Iliofemoral deep vein thrombosis (iliofemoral DVT) occurs when a thrombus in the iliac vein (common, external or internal) or common femoral vein obstructs the venous outflow from the lower limb leading to marked oedema; DVT of the IVC or the more distal lower limb veins may be present.
Deep vein thrombus of the lower limb deep venous system distal to the common femoral vein is termed distal, femoropopliteal or infrainguinal DVT 3.
Iliofemoral deep vein thrombosis accounts for approximately 25% of all cases of DVT.
Clinical presentation may be identical to that of a distal DVT i.e. lower limb swelling and pain. However as patients with iliofemoral deep vein thrombosis are at clear risk of lower limb ischaemia, phlegmasia cerulea dolens needs to be excluded as it can be limb- or life-threatening. Findings for this entity may include severe lower limb pain, gross oedema, cyanosis, pulselessness, blistering of the skin, and eventual gangrene 4.
Ultrasonography with Doppler is generally the first-line imaging modality for assessing lower limb DVT with a high sensitivity (95%) and specificity (96%) 4. This equally applies to DVT of the common femoral veins as for the more distal deep venous system.
However diagnosis of DVT of the pelvic veins can be very difficult, if not impossible, with ultrasound, due to multiple factors including bowel gas, large body habitus, normal anatomic depth of the vessels and abdominal pain. Iliac and IVC thrombosis will often require CT and/or MRI.
CT venography and/or MR venography of the pelvis may be required to evaluate the pelvic veins for DVT. Conventional pelvic venography is rarely performed nowadays 4.
Treatment and prognosis
Generally iliofemoral deep vein thrombosis is treated with anticoagulation much like regular deep vein thrombosis however they have very poor spontaneous recanalisation rates (30%), cf. femoral DVTs (70%).
Recurrent DVT is more common with iliofemoral, than femoropopliteal, DVT .
The majority of cases of severe post-thrombotic syndrome are associated with poorly-recanalised iliac veins. 80% of patients with iliofemoral deep vein thrombosis have an underlying venous stenosis proximally such as May-Thurner syndrome.
It is important to identify iliofemoral deep vein thrombosis as there is a role for catheter-directed thrombolysis 3.
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- 3. Fleck D, Albadawi H, Shamoun F, Knuttinen G, Naidu S, Oklu R. Catheter-directed thrombolysis of deep vein thrombosis: literature review and practice considerations. (2017) Cardiovascular diagnosis and therapy. 7 (Suppl 3): S228-S237. doi:10.21037/cdt.2017.09.15 - Pubmed
- 4. Liu D, Peterson E, Dooner J, Baerlocher M, Zypchen L, Gagnon J, Delorme M, Sing CK, Wong J, Guzman R, Greenfield G, Moodley O, Yenson P. Diagnosis and management of iliofemoral deep vein thrombosis: clinical practice guideline. (2015) CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 187 (17): 1288-96. doi:10.1503/cmaj.141614 - Pubmed