Pharmacomechanical Thrombectomy in Acute Iliofemoral Deep Vein Thrombosis

Abstract Pharmacomechanical thrombectomy (PMT) has become a primary interventional strategy for restoring venous patency in acute iliofemoral deep vein thrombosis (DVT), with the goals of rapid thrombus clearance, prevention of post-thrombotic syndrome (PTS), and improved quality of life. To synthesize contemporary evidence on PMT in acute iliofemoral DVT, comparing PMT-based strategies with catheter-directed thrombolysis (CDT) alone and conventional anticoagulation, and to appraise device technology, adjunctive stenting, safety, and intermediate-term outcomes. We integrated randomized trials, prospective and retrospective cohorts, and contemporary reviews evaluating rheolytic (AngioJet), rotational (Cleaner, Aspirex), and large-bore aspiration platforms, alone or combined with CDT and venous stenting, focusing on technical success, thrombus clearance, thrombolytic exposure, bleeding, patency, and PTS. PMT achieves high acute thrombus clearance (technical success ~ 80–95%) and rapid symptom relief, while reducing thrombolytic dose and procedure time relative to CDT alone. Selective iliac vein stenting for May–Thurner physiology or residual stenosis appears to preserve patency. Reported major bleeding is low but regimen- and patient-dependent, and reductions in PTS are nuanced and heterogeneous across studies. PMT is a well-supported, patient-centered option for select patients with acute iliofemoral DVT. Early intervention, careful selection, and image-guided stenting of residual obstruction support durable patency, but standardized outcome reporting and randomized data on long-term PTS are needed.