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VENOUS THROMBOEMBOLISM - MANAGEMENT
Deep vein thrombosis is a frequent manifestation of venous thromboembolism in which there is a blood clot blocking a deep vein.
Clinical findings are important to the diagnosis of deep vein thrombosis but are poor predictors of the presence or severity of thrombosis.
Pulmonary embolism is the blockage of the blood vessels in the lungs usually due to blood clots from the veins, especially veins in the legs and pelvis.
Dyspnea, pleuritic chest pain, syncope and tachypnea occur in most cases of pulmonary embolism.
Massive pulmonary embolism has the prime symptom of dyspnea and systemic arterial hypotension, that requires pressor support, is the predominant sign.

Invasive Procedures

  • In patients with cardiac arrest or refractory circulatory collapse, extracorporeal membrane oxygenation (ECMO) may be considered in combination with a catheter-directed treatment or surgical embolectomy

Catheter Extraction

  • Catheter extraction involves the suction extraction of PE under fluoroscopy with ECG monitoring
  • This approach should be reserved for highly compromised patients who cannot receive thrombolytic therapy or whose status is so critical that it does not allow time to infuse thrombolytic therapy

Pulmonary Embolectomy

  • Performed in emergency situations when more conservative measures have failed
  • Should be reserved for the following patients:
    • Massive PE (preferably angiographically documented)
    • Hemodynamic instability despite Heparin and resuscitation
    • High-risk PE or hemodynamically deteriorating patients with failure of thrombolytic therapy or contraindication to its use

Thrombectomy

Percutaneous Venous Thrombectomy

  • Patients with acute DVT should not be treated with percutaneous thrombectomy alone

Surgical Venous Thrombectomy

  • Reduces acute symptoms and post-thrombotic morbidity in patients with acute iliofemoral DVT 
  • These patients have extensive venous thrombosis and have contraindications for anticoagulation and thrombolytic therapy

Vena Caval Interruption

Inferior Vena Caval Filters

  • Should be considered in DVT/PE patients with contraindication or complication of anticoagulant therapy and in patients with large, free-floating iliocaval thrombus or with a PE that developed during anticoagulation therapy 
    • May consider removing the IVC filter if anticoagulation has been established and is no longer contraindicated
  • May also be considered in patients who suffer from recurrent VTE despite adequate anticoagulant therapy and patients with chronic recurrent embolism with pulmonary hypertension
  • May be indicated after surgical embolectomy or pulmonary thromboendarterectomy
  • Should not be used routinely in patients with DVT who are also being treated with anticoagulants
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