Pelvic Vein Thrombosis
Extensive clots in the pelvic veins are usually treated with blood-diluting medications and compression stockings. After undergoing this therapy, 50 percent of patients develop a postthrombotic syndrome. Especially in younger patients, an acute surgical or combined treatment should be considered, preserving the venous valves and thus completely reopening the affected blood vessel.
In a pelvic vein thrombosis located in deep tissue, blood clots can form in the deep-seated venous system, stretching across the knee, thighs and pelvis. A thrombosis of both pelvic and leg veins, also called a multi-level-thrombosis, in its acute phase can lead to a painful leg swelling with blueish color and in 50 percent of cases to a dangerous pulmonary embolism, which is fatal in 10 percent of cases. Conservative treatment of such a thrombosis still makes use of medications and compression stockings. Although a pulmonary embolism can be prevented that way, long-term damage of the venous valves still occurs in half of the patients. This results in a postthrombotic syndrome. When treated surgically (or with a combination of methods using catheter technology) in its acute phase, meaning during the first 7 to 10 days of the thrombosis, the damage of the venous valves can be prevented.
Current methods in the treatment of acute thrombi
The conventional therapeutic approaches consist of the surgical removal (thrombectomy using a balloon catheter) as well as the medicinal dissolution (local or systemic lysis) of the clot. The downside of this traditional surgical approach is the damage done to the venous valves when removing the balloon catheter. Moreover, clots located in the lower leg veins can rarely be fully removed. During lysis, medications are given intravenously, which dissolve the clot. This procedure has to be performed in intensiv care unit and can lead to a pulmonary embolism as well as severe bleeding.
Combined methods of treatment
This two-step therapy aims to remove the blood clot completely, whilst preserving the venous valves, so that they may continue to function properly. The vascular surgeon uses the advantages of both methods, while avoiding their weaknesses. Parts of veins that contain many valves (e.g. in the upper and lower thighs) are treated with lysis. In the pelvic area, where no valves are located, the ballon catheter is used.
At the start of the operation, which is performed in a hybrid operating room and requires a general anaesthetic, a pneumatic tourniquet is put on the thigh, isolating the leg from blood circulation. Through a vein in the foot, the lysis medication is injected, dissolving the clot in the lower and upper leg veins, preserving their venous valves. Subsequently, through a minor cut in the pelvic area, the balloon catheter is inserted to free the pelvic axis from clots. The upper end of the vein is then clamped, interrupting the blood flow. The pneumatic tourniquet is removed and the blood can be flushed out. No clot remains circulation. The blood is saved and given back to the patient later.
This method, when applied within 7 to 10 days, can completely reopen the pelvic and leg veins without damaging the valves in 90 percent of cases. In the long term, there are usually no significant complications or postthrombotic syndromes, even after stopping the blood-diluting medication and compression therapy.
Reopening chronic occlusions
Following an acute thrombosis, a chronic occlusion of a pelvic vein can cause a possthrombotic syndrome. Its symptoms are persistent tendencies to swell, a feeling of heaviness of the leg, chronic skin damage such as gaiter-like, brown pigmentation of the lower leg, subcutaenous hardening, eczemas and open legs, and circulatory bypasses are formed in the pelvic area. Furthermore, the risk of a renewed thrombosis is significantly higher in a vein that has experienced a posstthrombotic syndrome.
If such a syndrome leads to impairments in everyday life, in some cases even a year-old chronic occlusion can sometimes be reopened with catheter technology or in a combined treatment (so-called hybrid-technique). To determine the best method, an interdisciplinary cooperation including angiologists, vascular surgeons and radiologists is necessary. The operation is performed in a catheter laboratory, equipped with specialised screening devices or in a hybrid operating room. If the closed vein can be reopened, a stent is inserted.