Temporary Vena Caval Interruption and Thrombolysis in the Management of Deep Vein Thrombosis.

Temporary interruption of the inferior vena cava (IVC) with a retrievable filter should be considered in patients with objectively verified proximal deep vein thrombosis (DVT) of the legs who have a temporary contraindication to therapeutic anticoagulation, or in patients who experience severe complications from anticoagulation. The risk of the temporary filter being left in place permanently must be considered. Use of a retrievable filter in conjunction with therapeutic anticoagulation during the early phase of therapy for acute DVT in patients whose cardiopulmonary reserve is limited (ie, those with pre-existing pulmonary hypertension) may be a future indication for this intervention. Interruption of the superior vena cava with a retrievable filter has been performed in a small number of cases, but there are insufficient data to guide risk:benefit analysis for this procedure. Thrombolysis, either systemic or local, results in a higher rate of thrombus resolution than anticoagulation alone. However, the long-term benefit of thrombolysis in preventing or improving the post-thrombotic syndrome remains unproven. Due to the substantial risk and cost of thrombolytic therapy, it should not be performed in the routine treatment of DVT. Thrombolytic therapy, in the absence of contraindication, should be considered in highly symptomatic, massive iliofemoral DVT. Catheter-directed thrombolytic therapy has shown promise in case series, but its role remains to be elucidated in randomized trials.