The attract trial although flawed showed that the data is not obvious on who should be lysed. In my own practice iliac vein thrombosis should be lysed. Femoral poplieal thrombus is a case by case decision depending on patient age severity of symptoms and other factors. I will often put a patient on blood thinners and the see them in a week in clinic. If they worsen or are severely symptomatic I will offer lysis. I think that most people resolve dvt with minimal symptoms but there is a small subset that will develop deep venous obstruction and thus post thrombotic syndrome. The hard part is trying to identify those patients.

I think a major reason the attract trial failed was the technique of the operators. For acute lysis posterior tibial should be the access point. Poplieal vein access leaves thrombus in the poplieal vein. I have see patients with severe pts who had been lysed from pop access. These patients have pts due to pop occlusion. There is a learning curve for pop access but truely provides better outcomes.

I could go on for a while. One of the main advocates was one of my old partners Brooke Spencer. I trained under her and her techniques have excellent success rates. Although I think she can be too aggressive at times.

I treat post thrombotic syndrome like I treat clarification and pvd. If there is an ulcer or there lis life limiting pts then I offer intervention. If symptoms are mild then I prefer to continue anticoagulation and observe. Chronic dvt recanalization is very challenging and time consuming but the patients do remarkably well. Their leg will always have persistent swelling but their symptoms often improve significantly.

Kind of detailed but I do a lot of this kind of work. One thing with veins and especially iliac stents is that you need to do it right the first time. I see a lot of patients who were treated inappropriately and trying to fix the veins after the fact is way more challenging.

Happy to discuss anytime.