Full Length Article Theme 4: Invasive management of (recurrent) VTE and PTS Anthony J. Comerota a , Per Morten Sandset b , Stavros Konstantinides c , Rick de Graaf d , Thomas W. Wakefield e , Carsten W.K.P. Arnoldussen f , Yee Lai Lam g , Wijnand B. van Gent g , Mark A.F. de Wolf g , Fabio S. Catarinella g , Ralph L.M. Kurstjens g , Ashraf Alshabatat g,h , Cees H.A. Wittens g,h, ⁎ a Jobst Vascular Institute, Toledo Hospital, Toledo, OH, USA b Department of Hematology, Oslo University Hospital, Oslo, Norway c Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany d Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands e Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, MI, USA f Department of Radiology and Interventional Radiology, VieCuri Medical Centre, Venlo, The Netherlands g Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands h Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany article info Keywords: DVT PTS PE Obstruction Hemodynamics Venous claudication VCSS Villalta IVUS Duplex MRV CTV Thrombectomy Systemic thrombolysis CDT Stenting Endovenectomy AV-fistula Registry Inflammation Biomaker 1. Introduction Well-designed strategies of thrombus removal can reduce or eliminate the early symptoms of acute DVT, reduce postthrombotic syndrome (PTS), and reduce recurrence rates. Although international societies have suggested how to define PTS, there is much room for improvement. Systemic lytic therapy has given way to intrathrombus delivery of plasminogen activators, with two randomized trials demonstrating Thrombosis Research 136 (2015) S19–S25 ⁎ Corresponding author at: Maastricht University Medical Center, P. Debyelaan 25, PO box 5800, 6202 AZ Maastricht, The Netherlands. E-mail address: c.wittens@me.com (C.H.A. Wittens). benefit. The largest trial to date, the ATTRACT trial has completed enrollment of its target 692 patients and is now in the follow-up phase. The CAVA trial is still enrolling patients. Operative thrombectomy is an older but effective option if catheter-based techniques are not available. Pulmonary embolism (PE) represents the life-threatening complica- tion of acute DVT. Randomized NIH sponsored trials have shown signifi- cant long-term benefit to systemic lytic therapy, although bleeding complications were much higher with lysis. The recently reported trial in patients with sub-massive PE conducted by the PEITHO investigators observed significant benefit in the primary endpoint in patients random- ized to systemic tenecteplase at a cost of a significant increase in major and intracranial bleeding. All patients randomized to tenecteplase were therapeutically anticoagulated on heparin at the time of lytic infusion, which may have contributed to the bleeding complications. Similar to the evolution of the treatment of acute iliofemoral DVT, patients with massive and sub-massive PE are being treated with intrathrombus catheter-based therapies with favorable outcomes. Venoplasty and stenting is beneficial for correcting residual venous stenotic lesions following CDT for acute iliofemoral DVT and for restoring patency to veins with chronic, postthrombotic venous obstruction. Stenting of the entire diseased segment is important. Recently, the value of intravascular ultrasound (IVUS) for improving the accuracy of identifying and quantifying venous obstructions has been emphasized. These observations, however, are often compared to single plane contrast phlebograms, most frequently coming from reports from single centers. The construction of arteriovenous fistula (AVF) has been valuable in preserving patency in veins following thrombectomy, endovenectomy, and endothelial recanalization. The size and configuration of the AVF can have important functional and clinical consequences. A potentially impor- tant but understudied area is whether the significant alterations in hemo- dynamics produced by the AVF affect cellular or fluid phase coagulation. The mechanism of venous in-stent stenosis has not been clarified. Studies delineating the in-stent pathology are needed to properly manage patients long-term. PTS is the major limb morbidity of acute DVT. Animal models of venous thrombosis are increasing our understanding of thrombus http://dx.doi.org/10.1016/j.thromres.2015.07.037 0049-3848/© 2015 Published by Elsevier Ltd. Contents lists available at ScienceDirect Thrombosis Research journal homepage: www.elsevier.com/locate/thromres