[Management of the venous pole in pulmonary embolism].

The prognosis of thromboembolic disease depends, to a large degree, on the deep venous thrombosis. It is located in the legs in nearly 80% of cases and proximal to the popliteal vein in one out of two patients. It is the cause of recurrence and at longer term, of post-thrombotic disease, the frequency of which contrasts with the rarity of chronic post-embolic cor pulmonale. The deep vein thrombosis is often neglected, either because it has no clinical expression or because the symptoms it causes regress rapidly with treatment. Venous ultrasonography by a skilled operator, a painless and easily repeated investigation, is the method of first intention. When the thrombus is not well visualised, it is necessary to complete the investigation with bilateral phlebocavography in free flow or with a computerised tomography scan if the vena cava is poorly seen. The treatment of the pulmonary embolism depends on its size, its tolerance, the embolic source and sites of embolism. Severe pulmonary embolism may require surgical embolectomy at the outset, during which inferior vena cava interruption should be systematic. When thrombolytic therapy is considered, the implantation of a temporary caval filter should be proposed, especially if the thrombus is "floating" or extends into the inferior vena cava. If pulmonary embolism is associated with a recent proximal venous thrombosis it would seem logical to propose surgical thrombectomy or thrombolysis, at least in young patients. Conversely, distal deep vein thrombosis only requires heparin therapy. Interruption of the inferior vena cava is essential when embolism complicates well-treated deep vein thrombosis or when the thrombosis becomes more extensive despite effective treatment. It is also advisable when pulmonary sequellae are severe, long-term anticoagulant therapy is contra-indicated or when the aetiology of the thromboembolism cannot be determined.