Early Thrombus Removal in Iliofemoral DVT: Annals of Surgery | February 2026 | DOI: 10.1097/SLA.0000000000006765

Introduction

Iliofemoral deep vein thrombosis (IF-DVT) carries a high risk of post-thrombotic syndrome (PTS), a chronic and disabling complication that significantly impairs quality of life. Early thrombus removal strategies—either lytic (catheter-directed thrombolysis and pharmacomechanical techniques) or non-lytic (mechanical thrombectomy)—have been developed to reduce PTS beyond standard anticoagulation, but concerns about bleeding risk have led to conflicting guideline recommendations.

Summary

This PRISMA-guided systematic review and meta-analysis evaluated 20 studies comparing early thrombus removal strategies with anticoagulation alone in patients with acute (<28 days) IF-DVT. The pooled rate of PTS was 24.5% with lytic therapies and 40.4% with anticoagulation alone, translating to a number needed to treat (NNT) of 6 to prevent one case of PTS and 15 to prevent moderate-severe PTS. Non-lytic mechanical thrombectomy showed a PTS rate of 18.8%, though evidence was limited to a single observational study.

However, lytic therapies were associated with significantly higher odds of major bleeding compared with anticoagulation alone (OR 4.9), with a number needed to harm (NNH) of 33. Notably, no major bleeding events were reported with purely mechanical thrombectomy. Mortality and DVT recurrence rates were not significantly different across groups.

Overall, early thrombus removal reduces PTS risk but increases nonfatal major bleeding when lytics are used. Mechanical thrombectomy appears safer regarding bleeding, yet robust randomised efficacy data remain limited. Careful patient selection, balancing bleeding risk and long-term morbidity, is essential.