The role of surgery in the treatment of acute phlebitis in the lower members.

UNLABELLED: Most phlebitis responds favorably to medical treatment. Iliofemoral and iliocaval phlebitis, however, involve considerable risk as they may endanger life (pulmonary embolism), limb (ischemic forms) or the functioning of the limb (severe post-phlebitic syndromes). Because of this triple risk it is important to be able to judge when to opt for surgery. Surgical treatment is called for in cases of certain iliofemoral phlebitis developing in spite of medical treatment. Threat of "blue phlebitis" (acute arterial ischemia); threat of severe post-phlebitis syndrome (the thrombosed iliac veins do not easily recover their permeability); threat to life (iliac thromboses producing mortal embolism). These three risks justify emergency phlebography. The aims, means and limitations of surgery. 1. Aim - to maintain the permeability of the femoro-ilio-caval venous axis and to avoid pulmonary embolism. 2. Methods - Thrombectomy is done at the level of the femoral vein using Fogarty's catheter and Esmarch's bandage; this is carried out at an early stage (5 first days). A De W. clamp may be positioned at the level of the vena cava (in case of preexisting pulmonary embolism or incomplete thrombectomy). 3. INDICATIONS: --Phlebitis with ischemia. --Recent severe phlebitis not responding enough to urgent medical treatment particularly in the cases of young patients. --Clamp used in cases of pulmonary embolism or when threats of embolism are visible on the phlebography (floating clots). 4. MATERIALS: --82 patients were operated between 1970-1978. Phlebography showed: 44 iliofemoral phlebites, 11 femoropopliteal phlebites, 27 iliocaval phlebites. --Arterial affection revealed in the cases of 8 patients, four of which had blue phlebitis. --Pulmonary embolism was the symptom showing iliofemoral phlebitis in 7 cases. 5. OPERATIONS: 42 isolated clamps; 40 thrombectomies (in 15 cases completed by a clamp, in 12 cases by arteriovenous fistula; in 10 cases by treatment of an anomaly of the origin of the left common iliac vein. 6. RESULTS: --Two deaths. --In the long term (average interval = 4 years) the results were excellent in 54% of the cases (no oedema), good in 28% (light compression required), and bad in 8%. Conclusion. Certain iliac phlebites can, we believe, be cured by surgery.