What is the role of surgery in the treatment of venous thromboembolism (VTE)?

Updated: Nov 05, 2020
  • Author: Vera A De Palo, MD, MBA, FCCP; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Answer

Thrombectomy for venous embolism is performed less frequently, in view of the relatively high incidence of rethrombosis, unless heparin infusion is added to the therapeutic regimen.

Pulmonary embolectomy remains a therapeutic option, but mortality is extremely high. It is reserved for cases of massive PE in which an absolute contraindication for thrombolysis is present or when all other treatment modalities have failed. It is only effective when the clot is in the large central vessels.

Catheter pulmonary embolectomy is performed by inserting a cup-tipped, steerable catheter into the central venous system, with access gained through the jugular vein or through the right common femoral vein. When the cup reaches the thrombus, suction is applied and the thrombus is extracted.

The inferior vena cava (IVC) filter is designed to trap potentially lethal emboli while maintaining vena caval patency. It has been used in cases where anticoagulation is contraindicated, where there has been a complication of anticoagulation, where anticoagulation has failed, or in the case of pulmonary embolectomy. [53]

Although IVC filters are frequently placed in adults who have experienced acute PE or VTE to prevent a subsequent event, evidence for the safety and efficacy of the practice is limited. In a study published in late 2018, Bikdeli et al found that for older adults with PE, the use of IVC filters appears to offer no mortality benefit and may in fact confer a mortality risk. [54, 55]

Ligation of venous tributaries is an option that is rarely practiced today. Its use has been limited by a high mortality and the need for continuous anticoagulation. It essentially has been replaced by the percutaneous insertion of the IVC filter.


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