Venous Insufficiency: Acute and Chronic

Abstract

Optimal treatment for acute deep venous thrombosis is in a state of evolution. Conventional treatment is anticoagulation with heparin followed by chronic Coumadin administration. It has been realized for some time that this treatment is not ideal, as postthrombotic malsequelae affecting the lower limbs are quite common despite adequate anticoagulation. In addition, failure of anticoagulation to provide adequate control of thromboembolism occurs in a definite percentage of patients. Killewich and associates’ recent longitudinal study of deep venous thrombosis, performed with the aid of a duplex scanner, revealed significant residual obstruction as well as reflux in the affected limbs.¹ Sporadic attempts at surgical thrombectomy in the past, prompted by disenchantment with anticoagulation therapy, had yielded results that were considered no better than those produced by anticoagulation treatment. Eklof and colleagues have more recently reevaluated surgical thrombectomy, combining it with the creation of a temporary arterial-venous fistula to improve patency.² In a carefully controlled trial, this modality was shown to be superior to anticoagulation in achieving and maintaining iliac vein patency and functional integrity of the femoral/popliteal vein segment. Superiority of the surgical option was apparent at 6 months and was maintained long-term at five years.³ The superior anatomic and functional parameters, noted with surgical thrombectomy and temporary AV fistula, translated to a reduced incidence of postthrombotic syndrome with symptom presentation and clinical manifestations in the affected patients (Figs. 36.1, 36.2, and 36.3).⁴