**2. Treatment options**

The standard treatment for deep venous thrombosis and pulmonary is anti-coagulation embolism. Intravenous heparin is used in the acute hospital setting. Coumadin and the other low molecular weight heparin products are used as outpatient therapies.

For those patients with significant clot burden within peripheral or pulmonary embolism, endovenous therapies can be used if not candidates for anticoagulation. These patients present emergently with significant morbidity. In fact, acute extensive DVT of the lower extremity can cause severe peripheral vascular arterial emergency called Phlegmasia Cereulens Dolans. This disorder needs rapid clot lysis to dissolve the massive clot burden. Thus, only catheter directed thrombolysis could provide this direct form of endovenous therapy. Whether it is acute, semi acute or chronic venous occlusive process, endovenous therapies have become the first line of therapy. If left untreated or inadequately treated with conventional means, patients may develop post thrombotic syndrome.

Current Endovascular Treatments for Venous Thrombosis 81

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Fig. 1. 64 y/o female with left leg swelling and pain and a positive U/S for DVT A) Extensive DVT Left SFV extending into iliac system B) EKOS Endowave combination thrombolysis catheter in place with TNK infusion overnight C) Widely patent ilio-femoral

venous system following thrombolysis

Various areas may be treated within the venous distribution. The treatable areas include extremity veins, superior venacava, portal vein, inferior venacava, mesenteric veins, renal veins, and pulmonary veins. These cases present in various different clinical scenarios based on acuity and severity of symptoms. Extremity swelling, pain and positive Doppler duplex venous ultrasound are the typical presenting clinical picture. For other venous thromboses, more severe clinical sequela are evident in the setting of portal vein and mesenteric vein thromboses. If not treated quickly, these can present with severe bowel compromise requiring emergent surgery. Computed tomographic angiographic images usually confirm the findings. Massive pulmonary emboli can also present as cardiovascular collapse if not treated emergently. Various scenarios from life threatening entities to outpatient treatments can be approached with endovascular means.
