What is the role of thrombectomy in the treatment of phlegmasia alba dolens (PAD) and phlegmasia cerulea dolens (PCD)?

Updated: Aug 13, 2018
  • Author: Cassius Iyad Ochoa Chaar, MD, MS, FACS; Chief Editor: Vincent Lopez Rowe, MD  more...
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Open surgical thrombectomy is an alternative treatment for patients who cannot undergo thrombolysis and who require thrombus removal.

The patient is taken to the operating room. Placement of an IVC filter can protect the lungs from embolization during thrombectomy and should be done at the beginning of the procedure. An intraoperative Trendelenburg position may be used to decrease the risk of PE as well.

A longitudinal incision is made in the groin area to explore the femoral vein. A venotomy is performed to decompress the vein and allow passage of a Fogarty balloon catheter antegrade and retrograde in the vein to remove thrombus. Open access of the popliteal or tibial veins is sometimes needed to permit a more extensive thrombectomy and to facilitate pasage of the Fogarty balloons against the valves in the veins. A tourniquet can also be applied on the lower extremities with gradual compression to try to squeeze or “milk” thrombus out of the femoral venotomy. [19]

Transabdominal cavotomy and thrombectomy can also be performed. This approach permits better control of the cava above the thrombus and thus provides protection against PE, but it carries a higher morbidity.

Procedures that have been performed in an effort to decrease the rethrombosis rate include cross-pubic vein-to-vein reconstruction with polytetrafluoroethylene (PTFE) or the great saphenous vein (GSV) in conjunction with an arteriovenous fistula between the femoral artery and the GSV. These adjuvant procedures may be especially beneficial in cases that involve proximal iliofemoral vein constriction, damage, or external compression.

Surgical thrombectomy cannot open the small venules that are affected in venous gangrene and is therefore thought to be less effective than thrombolysis in clearance of acute thrombus.

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