In patients with venous thrombotic disease and in whom anticoagulation or
thrombolytic therapy is inappropriate, ineffective, or even contraindicated, insertion of vena caval filters or venous
thrombectomy must be considered. The primary indication for the placement of vena caval filters is in patients who have developed a pulmonary
embolus and in whom anticoagulation is either contraindicated or in whom anticoagulation must be discontinued because of the development of
bleeding complications. At the present time, either the Greenfield filter placed through a jugular, femoral, or axillary venotomy or the bird's nest filter are appropriate and appear to be the most effective and least fraught with complications. The use of venous
thrombectomy has waxed and waned over the last several decades. At the present time, the procedure is advocated mainly for lower limb
venous thrombosis which is extensive enough to threaten limb viability. On occasion, it may be appropriate to extend the indications for venous
thrombectomy to include femoral
thrombosis of less than 10 days duration or iliac
thrombosis of less than 3 weeks duration with floating thrombi at the level. Technical modifications which improve the patency of the obliterated veins which are predisposed to rethrombosis include the creation of a temporary
arteriovenous fistula and meticulous care in removing the entire clot. The patient should be treated with
anticoagulants postoperatively to prevent a recurrence of the problem. The main theoretical advantage of venous
thrombectomy is a reduced incidence of
postthrombotic syndrome. Objective data to support this contention do not exist.