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Iliofemoral deep vein thrombosis, thrombus removal and vena cava filters

Deep vein thrombosis of the iliac and femoral veins carries a risk of severe post-thrombotic syndrome, so in selected patients with short symptoms and low bleeding risk catheter-directed thrombus removal may be considered; in phlegmasia cerulea dolens urgent thrombus removal saves the limb; and an inferior vena cava filter suits only a patient who cannot receive anticoagulation.

לקריאה בעברית

Why it matters in the exam

Most patients with DVT are treated with anticoagulation alone (at least 3 months, usually a DOAC), and the surgical topic deals with the exceptions. Iliofemoral thrombosis — in the common iliac or common femoral vein — causes post-thrombotic syndrome more often (pain, oedema, skin changes and ulcers). The ATTRACT trial (2017) did not show a reduction in the syndrome after pharmacomechanical thrombolysis across all patients, and it increased bleeding; in the iliofemoral subgroup a reduction in syndrome severity was found. So ESVS 2021 recommends considering early thrombus removal only in selected patients: symptomatic iliofemoral thrombosis, symptoms for less than 14 days, low bleeding risk and good functional status. Thrombosis of the left iliac vein in a young woman raises suspicion of May–Thurner syndrome — compression of the left iliac vein by the right iliac artery — and after thrombus removal a venous stent is placed.

Phlegmasia cerulea dolens is extensive venous thrombosis blocking all venous drainage: a very swollen, blue, painful leg, with danger of compartment syndrome, venous gangrene and shock. This is an emergency: limb elevation, therapeutic heparin, and urgent thrombus removal (catheter-directed thrombolysis or surgical thrombectomy), sometimes with fasciotomy. An inferior vena cava filter suits only a patient with acute proximal DVT or pulmonary embolism who cannot receive anticoagulation (for example active bleeding or urgent surgery), or a significant complication of anticoagulation. The PREPIC2 trial (2015) showed that a filter in addition to anticoagulation does not reduce recurrent embolism. A retrievable filter is removed as soon as anticoagulation can be given, because leaving it increases vena cava thrombosis, filter penetration of the wall, migration and fracture. Compression stockings are no longer routinely given to prevent the syndrome, but help relieve symptoms.

In every patient with unprovoked DVT a work-up for malignancy is considered according to age and symptoms, and the duration of treatment is matched to the cause.

Key points

• Most patients — anticoagulation alone.
• Thrombus removal — selected iliofemoral, less than 14 days.
• Phlegmasia — urgent thrombus removal.
• May–Thurner — left iliac vein stent.
• Filter only without anticoagulation; remove early.

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Sources

• ESVS Clinical Practice Guidelines on the Management of Venous Thrombosis, 2021 — Early thrombus removal and vena cava filters
• Vedantham et al., ATTRACT, N Engl J Med, 2017 — Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis
• CHEST Guideline: Antithrombotic therapy for VTE disease, second update, 2021 — Recommendations

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.