Venous, Lymphatic and Access Device Intervention
This domain tests venous thrombolysis, inferior vena cava filters, venous stenting, varicocele and pelvic vein embolisation, central venous access and dialysis access. The exam favours indications, contraindications and device positioning.
Core rules
- Iliofemoral deep vein thrombosis: catheter-directed thrombolysis is considered for limb-threatening phlegmasia or extensive thrombosis with low bleeding risk. Exclude a contraindication to thrombolysis and check for May–Thurner anatomy before stenting.
- Inferior vena cava filter: indicated when anticoagulation is contraindicated or has failed (recurrent pulmonary embolism despite therapeutic anticoagulation). Retrievable filters should be removed as soon as protection is no longer needed, commonly within 3–6 months; track them.
- Central venous access: tip at the cavoatrial junction; confirm position before use; use ultrasound for the internal jugular vein.
- Dialysis access: assess inflow, outflow and access flow; treat stenosis before thrombosis.
Worked example
A 45-year-old woman has acute iliofemoral deep vein thrombosis with phlegmasia and a low bleeding risk. Reasoning: start anticoagulation, assess for May–Thurner compression, then perform catheter-directed thrombolysis with overnight infusion; treat any underlying iliac stenosis with a stent. Avoid thrombolysis if there is recent surgery, intracranial disease or uncontrolled hypertension.
Traps
Placing a filter without documenting its position; leaving a retrievable filter without a retrieval plan; accepting a central line tip in the right atrium; missing May–Thurner syndrome before stenting; treating chronic occlusion as acute thrombosis.