Radiologic Management of Iliofemoral Venous Thrombosis

Variant: 1 Acute iliofemoral DVT with mild symptoms less than 14 days, otherwise healthy.

Procedure	Appropriateness Category
Anticoagulation alone	Usually Appropriate
Graded compression stocking therapy	May Be Appropriate
CDT/PMT with or without stent placement	Usually Not Appropriate
Surgical thrombectomy techniques	Usually Not Appropriate

Variant: 2 Acute iliofemoral DVT with moderate to severe symptoms present for less than 14 days, otherwise healthy.

Procedure	Appropriateness Category
CDT/PMT with or without stent placement	Usually Appropriate
Anticoagulation alone	Usually Appropriate
Surgical thrombectomy techniques	May Be Appropriate

Variant: 3 Acute femoropopliteal DVT with mild to moderate symptoms present for less than 14 days, otherwise healthy.

Procedure	Appropriateness Category
Anticoagulation alone	Usually Appropriate
Graded compression stocking therapy	May Be Appropriate
CDT/PMT	Usually Not Appropriate

Variant: 4 Acute iliofemoral DVT and symptoms less than 14 days. Cross-sectional imaging consistent with May-Thurner syndrome.

Procedure	Appropriateness Category
CDT/PMT with or without stent placement	Usually Appropriate
Anticoagulation alone	May Be Appropriate
Hybrid surgical thrombectomy with stenting	May Be Appropriate

Variant: 5 Acute iliofemoral DVT and limb-threatening ischemia (phlegmasia cerulea dolens).

Procedure	Appropriateness Category
CDT/PMT with or without stent placement	Usually Appropriate
Surgical thrombectomy with or without stent placement	Usually Appropriate
Systemic thrombolysis	May Be Appropriate
Anticoagulation alone	Usually Not Appropriate

Variant: 6 Iliofemoral DVT with persistent moderate symptoms at least 3 months after initial treatment with anticoagulation alone.

Procedure	Appropriateness Category
Anticoagulation alone	May Be Appropriate
CDT/PMT with or without stent placement	May Be Appropriate
Graded compression stocking therapy	May Be Appropriate
Surgical thrombectomy with or without stent placement	May Be Appropriate (Disagreement)

Variant: 7 Acute iliofemoral DVT in a pregnant patient with moderate to severe symptoms.

Procedure	Appropriateness Category
Anticoagulation alone	Usually Appropriate
CDT/PMT with or without stent placement	May Be Appropriate
Graded compression stocking therapy	May Be Appropriate
Surgical thrombectomy with or without stent placement	May Be Appropriate

Panel Members

Khashayar Farsad, MD, PhD^a; Baljendra S. Kapoor, MD^b; Nicholas Fidelman, MD^c; Thomas R. Cain, MD^d; Drew M. Caplin, MD^e; Jens Eldrup-Jorgensen, MD^f; Amit Gupta, MD^g; Mikhail C.S.S. Higgins, MD, MPH^h; Eric J. Hohenwalter, MDⁱ; Margaret H. Lee, MD^j; Joseph J. McBride, MD^k; Jeet Minocha, MD^l; Paul J. Rochon, MD^m; Patrick D. Sutphin, MD, PhDⁿ; Jonathan M. Lorenz, MD^o.

Summary of Literature Review

Introduction/Background

Overview of diagnostic and therapeutic options

Discussion of Procedures by Variant

Variant 1: Acute iliofemoral DVT with mild symptoms less than 14 days, otherwise healthy.

Variant 1: Acute iliofemoral DVT with mild symptoms less than 14 days, otherwise healthy.
A. Anticoagulation alone

Variant 1: Acute iliofemoral DVT with mild symptoms less than 14 days, otherwise healthy.
B. CDT/PMT with or without stent placement

Variant 1: Acute iliofemoral DVT with mild symptoms less than 14 days, otherwise healthy.
C. Graded compression stocking therapy

Variant 1: Acute iliofemoral DVT with mild symptoms less than 14 days, otherwise healthy.
D. Surgical thrombectomy techniques

Variant 2: Acute iliofemoral DVT with moderate to severe symptoms present for less than 14 days, otherwise healthy.

Variant 2: Acute iliofemoral DVT with moderate to severe symptoms present for less than 14 days, otherwise healthy.
A. Anticoagulation alone

Variant 2: Acute iliofemoral DVT with moderate to severe symptoms present for less than 14 days, otherwise healthy.
B. CDT/PMT with or without stent placement

Variant 2: Acute iliofemoral DVT with moderate to severe symptoms present for less than 14 days, otherwise healthy.
C. Surgical thrombectomy techniques

Variant 3: Acute femoropopliteal DVT with mild to moderate symptoms present for less than 14 days, otherwise healthy.

Variant 3: Acute femoropopliteal DVT with mild to moderate symptoms present for less than 14 days, otherwise healthy.
A. Anticoagulation alone

Variant 3: Acute femoropopliteal DVT with mild to moderate symptoms present for less than 14 days, otherwise healthy.
B. CDT/PMT

Variant 3: Acute femoropopliteal DVT with mild to moderate symptoms present for less than 14 days, otherwise healthy.
C. Graded compression stocking therapy

Variant 4: Acute iliofemoral DVT and symptoms less than 14 days. Cross-sectional imaging consistent with May-Thurner syndrome.

Variant 4: Acute iliofemoral DVT and symptoms less than 14 days. Cross-sectional imaging consistent with May-Thurner syndrome.
A. Anticoagulation alone

Variant 4: Acute iliofemoral DVT and symptoms less than 14 days. Cross-sectional imaging consistent with May-Thurner syndrome.
B. CDT/PMT with or without stent placement

Variant 4: Acute iliofemoral DVT and symptoms less than 14 days. Cross-sectional imaging consistent with May-Thurner syndrome.
C. Hybrid surgical thrombectomy with stenting

Variant 5: Acute iliofemoral DVT and limb-threatening ischemia (phlegmasia cerulea dolens).

Variant 5: Acute iliofemoral DVT and limb-threatening ischemia (phlegmasia cerulea dolens).
A. Anticoagulation alone

Variant 5: Acute iliofemoral DVT and limb-threatening ischemia (phlegmasia cerulea dolens).
B. CDT/PMT with or without stent placement

Variant 5: Acute iliofemoral DVT and limb-threatening ischemia (phlegmasia cerulea dolens).
C. Surgical thrombectomy with or without stent placement

Variant 5: Acute iliofemoral DVT and limb-threatening ischemia (phlegmasia cerulea dolens).
D. Systemic thrombolysis

Variant 6: Iliofemoral DVT with persistent moderate symptoms at least 3 months after initial treatment with anticoagulation alone.

Variant 6: Iliofemoral DVT with persistent moderate symptoms at least 3 months after initial treatment with anticoagulation alone.
A. Anticoagulation alone

Variant 6: Iliofemoral DVT with persistent moderate symptoms at least 3 months after initial treatment with anticoagulation alone.
B. CDT/PMT with or without stent placement

Variant 6: Iliofemoral DVT with persistent moderate symptoms at least 3 months after initial treatment with anticoagulation alone.
C. Graded compression stocking therapy

Variant 6: Iliofemoral DVT with persistent moderate symptoms at least 3 months after initial treatment with anticoagulation alone.
D. Surgical thrombectomy with or without stent placement

Variant 7: Acute iliofemoral DVT in a pregnant patient with moderate to severe symptoms.

Variant 7: Acute iliofemoral DVT in a pregnant patient with moderate to severe symptoms.
A. Anticoagulation alone

Variant 7: Acute iliofemoral DVT in a pregnant patient with moderate to severe symptoms.
B. CDT/PMT with or without stent placement

Variant 7: Acute iliofemoral DVT in a pregnant patient with moderate to severe symptoms.
C. Graded compression stocking therapy

Variant 7: Acute iliofemoral DVT in a pregnant patient with moderate to severe symptoms.
D. Surgical thrombectomy with or without stent placement

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

· ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

· ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

· ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

· ACR Manual on Contrast Media

· ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

References

1.	Grosse SD, Nelson RE, Nyarko KA, Richardson LC, Raskob GE. The economic burden of incident venous thromboembolism in the United States: A review of estimated attributable healthcare costs. [Review]. Thrombosis Research. 137:3-10, 2016 Jan.
2.	Sudheendra D, Vedantham S. Catheter-Directed Therapy Options for Iliofemoral Venous Thrombosis. [Review]. Surgical Clinics of North America. 98(2):255-265, 2018 Apr.
3.	Haig Y, Enden T, Grotta O, et al. Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis (CaVenT): 5-year follow-up results of an open-label, randomised controlled trial. The Lancet Haematology. 3(2):e64-71, 2016 Feb.
4.	Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.[Erratum appears in Chest. 2012 Dec;142(6):1698-1704]. Chest. 141(2 Suppl):e419S-e496S, 2012 Feb.
5.	Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 149(2):315-352, 2016 Feb.
6.	Minocha J, Smith AM, Kapoor BS, et al. ACR Appropriateness Criteria R Radiologic Management of Venous Thromboembolism-Inferior Vena Cava Filters. Journal of the American College of Radiology. 16(5S):S214-S226, 2019 May.J. Am. Coll. Radiol.. 16(5S):S214-S226, 2019 May.
7.	Muriel A, Jimenez D, Aujesky D, et al. Survival effects of inferior vena cava filter in patients with acute symptomatic venous thromboembolism and a significant bleeding risk. Journal of the American College of Cardiology. 63(16):1675-83, 2014 Apr 29.
8.	Vedantham S, Goldhaber SZ, Julian JA, et al. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. New England Journal of Medicine. 377(23):2240-2252, 2017 12 07.
9.	Burgstaller JM, Steurer J, Held U, Amann-Vesti B. Efficacy of compression stockings in preventing post-thrombotic syndrome in patients with deep venous thrombosis: a systematic review and metaanalysis. [Review]. Vasa. 45(2):141-7, 2016.
10.	Jayaraj A, Meissner M. Impact of graduated compression stockings on the prevention of post-thrombotic syndrome - results of a randomized controlled trial. Phlebology. 30(8):541-8, 2015 Sep.PHLEBOLOGY. 30(8):541-8, 2015 Sep.
11.	Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet. 383(9920):880-8, 2014 Mar 08.
12.	Mol GC, van de Ree MA, Klok FA, et al. One versus two years of elastic compression stockings for prevention of post-thrombotic syndrome (OCTAVIA study): randomised controlled trial. BMJ. 353:i2691, 2016 May 31.BMJ. 353:i2691, 2016 May 31.
13.	Skervin AL, Thapar A, Franchini AJ, Prandoni P, Shalhoub J, Davies AH. Systematic Review and Meta-Analysis of Utility of Graduated Compression Stockings in Prevention of Post-Thrombotic Syndrome. [Review]. European Journal of Vascular & Endovascular Surgery. 51(6):838-45, 2016 Jun.
14.	Subbiah R, Aggarwal V, Zhao H, Kolluri R, Chatterjee S, Bashir R. Effect of compression stockings on post thrombotic syndrome in patients with deep vein thrombosis: a meta-analysis of randomised controlled trials. The Lancet Haematology. 3(6):e293-300, 2016 Jun.
15.	Meissner MH.. Rationale and indications for aggressive early thrombus removal. [Review]. Phlebology. 27 Suppl 1:78-84, 2012 Mar.
16.	Watson L, Broderick C, Armon MP. Thrombolysis for acute deep vein thrombosis. [Review][Update of Cochrane Database Syst Rev. 2014 Jan 23;(1):CD002783; PMID: 24452314]. Cochrane Database of Systematic Reviews. 11:CD002783, 2016 11 10.
17.	Comerota AJ, Kearon C, Gu CS, et al. Endovascular Thrombus Removal for Acute Iliofemoral Deep Vein Thrombosis. Circulation. 139(9):1162-1173, 2019 Feb 26.
18.	Hogg K, Kimpton M, Carrier M, Coyle D, Forgie M, Wells P. Estimating quality of life in acute venous thrombosis. JAMA Internal Medicine. 173(12):1067-72, 2013 Jun 24.
19.	Cakir V, Gulcu A, Akay E, et al. Use of percutaneous aspiration thrombectomy vs. anticoagulation therapy to treat acute iliofemoral venous thrombosis: 1-year follow-up results of a randomised, clinical trial. Cardiovasc Intervent Radiol. 37(4):969-76, 2014 Aug.
20.	Holper P, Kotelis D, Attigah N, Hyhlik-Durr A, Bockler D. Longterm results after surgical thrombectomy and simultaneous stenting for symptomatic iliofemoral venous thrombosis. Eur J Vasc Endovasc Surg. 39(3):349-55, 2010 Mar.
21.	Koopmann MC, McLafferty RB. Advances in Operative Thrombectomy for Lower Extremity Venous Thrombosis. [Review]. Surg Clin North Am. 98(2):267-277, 2018 Apr.
22.	Plate G, Eklof B, Norgren L, Ohlin P, Dahlstrom JA. Venous thrombectomy for iliofemoral vein thrombosis--10-year results of a prospective randomised study. Eur J Vasc Endovasc Surg. 14(5):367-74, 1997 Nov.
23.	Rodriguez LE, Aboukheir-Aboukheir A, Figueroa-Vicente R, et al. Hybrid operative thrombectomy is noninferior to percutaneous techniques for the treatment of acute iliofemoral deep venous thrombosis. J Vasc Surg Venous Lymphat Disord. 5(2):177-184, 2017 03.
24.	Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. [Review]. Vascular Medicine. 20(1):74-83, 2015 Feb.Vasc Med. 20(1):74-83, 2015 Feb.
25.	Hartung O, Benmiloud F, Barthelemy P, Dubuc M, Boufi M, Alimi YS. Late results of surgical venous thrombectomy with iliocaval stenting. J Vasc Surg. 47(2):381-7, 2008 Feb.
26.	Mickley V, Schwagierek R, Rilinger N, Gorich J, Sunder-Plassmann L. Left iliac venous thrombosis caused by venous spur: treatment with thrombectomy and stent implantation. J Vasc Surg. 28(3):492-7, 1998 Sep.
27.	Ming ZB, Li WD, Yuan RF, Li XQ, Ding WB. Effectiveness of catheter directed thrombolysis and stent implantation on iliofemoral vein thrombosis caused by iliac vein compression. Journal of Thrombosis & Thrombolysis. 44(2):254-260, 2017 Aug.
28.	Park JY, Ahn JH, Jeon YS, Cho SG, Kim JY, Hong KC. Iliac vein stenting as a durable option for residual stenosis after catheter-directed thrombolysis and angioplasty of iliofemoral deep vein thrombosis secondary to May-Thurner syndrome. Phlebology. 29(7):461-70, 2014 Aug.
29.	Zhu QH, Zhou CY, Chen Y, et al. Percutaneous manual aspiration thrombectomy followed by stenting for iliac vein compression syndrome with secondary acute isolated iliofemoral deep vein thrombosis: a prospective study of single-session endovascular protocol. European Journal of Vascular & Endovascular Surgery. 47(1):68-74, 2014 Jan.Eur J Vasc Endovasc Surg. 47(1):68-74, 2014 Jan.
30.	Igari K, Kudo T, Toyofuku T, Jibiki M, Inoue Y. Surgical thrombectomy and simultaneous stenting for deep venous thrombosis caused by iliac vein compression syndrome (May-Thurner syndrome). Annals of Thoracic & Cardiovascular Surgery. 20(6):995-1000, 2014.Ann Thorac Cardiovasc Surg. 20(6):995-1000, 2014.
31.	Laohapensang K, Hanpipat S, Aworn S, Orrapin S. Surgical venous thrombectomy for phlegmasia cerulea dolens and venous gangrene of the lower extremities. Journal of the Medical Association of Thailand. 96(11):1463-9, 2013 Nov.
32.	Avgerinos ED, Hager ES, Naddaf A, Dillavou E, Singh M, Chaer RA. Outcomes and predictors of failure of thrombolysis for iliofemoral deep venous thrombosis. Journal of Vascular Surgery. 3(1):35-41, 2015 Jan.
33.	Ruihua W, Xin W, Guang L, et al. Technique and Clinical Outcomes of Combined Stent Placement for Postthrombotic Chronic Total Occlusions of the Iliofemoral Veins. Journal of Vascular & Interventional Radiology. 28(3):373-379, 2017 Mar.
34.	Sarici IS, Yanar F, Agcaoglu O, et al. Our early experience with iliofemoral vein stenting in patients with post-thrombotic syndrome. Phlebology. 29(5):298-303, 2014 Jun.
35.	Ye K, Lu X, Jiang M, et al. Technical details and clinical outcomes of transpopliteal venous stent placement for postthrombotic chronic total occlusion of the iliofemoral vein. Journal of Vascular & Interventional Radiology. 25(6):925-32, 2014 Jun.J Vasc Interv Radiol. 25(6):925-32, 2014 Jun.
36.	Yin M, Shi H, Ye K, et al. Clinical Assessment of Endovascular Stenting Compared with Compression Therapy Alone in Post-thrombotic Patients with Iliofemoral Obstruction. European Journal of Vascular & Endovascular Surgery. 50(1):101-7, 2015 Jul.
37.	Zhang X, Ren Q, Jiang X, et al. A prospective randomized trial of catheter-directed thrombolysis with additional balloon dilatation for iliofemoral deep venous thrombosis: a single-center experience. Cardiovascular & Interventional Radiology. 37(4):958-68, 2014 Aug.
38.	Vogel D, Comerota AJ, Al-Jabouri M, Assi ZI. Common femoral endovenectomy with iliocaval endoluminal recanalization improves symptoms and quality of life in patients with postthrombotic iliofemoral obstruction. Journal of Vascular Surgery. 55(1):129-35, 2012 Jan.
39.	Pokrovsky A, Ignatyev I, Gradusov E. First Experience of Performing Hybrid Operations in Chronic Venous Obstructions of Iliofemoral Segments in Patients With Postthrombotic Syndrome. Vasc Endovascular Surg. 51(7):447-452, 2017 Oct.
40.	Shaydakov E, Porembskaya O, Geroulakos G. The May-Husni Procedure: A Reappraisal. [Review]. Eur J Vasc Endovasc Surg. 50(4):513-7, 2015 Oct.
41.	Bates SM, Middeldorp S, Rodger M, James AH, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. J Thromb Thrombolysis. 41(1):92-128, 2016 Jan.
42.	Bloom AI, Farkas A, Kalish Y, Elchalal U, Spectre G. Pharmacomechanical catheter-directed thrombolysis for pregnancy-related iliofemoral deep vein thrombosis. Journal of Vascular & Interventional Radiology. 26(7):992-1000, 2015 Jul.J Vasc Interv Radiol. 26(7):992-1000, 2015 Jul.
43.	Devis P, Knuttinen MG. Deep venous thrombosis in pregnancy: incidence, pathogenesis and endovascular management. [Review]. Cardiovasc. diagn. ther.. 7(Suppl 3):S309-S319, 2017 Dec.
44.	Herrera S, Comerota AJ, Thakur S, et al. Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity. Journal of Vascular Surgery. 59(2):456-64, 2014 Feb.J Vasc Surg. 59(2):456-64, 2014 Feb.
45.	Pillny M, Sandmann W, Luther B, et al. Deep venous thrombosis during pregnancy and after delivery: indications for and results of thrombectomy. Journal of Vascular Surgery. 37(3):528-32, 2003 Mar.J Vasc Surg. 37(3):528-32, 2003 Mar.
46.	American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=89+&releaseId=2.
47.	American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=23+&releaseId=2.
48.	American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=28+&releaseId=2.
49.	American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual.
50.	Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 37(3):501-30, 2013 Mar.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.