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d/Surgical treatment of septic deep venousthrom bosisHerstW. Kniemeyer, MD, Klaus Grabitz, MD, RolfBuhl, MD, HansJ. Wüst, MD, andWIlhelm Sandmann, MD, Düsseldo1j; Germany

Background. Septic deep venous thrombosis (SDVT) is an uncommon but occasionally lethal diseasecaused by systemic comPlications. es 11 orted in the literature SD .ca .vena

or ira Conservaúve managemen Wt anú tO tC rugs an systemtcanticoagulaúon zs usually successful, and the surgical approach is regarded as not indicated orunnecessary. Occasionally, however, conservative management fails, thrombosis progresses, and septicembolism develops.Methods. In a 7-year period five patients (three mate and two female,. mean age, 21.2 years), three withsevere systemic complications of SDVT (femoropopliteal, 1,. iliofemoral, 1,. iliofemoral + vena cava, 3),were treated by venous thrombectomy in addition to intravenous antibiotic administration. Simultaneoustransabdominal caval thrombectomy was perjormed twice.Results. Two patients suffered from resPiratory failure caused by previous septic embolization. One patienthad experienced multiorgan failure before thrombectomy was perjormed. Intensive caTe was necessary forall patie.nts (~~ .

( ~VRGERV

From the Clinic 01 Vascular Surgery and Kidney Transplantation, Department 01 Anesthesiology,

Heinrich-Heine-University Düsseldorj; Düsseldorj; Germany

CuNlCAU.Y APPARENT 'septic deep venous thrombosis(SDvr) is an uncommon disease. In most cases fueinfection of fue thrombusis caused by intravenousdrug abuse or by percutaneous insertion of centralintravenous catheter linesin critically ill patients. Al-though fue incidence of infection is reported to below, fue rate of centralline catheter-related sepsis ina randomized prospective study was 5.7%.1 In mostcases conaervative management consisting ofre-moval afilie catheter, antibiotic therapy, and antico-agulation is sufficienL Occasionally, however,thisconservative management fails.2 Other patientsex-perience septic phlebitis after delivery or abortion,3as a late complication of pyonephrosis4 or of otherlocal infections, and even spontaneously without anydetectable underlying cause. Some of fuese patientsare admitted with clinical signs of severe sepsis andoccasionally withcomplications as a result of septicembolization. Sometimesthe underlying suppurativedeep venousthrombosis is detected incidentallydur-ing diagnosticwork-up. '1..;,

The best treatment of suppurative thrombosis isunclear. In most cases conseIVative management isrecommended. Occasional surgical approach con-sists of resection and/ or ligation of fue involved veinsorthrombectomywith removal afilie infected clots.5-7Other authors, however, consider venous thrombec-tomy unnecessary.8 We reviewed our patients oper-ated on for septic phlebitis to determine fue place ofsurgical management in fue treatment of SnVT.

MATERIAL AND METHODS

In a 7-year period five patients with SnVT (threemate and two remate) underwent venous thrombec-tomywith arteriovenous fistula (Table). Ages rangedfrom 12 to 36 years (mean, 21.2 years). The under-lying disease was osteomyelitis and an infected woundof fue foot for two patients,one woman experiencedSnVT after delivery, and fue cause remaineduQclearin fue other two cases. Non~ h~d a history of intrave-nóus drug abuse. Three pati~nts suffered fromcrecurrent pulmonary embolism and were critically in.snVT involved fue iliofemoral and caval vein in threepa~en~andthe iliofemoral ~d fue femoropopliteal

,regIonmthe other twoc~es.A..I2-:year-oldboy pre-

~corifi~éd by. ~posi~ve'?ul~ureof!?lo~dand/o~re-"moved thrombusmatenal(~n four; rallen ts; theor-"ganismremairiedunclea:r;~~one cáse Withpuerperal

ACcepted forpüblicarlon Dec.6, 1994.

~P?nt request5:H.W. Knie~eyer; MD~P~~e~!Jr;gf §~rge~,ainlcofVascularSurgery and Kidney Transplantauon..Vrnverslt,y

,. c ";of Düsseldorf, Moorenstr.5, D-40225 Düsseldorf, ~rrilany..:

"" " ,. c" C"Copyright @ 1995 by Mósby-Year Book;Inc." "r.f;:;~";

0039-6060/95/$3.00 + O 11/56/63436

50 Kniemeyer et al.Surgery

July 1995

Table. History, treatment, and outcome in five patients with SDVI'

Case] Case 2 Case 3 Case 4 Case 5

Age (yr)/genderCause of septic

Dvr

27/maleAT-1ll deficiency,

?

16/maleInfection right

foot, ?

Involved vein Right iliac + venacava

RightS. aureus

Iliofemoral

12!maleProtein-C

deficiency,trauma

Femoro popliteral(ischemic)

RightS. aureus

Involved sirleInfectiveorganismPretreatrnent

RightS. aureus

Totalleg + venacava

LeftP. maltophilia

Antibiotic drugs,anticoagulation,fibrinolysis

Antibiotic drugs,fenestration offemur

Antibiotic drugs,

anticoagulationAntibiotic drugs,

anticoagulation

SurgicaI therapy Transfemoral +cava!

thrombectomy

Thrombectomy,ligation ofsuperiorfemoral vein

Right groin

Thrombectomy

Antibiotic drugs.incision ofabscess, in rightgroin

Cava!

thrombectomy.ligation of rightiliac vein

Left groin

Bilateraltransfemoral

thrombectomy

Location ofarteriovenousfistula

Complicatingproblems

Left groinPopliteal Both groins

Right-sidediliofemoralthrombosis onpostoperativedar 7 (treated

surgicalIy)

Pulmonaryembolism,pulmonaryabscesses, lungresection

Stress ulcer,

pulmonaryinsufficiency ,pleuraldrainage

Multiorganfailure,bilateral

pulmonaryabscess,cerebral abscess

No

24moNoNoNo PTS

7~NoNoModerate

5yrNoNoNo PI'S

OutcomeFollow-úp 5 yr..Recurrent DVT VesRecurrent PE NoDegree oí PTS Moderate,

bilate,ral

24móNoNoAmputation

A7; Antithrombin; p~ pulmonary embolism.

sepsis. The predominant infective organism was Sta-phylococcus aureus. Conservative management withantibiotic therapy and systemic anticoaguIationwasstarted in all casesbefore venous thrombectomy.

At fue time ofadmittance three patients sufferedfrom respiratory failure (multiple pulmonary ab-scesses, 2; multi~rgan failure, 1). In all patients atransfemoral venous thrombectomy with arterio-venous fistula was performed (simultaneous transab-dominal cava! and bilateral thrombectomy in twocases). In addition, patients received antibiotic ther-apy and intravenous anticoagulation (2 times fuenoririal partialthromboplastin time). According toseptic embolization, two patients hadpulmonary ab-scesseswith ~roriéhopleui-aI fistulasrequiring atypi-cal se~ental,reseétion,?\the lung, decorticatio~,and bilateral pleural dI"alnage.Temp9raryhemod¡-

..';; ..

alysi~,~ necessaryiri ~~ pati~nts.A 12-year-old boywith'~~tio~ tail~r~andphlegmasia cerulea do-

iJens reqUired abélowkriee amputation and ..experi-

enced a focalleukoencephalopathy (result ofbrain.abscesses?) with paresis of fue right oculomotoriusneIVe and fue left abducens neIVe.

AlI patients survived. Intensive care was necessaryfor mean of28.8 days (range, 3 to 64 days); length of

hospitalization rangedfrom 13 to 163 days (mean, 87days) .

,At follow-up (2 to 7years after operation; mean,50.4 :t 23.3 months) all patientswere alive. No laterecurrent septic or emboliccomplications occurred.One patient with ligated cornmon iliac vein was,totally free of symptoms; two had mild and one hadsevere postthrombotic syndrome (PTS).Theyounghoy who had undergon~ amputation for phlegmasiacerulea dolens unde~ent ~~<7liabilitatio~ pro~.,cASE' '

Casel;;"A;27-yeár.oldm~C wastreated elSewhere forspo~tai:ie~U¿'.I~~~~~edili?K~~oi-á1 DVf.CIntravenous sys-temlC fibnnolys1Swasperfqrm~d but wasnot successful.

, j:,

"

~~~

36/femalePuerperal rever

Biiliac + vena cava

Bilateral?

Kniemeyer el al. 51SUJgeryVolume 118, Number 1

right femoral osteomyelitis and pulmonary insufficiency. Aright iliofemoral DVI'with recurrent pulmonary embolismwas revealed as fue underlying cause. Fenestration of fue

boDe, antibiotic therapy, and systemic anticoagulationcould not avoid recurrent PE. On fue supposition thatSDVI'was fue main embolic source, a transfemoral removalofthe infected thrombus, a ligation of fue involved super-ficial femoral vein, and an arteriovenous flStula in fue groinwere performed. S. aureus was identified from removedthrombus specimen. Right pleural drainage and pro-longed stay in fue ICU for 21 days were necessary. The pa-tient recovered completely. She experienced a moderatePTS of fue right leg during follow-up of 7 years. No differ-ente in length of fue lower extremities occurred.

Case 4. A 12-year-old hoy was admitted from elsewherewith femoropopliteal DVI' and phlegmasia cerulea of fueright leg after a bicycle accident. He was transferred in aseverely reduced general condition with high temperature,diffuse intravascular coagulation, and multiorgan failure,which had developed within 36 hours. A protein-C defi-ciency was identified. A traÍlsfemoral venous thrombec-tomy was performed to prevent amputation. S. aureus wasidentified as fue infective organismo Unfortunately, re-thrombosis occurred and above knee amputation couIdnot be avoided. Bilateral pulmonary abscesses developed,requiring several surgical interventions. In addition, hesuffered from focalleukoencephalopathy (remnants ofin-tracerebral abscesses?) causing hemianopia. Despite muI-tiorgan failure (lung, kidney, and liver), fue hoy recoveredbut subsequently required 64 days of intensive careo He suc-

cessfully underwent a special rehabilitation programo After2 years of follow-up he went to school again and was notfound to be mentally retarded.

Case 5. A 36-year-old woman had signs of puerperal sep-gis. Venogram and cr scan revealed a right iliofemoral anda left iliac thrombosis with propagation of fue thrombusinto fue NC. Immediate antibiotic therapy was started.With persistent fever and elevated leukocytes fue patientwas transferred for venous thrombectomy. The removal offue clots was performed via a bilateral transfemoral throm-

bectomy. Arteriovenous fistulas were made at both sides. Aspecific infective organism could not be detected from in-

traoperativethrombus specimen, probably because of earlyantibiotic treatment. The clots contained a considerableamount ofleukocytes typical for infected material. The pa-tient did well. During follow-up (60 months) no PTS devel-

oped.

DISCUSSION

SDVT is not common, but occasionally it is a lethal

disease.2.9 The diagnosis of SDVT is difficult to

establish by clinical examination in immobilized andcritically ill patients.3, 10 Sonographic evaluation mar

help 10 detectthe venous occlusion, but phlebogra-

phy and CT scans are of majar diagnostic yalue. 3~,1 1, !2; Especially forcentral and pelvic venouSthromb~is,

;CT :scanis ofgreat benefit,'providirig'i~ormat;ion

cabout the:throínbus itself,:o theextensiori,;of,the

;thrombosis;perivenous fluid, soft tissue abscesses,or

The DVT propagated into fue inferior vena cava, and fuepatient experienced fever. Despite systemic antibiotic ther-apy, septic rever and high leukocytes remained unchanged.A definite septic focus could not be identified, but fue pa-tient was transferred for venous thrombectomy on fue as-sumption of a SDVT.

At admission fue patient was found in a reduced generalcondition. Left-sided transfemoral and transperitonealcaval thrombectomy was performed; an arteriovenous f15-tula was constructed at fue left groin to guarantee vein pa-tency. Thrombus specimen from fue inferior vena cava(IVC) revealed Pseudomonas maltophilia as fue infective or-

ganism. Intravenous anticoagulation with heparin was noteffective despite continuous increased dosages accordingto an antithrombin III deficiency. Coumarin medicationwas started on postoperative dar 3, but despite anticoagu-lation a right iliac DVT developed on postoperative dar 7,which was again treated surgically. The left iliac vein hadremained patent, probably because of fue effective arteri-ovenous fistula with a high shunt volume. The patient wasdischarged on postoperative dar 13. The artenovenous fis-tulas were closed after 3 months. Both iliac veins and fuevena cava were patent.

Within 1 year during follow-up he experienced a recur-rent DVT of fue iliac veins, which was treated conserva-tively. Five years after operation pe suffered from a moder-ate bilateral PTS. A recurrent septic event was not reported.

Case 2. A 11>-year-old hoy was admitted from an outsidehospital with a temperature indicative of sepsis, bilateralpneumonia, and pulmonary insufficiency requiring respi-ratory support. A right-sided extraperitoneal abscess closeto fue groin hád already been incised. A nght iliac SDVTwith propagation to fue IVC and recurrent pulmonary em-bolization were found. Besides a minimal injury at fue footwith subsequent local infection, no objective underlyingcause could be identified.

Transabdominal caval thrombectomy, ligation of fueright common iliac vein close to vein confluens, and a left-sided arteriovenous ~tula in fue groin were performed onfue dar of admission. Intraoperative specimen revealed S.aureus as fue infective organismo A special antibiotic ther-apy was started immediately in addition to systemic antico-

agulation.A prolonged stay of 36 days in fue intensive care unit

(ICU) was necessary with bilateral pleural drainage andrespiratory support. Bilateral bronchopleural fistulas devel-oped, and atypicallung resection for pulmonary abscesses wasperformed. He recovered subsequently and was dischargedafter 163 days.

The arteriovenous fistula was closed surgically after 12months. At follow-up (24 months) fue vena cava andleftiliac vein were patent. The right common iliac veinwas occluded (ligated during operation), but fue rightextremity was drained via transverse intemal iliac col-lateral veins to fue leftcornmon iliac vein. Because of

.' '".femoral and popbteal valve competente no swellmgióf die right extremity arid no signs of a PTS hád developed.

, Coumarin therapy wasstopped 24 móí1ths'after ópera-

tion. ;" f ...'jic":-':'c.'-

Case 3. A 14-year-old female patient was admittedwith

Kniemeyer et al.52 Surge')'luZy 1995

additional trgan involvement 13 In our experience

cr scan was particularly useful in four cases, identi-fying fue thrombus, a pelvic abscess, and multiplepulmonary abscesses. T orlar we perform a cr scan inany case with iliofemoral DVf and suspected exten-sion into fue IVC.

Most reported septic thromboses were related toperipheral intravenous catheter lines or intravenousdrug abuse and were located in fue arm veins or su-perior vena cava.9. 14 Special meticulous techniques

for catheter placement and management of insertedintravenous lines have been developed, thus mini-mizing "fue risk of septic phlebitis and complica-tions.9.14 In case of a suspected septic thrombosiscaused by intravenous lines treatment includesprompt remova! of fue catheter, antibiotics, antico-agulation, blood cultures, and cultures from fue tipof fue catheter. Good experience with this kind ofmanagementcombinedwith modern, more effectiveantibiotic drugs are fue main cause that manyauthors regard anticoaguiation and antibiotic ther-apy as sufficiently adequate.8. 15 In a recent retro-

spective review of seven patients (all became afebrilewithin 3 to 18 days, no case of recurrent sepsisoccurred) Ang and Brown8 considered fue surgicalapproach (venous thrombectomy) as unnecessary.

)t is well known that fue risk of complicationscaused by catheter-related SDVf is high. Baker etal.14 pointed outthat septic embolism was fue mostcommon complication and sepsis occurred morefrequently from intravenous catheters than fromdrug abuse. The reported overall complication ratewas 56%.14 Conservative management for cases withseptic phlebitis after intravenous catheter placementmar be adequate in most cases, but because of a highcomplicatión rate several authors recommended asurgical approach if sepsis was refractory to this con-servative treatment5. 14. 16

Surgical management of septic phlebitis consists ofa variety of treatment modalities. Drainage ofperivenous or metastatic abscesses is mandatory.Some authors recommended fue total excision5.6.17of fue vein segment or at le~t ligation of fue involved

veins.6. 18 Total excision of fue vein can remove fue

septic source radically, but it is limit~d t~ lo~ally in-volved vein segments, is not feasible in extensiveiliofemoral and cava! DVf, and mar be inaccessiblein large diameter central veins.Vein ligation was ad-vocated!8-,2~..buisilriple ligation cannot remove fueseptic focus andállows further bacteremiathrough..collateral pathways.: Thrombus formatiónabove fueligation and recurrent septicembolizatiónhave be:enreported.14.~! Becausethe patientsare endangeredtwofold, by ,systemic:septic:complications and life-threatening orrecurrentsepticpulmonary erilboliza-

tion, Hoffman and GreenfieldlO (1986) successfullyperformed venous thrombectomy in a case of upperextremity vein thrombosis shielded by a percutane-ously placed superior vena cava Greenfield filter.Thus fue septic focus was removed and fue risk of in-traoperative embolization was minimized. In a previ-Ous experimental study comparing Greenfield filterinsertion and vena cava ligation for septic throm-boembolism, Peyton et al.22 could demonstrate thatsepsis did not necessarily preclude fue placement ofGreenfield filters. They supposed that according tofue high patency rate thedevices mar be sterilized invivo with antibiotic treatment.

Because we have gained rather large experiencetreating acute and embolizing deep venous throm-boses by venous thrombectomy combined with anarteriovenous futula, avoiding fue insertion of intra-cava! filter devices, we performed venous thrombec-tomy in patients with SDVT as well.23. 24 As previously

reported,24 fue source of embolization (in this reportfour patients with embolized SDVT) can be removedsafely, and patency of fue vein is reestablished inmany cases. In addition, fue effectiveness of antibi-otic therapy in SDVT may be enhanced because mostof fue infected material is removed and fue infectedvein wall is in close contact with fue effective antibi-otic substance. According to fue severity of fuedisease and fue treatment previously performedelsewhere, this technique was combined with venousligation (iliac and femoral vein) in two cases. Trans-abdominal cava! thrombectomy was necessary twicebecause of propagation of fue thrombus andocclusion ofthe NC, allowing central control duringthrombectomy and reducing fue risk of intra-operative embolization. Temporary or permanenttransvenous cava! interruption was not necessary and,from our point of view, not indicated. Of majorimportance is fue construction of an effectivearteriovenous flstula with a high shunt volume toprevent rethrombosis, because in most case~ fuethrombus material is old and smaller remnants offue partially organized clots can remain at fue veinwall. We are convinced that fue low incidence of re-thrombosis in OUT cohort of surgically treated pa-tients with acute andembolizing DVT is strongly re-lated to fue construction of an effective arteriovenousfistula.24

AlI of our patients surnved. Complications wererelated tosystemicseptic reactions{multiorganfail-

..ure, pulmonary abscesses) reqmnng a prolonged stay

...at fue ICU i~~~~e cases. peep yein patenq COuld.be, "." ; , , "', ",. "'..'

e~~bllSh~d,m ;~~~t p~~,en~; how~~r,,"on~cp~~~~t.,With sepsls an4;~c~~~~thro~bo~lS and protem~deficiency had ío'undergo amputation,and two ex-perienceda moderate fiS '(in,one case with anti-