The aim of our study was to evaluate the results of catheter-directed thrombolysis and complementary procedures to treat acute iliofemoral deep vein thrombosis (DVT). A total of 24 consecutive patients with acute iliofemoral DVT underwent intrathrombus drip infusion of alteplase (3 mg/h; mean dosage 86 mg, range 45-174 mg), while intravenous heparin (1000 U/h) was continued. Complementary procedures were hydrodynamic thrombectomy in 3 and primary insertion of a Wallstent in 9 patients. Patency of 19 thrombosed veins (79 %) was restored with prompt symptomatic relief. An underlying anatomical anomaly or lesion was present in 13 patients: iliac vein compression syndrome (n = 8), absent (n = 2) or obstructed (n = 1) vena cava or venous stenosis (n = 2). Ten of the abnormalities were unknown before lysis and eight were relieved by stent deployment. Puncture site bleeding was the only complication but led to transfusion in 6 patients (25 %). Symptomatic reocclusion occurred in 4 patients. Catheter thrombolysis of iliofemoral vein thrombosis revealed many anatomical abnormalities which may predispose to thrombosis and are often amenable to stenting.