Catheter-directed thrombolytic therapy for iliofemoral venous thrombosis in the posturokinase era

Iliofemoral venous thrombosis represents approximately 5% of lower-extremity deep vein thrombosis (DVT). Clinical features often include massive unilateral leg edema, pain, and cyanosis. Conventional therapy with anticoagulation is often inadequate for relieving acute symptoms, and patients are at high risk for developing sequelae of post-thrombotic syndrome (PTS) (chronic leg pain, edema, hyperpigmentation, and venous claudication). Prior to 1999, urokinase was the dominant drug for venous thrombolytic therapy. Catheter-directed thrombolytic therapy using alteplase (recombinant tissue plasminogen activator [rt-PA]) has emerged as a viable alternative in patients with no contraindications to thrombolytic therapy. Many of these patients, especially young otherwise healthy women with acute left leg pathology, have a potentially curable underlying anatomic lesion (iliac vein compression syndrome [IVCS]) amenable to percutaneous therapy. The purpose of this article is to review the indications, techniques, and outcomes related to endovascular management of iliofemoral DVT.