Treating a unique DVT case with rheolytic mechanical thrombectomy and infusion thrombolysis

T he treatment of iliofemoral thrombophlebitis has changed little since the initiation of heparin use in the 1930s. Whereas current management strategies focus on the outpatient use of lowmolecular-weight heparin, treatment relies on the prevention of clot propagation rather than any effort to resolve the clot burden present. As a result, preservation of valve function is unusual, with most patients resolved to lifelong postphlebitic syndrome, often leading to chronic debilitating swelling and ulceration in the leg. If practitioners are to make a difference in the chronic debilitating outcomes associated with thrombophlebitis and valve destruction, they must obviously develop a treatment strategy that prevents venous reflux and obstruction. To this end, if the patient presents with a first-time venous thrombosis in the proximal lowerextremity veins, more aggressive treatment in an effort to preserve valve function may be warranted. Modern therapy with percutaneous mechanical thrombectomy and thrombolysis may allow preservation of valve function and avoid the sequelae of chronic venous insufficiency.1 Although this hypothesis is not yet definitively proven, several studies suggest improved outcomes associated with thrombolysis in deep venous thrombosis (DVT).2-7 Left-leg DVT is nearly twice as common as DVT in the right leg. The etiology of this is related to the anatomic compression of the left common iliac vein by the right common iliac artery, known as May-Thurner syndrome.8 Therefore, particularly in the proximal venous segments, DVT may be secondary to the anatomic compression that is readily treatable with modern endovascular techniques.9-17 For this reason, left iliofemoral DVT warrants aggressive early treatment to prevent valve destruction and possibly relieve anatomic venous compression.18 In this case report, we review the treatment of iliofemoral thrombophlebitis in a young male physician with a second episode of left lower-extremity DVT with pulmonary embolus.