):131-3, 2015
                                      5. Du GC et al: Catheter-directed thrombolysis plus anticoagulation versus anticoagulation alone in the treatment of proximal deep vein thrombosis - a meta-analysis. Vasa. 44(3):195-202, 2015
                                      6. Vedantham S: Interventional therapy for venous thromboembolism. J Thromb Haemost. 13 Suppl 1:S245-51, 2015
                                      7. Kahn SR et al: Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet. 383(9920):880-8, 2014
                                      8. Enden T et al: Health-related quality of life after catheter-directed thrombolysis for deep vein thrombosis: secondary outcomes of the randomised, non-blinded, parallel-group CaVenT study. BMJ Open. 3(8):e002984, 2013
                                      9. Vedantham S et al: Rationale and design of the ATTRACT Study: a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of postthrombotic syndrome in patients with proximal deep vein thrombosis. Am Heart J. 165(4):523-530.e3, 2013
                                      10. Enden T et al: Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 379(9810):31-8, 2012
                                      11. Kearon C et al: Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):e419S-94S, 2012
                                      12. Meissner MH et al: Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 55(5):1449-62, 2012
                                      13. Broholm R et al: Acute iliofemoral venous thrombosis in patients with atresia of the inferior vena cava can be treated successfully with catheter-directed thrombolysis. J Vasc Interv Radiol. 22(6):801-5, 2011
                                      14. Chinsakchai K et al: Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 45(1):5-14, 2011
                                      15. Jaff MR et al: Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 123(16):1788-830, 2011
                                      16. Karthikesalingam A et al: A systematic review of percutaneous mechanical thrombectomy in the treatment of deep venous thrombosis. Eur J Vasc Endovasc Surg. 41(4):554-65, 2011
                                      17. Khan IR et al: Simultaneous arterial and venous ultrasound-assisted thrombolysis for phlegmasia cerulea dolens. Ann Vasc Surg. 25(5):696, 2011
                                      18. Maleti O et al: Reconstructive surgery for deep vein reflux in the lower limbs: techniques, results and indications. Eur J Vasc Endovasc Surg. 41(6):837-48, 2011
                                      19. Popuri RK et al: The role of thrombolysis in the clinical management of deep vein thrombosis. Arterioscler Thromb Vasc Biol. 31(3):479-84, 2011
                                      20. Sarlon G et al: Congenital anomalies of inferior vena cava in young patients with iliac deep venous thrombosis. Ann Vasc Surg. 25(2):265, 2011
                                      21. Donati F et al: An uncommon clinical condition: chronic thrombosis of the inferior vena cava. A case report and review of literature. Monaldi Arch Chest Dis. 74(1):36-9, 2010
                                      22. Golarz SR et al: Use of Wall stent to exclude a thrombosed inferior vena cava filter. Ann Vasc Surg. 24(5):690, 2010
                                      23. Suwanabol PA et al: Syndromes associated with the deep veins: phlegmasia cerulea dolens, May-Thurner syndrome, and nutcracker syndrome. Perspect Vasc Surg Endovasc Ther. 22(4):223-30, 2010
                                      24. Muranishi H et al: Thrombo-occlusion of inferior vena cava filter in a patient with polycythemia vera. J Cardiol. 54(2):307-10, 2009
                                      25. Wicky ST: Acute deep vein thrombosis and thrombolysis. Tech Vasc Interv Radiol. 12(2):148-53, 2009
                                      26. Protack CD et al: Long-term outcomes of catheter directed thrombolysis for lower extremity deep venous thrombosis without prophylactic inferior vena cava filter placement. J Vasc Surg. 45(5):992-7; discussion 997, 2007
                                      27. Forauer AR et al: Intravascular ultrasound in the diagnosis and treatment of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol. 13(5):523-7, 2002
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Procedure

                                          • Post Procedure

                                            • Outcomes

                                              TERMINOLOGY

                                              • Synonyms

                                                • May-Thurner syndrome = Cockett syndrome, iliac vein or iliocaval compression syndrome
                                                • Femoral vein = superficial femoral vein
                                              • Definitions

                                                • Venous thromboembolism (VTE)
                                                  • Includes deep vein thrombosis (DVT) & pulmonary embolism (PE)
                                                  • Significant source of morbidity & mortality
                                                  • Occurs in 1:1000 people yearly
                                                • Catheter-directed thrombolysis (CDT)
                                                  • Delivery of fibrinolytic agent directly into thrombus via intravascular catheter
                                                  • Allows increased dose of fibrinolytic into thrombus
                                                  • Decreases fibrinolytic bypassing thrombus via collaterals
                                                  • May decrease total fibrinolytic dose, treatment/hospitalization time
                                                • Pharmacomechanical thrombolysis (PMT)
                                                  • Thrombolytic infusion + mechanical thrombus disruption
                                                  • Increases contact area between fibrinolytic & thrombus
                                                  • May improve thrombolytic action, further decreasing fibrinolytic dose & treatment/hospitalization time
                                                • Chronic venous insufficiency (CVI)
                                                  • Venous reflux & ambulatory venous hypertension
                                                  • Result of damaged, incompetent valves & venous obstruction
                                                • DVT: Formation of blood clot(s) in deep veins (usually lower extremities), often accompanied by inflammation (thrombophlebitis)
                                                  • Anatomic distribution
                                                    • Iliofemoral DVT: Includes any part of iliac vein &/or common femoral vein (CFV)
                                                      • High incidence of recurrent hospitalizations
                                                      • High incidence of postthrombotic venous ulceration
                                                    • Femoropopliteal DVT: Involvement limited to popliteal, femoral, &/or deep femoral veins
                                                    • Calf DVT: Involves any of paired deep calf veins
                                                      • Peroneal, anterior, &/or posterior tibial veins
                                                      • Calf DVT does not include popliteal vein
                                                  • Duration of positive DVT symptoms/imaging tests
                                                    • Acute DVT: < 14 days duration
                                                    • Subacute DVT: 15-28 days duration
                                                    • Chronic DVT: > 28 days duration
                                                  • DVT involves left leg 3-5x more than right
                                                    • Likely due to May-Thurner anatomy/syndrome
                                                  • More severe initial symptoms with iliofemoral compression/occlusion than with more distal DVT
                                                    • Much greater likelihood of developing postthrombotic syndrome (PTS)
                                                  • Responsible for > 250,000 hospitalizations in USA/year
                                                  • Risk factors: Acute medical illness, antiphospholipid syndrome, active cancer, inherited thrombophilia, later age, long-distance travel, major trauma, obesity, oral contraceptives/hormone replacement therapy, paralytic stroke or immobilization, pregnancy, previous VTE, recent surgery, varicose veins
                                                • PTS: Late DVT sequela
                                                  • 20-40% of 1st-time, acute, iliofemoral DVT develop PTS within 2 years
                                                    • 5-10% develop severe PTS
                                                    • Recurrent ipsilateral DVT associated with 2-6x ↑ risk PTS
                                                  • Result of chronic venous hypertension
                                                    • Due to valvular reflux & venous obstruction
                                                      • Post-DVT valvular damage leads to reflux
                                                      • Thrombosed veins impair venous return
                                                  • Villalta scale of PTS: Evaluate severity of PTS
                                                    • Scoring with rating for each sign/symptom of 0 (none), 1 (mild), 2 (moderate), 3 (severe)
                                                      • < 5 = no PTS, 5-14 = mild/moderate PTS, ≥ 15 = severe PTS
                                                    • Patient symptoms
                                                      • Pain (at rest or with ambulation), cramping, heaviness, itching, numbness
                                                    • Clinical signs
                                                      • Redness, hyperpigmentation, skin induration, venous ectasia, pretibial edema
                                                    • Additional signs/symptoms
                                                      • Venous claudication, skin lipodermatosclerosis & ulceration, worsening of symptoms with upright position/activity
                                                • May-Thurner anatomy: Incidental finding; no associated DVT
                                                  • Left iliac vein compressed obliquely & anteriorly by right iliac artery
                                                    • Right iliac artery compresses vein against spine
                                                    • Occurs near iliac venous confluence into inferior vena cava (IVC)
                                                  • Very common finding
                                                    • Incidence: Female (41%) > male (27%)
                                                    • Rarely symptomatic
                                                • May-Thurner syndrome: Symptomatic finding; DVT present
                                                  • Left iliac vein compressed obliquely & anteriorly by right iliac artery
                                                    • Right iliac artery compresses vein against spine
                                                    • Occurs near iliac venous confluence into IVC
                                                    • Produces endoluminal fibrous venous scar
                                                      • Well seen by intravascular ultrasound (IVUS)
                                                      • Termed venous "spur" by surgeons & pathologists
                                                • Phlegmasia alba dolens: Massive venous thrombosis-associated lower extremity swelling without cyanosis
                                                • Phlegmasia cerulea dolens: Massive venous thrombosis-associated lower extremity swelling with limb-threatening cyanosis of lower extremity
                                                • Proximal/distal thrombus: Society for Vascular Surgery (SVS) recommends use of precise anatomic terminology (e.g., iliofemoral, femoropopliteal, calf) over characterization of thrombus as proximal/distal
                                                  • Include ± extension into IVC

                                              PREPROCEDURE

                                              • Indications

                                                • Contraindications

                                                  • Preprocedure Imaging

                                                    • Getting Started

                                                      • Society Guidelines

                                                        PROCEDURE

                                                        • Procedure-Specific Goals

                                                          • Patient Position/Location

                                                            • Procedure Steps

                                                              • Findings and Reporting

                                                                • Alternative Procedures/Therapies

                                                                  POST PROCEDURE

                                                                  • Things to Do

                                                                    OUTCOMES

                                                                    • Problems

                                                                      • Complications

                                                                        • Expected Outcomes

                                                                          Selected References

                                                                          1. Kearon C et al: Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 149(2):315-52, 2016
                                                                          2. Mousa AY et al: Catheter-directed thrombolysis versus full anticoagulation alone in treating proximal iliofemoral deep venous thrombosis. Vascular. ePub, 2016
                                                                          3. Birn J et al: May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med. 20(1):74-83, 2015
                                                                          4. Comerota AJ: Catheter-directed thrombolysis for iliofemoral deep vein thrombosis: helpful or hurtful? Expert Rev Hematol. 8(2):131-3, 2015
                                                                          5. Du GC et al: Catheter-directed thrombolysis plus anticoagulation versus anticoagulation alone in the treatment of proximal deep vein thrombosis - a meta-analysis. Vasa. 44(3):195-202, 2015
                                                                          6. Vedantham S: Interventional therapy for venous thromboembolism. J Thromb Haemost. 13 Suppl 1:S245-51, 2015
                                                                          7. Kahn SR et al: Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet. 383(9920):880-8, 2014
                                                                          8. Enden T et al: Health-related quality of life after catheter-directed thrombolysis for deep vein thrombosis: secondary outcomes of the randomised, non-blinded, parallel-group CaVenT study. BMJ Open. 3(8):e002984, 2013
                                                                          9. Vedantham S et al: Rationale and design of the ATTRACT Study: a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of postthrombotic syndrome in patients with proximal deep vein thrombosis. Am Heart J. 165(4):523-530.e3, 2013
                                                                          10. Enden T et al: Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 379(9810):31-8, 2012
                                                                          11. Kearon C et al: Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):e419S-94S, 2012
                                                                          12. Meissner MH et al: Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 55(5):1449-62, 2012
                                                                          13. Broholm R et al: Acute iliofemoral venous thrombosis in patients with atresia of the inferior vena cava can be treated successfully with catheter-directed thrombolysis. J Vasc Interv Radiol. 22(6):801-5, 2011
                                                                          14. Chinsakchai K et al: Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 45(1):5-14, 2011
                                                                          15. Jaff MR et al: Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 123(16):1788-830, 2011
                                                                          16. Karthikesalingam A et al: A systematic review of percutaneous mechanical thrombectomy in the treatment of deep venous thrombosis. Eur J Vasc Endovasc Surg. 41(4):554-65, 2011
                                                                          17. Khan IR et al: Simultaneous arterial and venous ultrasound-assisted thrombolysis for phlegmasia cerulea dolens. Ann Vasc Surg. 25(5):696, 2011
                                                                          18. Maleti O et al: Reconstructive surgery for deep vein reflux in the lower limbs: techniques, results and indications. Eur J Vasc Endovasc Surg. 41(6):837-48, 2011
                                                                          19. Popuri RK et al: The role of thrombolysis in the clinical management of deep vein thrombosis. Arterioscler Thromb Vasc Biol. 31(3):479-84, 2011
                                                                          20. Sarlon G et al: Congenital anomalies of inferior vena cava in young patients with iliac deep venous thrombosis. Ann Vasc Surg. 25(2):265, 2011
                                                                          21. Donati F et al: An uncommon clinical condition: chronic thrombosis of the inferior vena cava. A case report and review of literature. Monaldi Arch Chest Dis. 74(1):36-9, 2010
                                                                          22. Golarz SR et al: Use of Wall stent to exclude a thrombosed inferior vena cava filter. Ann Vasc Surg. 24(5):690, 2010
                                                                          23. Suwanabol PA et al: Syndromes associated with the deep veins: phlegmasia cerulea dolens, May-Thurner syndrome, and nutcracker syndrome. Perspect Vasc Surg Endovasc Ther. 22(4):223-30, 2010
                                                                          24. Muranishi H et al: Thrombo-occlusion of inferior vena cava filter in a patient with polycythemia vera. J Cardiol. 54(2):307-10, 2009
                                                                          25. Wicky ST: Acute deep vein thrombosis and thrombolysis. Tech Vasc Interv Radiol. 12(2):148-53, 2009
                                                                          26. Protack CD et al: Long-term outcomes of catheter directed thrombolysis for lower extremity deep venous thrombosis without prophylactic inferior vena cava filter placement. J Vasc Surg. 45(5):992-7; discussion 997, 2007
                                                                          27. Forauer AR et al: Intravascular ultrasound in the diagnosis and treatment of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol. 13(5):523-7, 2002