As global demographics shift toward an increasingly aging population, established guidelines in the diagnosis and treatment of complex venous conditions may need to be adjusted for these older patients. Treatment approaches need to be more nuanced and individualized to take into consideration the frailty of these older patients and the co-morbid conditions that many of these older patients may have concurrently. Among venous conditions, venous thromboembolism (VTE), specifically deep vein thrombosis (DVT), presents significant clinical challenges due to the increased morbidity and greater reduction in quality of life resulting from chronic venous insufficiency, post-thrombotic syndrome (PTS), and venous ulcers [1]. It is important to point out that these complex venous conditions also occur at higher incidence among older patients. The overall incidence of DVT in the general population is approximately 5.04 per 10,000 persons per year, with marked increases observed in older age groups [2]. The risk of developing DVT is notably age-dependent; it is relatively rare among individuals younger than 40 years, with incidence rates increasing significantly thereafter [2]. The incidence is particularly pronounced in individuals aged 70 and older, where annual incidence rates can approximate 2 to 7 per 1,000 persons [3]. Additionally, the lifetime risk of venous thromboembolism is notably higher in men, escalating considerably with advancing age, further highlighting the importance of age as a critical determinant in DVT risk.

Defining ``older'' or ``elderly'' adults within the context of venous disease management warrants additional clarification due to the variability within this demographic. While chronological age alone—typically defined as 65 or 70 years—is often utilized in clinical research and practice, this approach may incompletely capture the complexity and diversity of aging-related health statuses. Advanced age frequently correlates with increased frailty, diminished physiological reserve, and greater prevalence of comorbidities, which are critical factors influencing surgical decision-making and perioperative risk. Therefore, this review adopts a comprehensive definition of older adults, incorporating functional criteria such as frailty indices, cognitive assessment, and comorbidity burden, alongside chronological age.

While the primary focus of this discussion is age, it should be pointed out that the race and ethnicity of the patient may have an additional effect on DVT. Studies have indicated variations in DVT prevalence and outcomes among different racial and ethnic groups [4].

The primary goals of interventions in a DVT are to restore vessel patency and to reduce venous hypertension, which if successful will alleviate the debilitating symptoms and mitigate the longer-term complications. Examples of these interventions currently include open surgical thrombectomy, catheter-directed thrombolysis, catheter-directed thrombectomy, and iliocaval stent placement. Thrombectomy, especially when catheter-based, has shown promising long-term patency rates and substantial symptomatic improvement in appropriately selected elderly patients. The role of concurrent stent placement during thrombectomy is unclear and not fully investigated. Endovascular approaches such as catheter-directed pharmaco-mechanical thrombectomy provide an especially attractive minimally invasive option with lower immediate recovery times but necessitate cautious consideration of potential complications such as acute kidney injury and bleeding complications, particularly in elderly patients with renal impairment, multiple comorbidities, and likely a diseased and aged circulatory system [[5], [6], [7]].

Older adults undergoing these procedures present unique challenges stemming from an intricate interplay of vascular aging processes, compromised hemostatic mechanisms, and reduced regenerative capacity. These challenges include increased susceptibility to procedural complications such as bleeding and renal dysfunction, exacerbated by factors like polypharmacy, cognitive decline, and patient frailty. The likelihood of developing DVT significantly increases with hospitalization for major illnesses and surgical interventions, particularly among elderly patients experiencing common ailments such as fractures and pneumonia [3]. Furthermore, interventions such as anticoagulation therapy, thrombolytic agents like tissue plasminogen activator (tPA), and thrombectomy procedures themselves, while essential, are associated with a higher risk of complications in older adults, necessitating careful stratification and management based on age.

Recognizing these complexities, this review provides a comprehensive examination of venous thrombectomies and related interventions in older adults. It critically evaluates the current evidence regarding indications, procedural techniques, outcomes, and potential complications, emphasizing crucial considerations that shape clinical decision-making in this vulnerable demographic (Table 1). Additionally, the review explores emerging technologies and strategies designed to enhance perioperative safety, improve long-term outcomes, and ultimately advance both lifespan and quality of life for older adults affected by complex deep venous pathologies.