First, anticoagulation therapy is started, and a venogram (x-ray of the vein with a contrast medium) is taken to learn the exact location of the clot.

Figure 1

An incision is made in the groin to expose the long saphenous vein. The length of the incision depends on the location of the thrombus. Then the common femoral vein—a continuation of the superficial femoral vein—is opened. A venous Fogarty catheter with a balloon tip is passed through the thrombus into the inferior vena cava, which is the large vein that returns blood to the heart from the lower part of the body (Figure 1). The balloon is inflated, and repeated passes are done with the catheter until no more thrombotic material is extracted. Then the surgeon introduces a suction catheter to evacuate thrombi from the vein. A venogram is again taken. Any thrombus in the lower leg is removed by manual massage, starting at the foot.

Figure 1.The common femoral vein is opened (venotomy), and a venous Fogarty catheter is passed through the clot into the inferior vena cava. The surgeon inflates the balloon and makes repeated passes with the catheter until no more thrombotic material is extracted. (Gloviczki P, Yao, JST, eds. Handbook of Venous Disorders, 2nd ed. London: Arnold, 2001:204, Fig. 20.2).

The vein is sutured closed, and an arteriovenous fistula is created, using the long saphenous vein. An arteriovenous fistula is a connection that is made between an artery and a vein to avoid early re-thrombosis.

The objectives for placing a temporary arteriovenous fistula are to increase blood flow in the segment where the thrombus was removed, to allow time for the endothelium (cells that line the inner vessel wall) to heal, and to promote the development of small branches of vessels in case of incomplete clearance or immediate re-thrombosis. The patient returns after 6 weeks to have the fistula closed.

Heparin is given for at least 5 days after surgery. Warfarin is started on the first postoperative day and continued for 6 months. The patient walks with a compression stocking the day after surgery and usually leaves the hospital 5–10 days after surgery.