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Fig. 1. Ascending venogram shows patent and recanalized femoral veins in the left thigh. |
Fig. 2. Ascending venogram shows complete iliac vein occlusion. |
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Fig. 3. Iliac lumen following treatment with an 8-mm angioplasty balloon. |
Fig. 4. Wallstents (12 mm) were used to reconstruct the iliac vein. | |
Case Reference No. CC-0298-03 The patient is a 68-year-old woman with 3-month history of an acute left iliofemoral DVT treated with heparin and warfarin. She complained of persistent tense left leg edema, pain, and fatigue during walking. Ultrasound examination revealed recanalized and patent femoral vessels in the thigh but complete occlusion of the iliac vein. Ascending venography was performed from a popliteal approach and demonstrated collateralized flow through the superficial femoral region (Fig. 1), and complete iliac vein obstruction with poor collateral outflow (Fig. 2). |
Fig. 5. Completion venography. | |
Following overnight catheter-directed thrombolysis, the iliac vein remained occluded. The vein was dilated with use of an 8-mm angioplasty balloon but the lumen was small (Fig. 3). The entire iliac segment was treated with stent placement, with use of 12-mm x 90-mm and 12-mm x 68-mm Wallstents (Fig. 4). The completion venogram shows a widely patent reconstructed iliac vein with brisk venous outflow to the inferior vena cava (Fig. 5). The patient was placed on warfarin for 6 months (INR, 23). She was followed up at 3, 6, and 12 months with Doppler ultrasound, which showed persistent patency of the iliac stents and no evidence of venous reflux. Her leg was normal in size and color. Question 1) We elected to use catheter-directed thrombolysis prior to stent placement in this patient with known chronic DVT (>4 weeks duration). What is the role of urokinase in this setting? 2) We had no choice but to extend the stents below the inguinal ligament into the femoral vein. Has anyone experienced complications as a result of this technique? 3) This patient suffered from venous hypertension due to venous outflow obstruction from the limb and not from venous reflux. Our goal was to reduce the venous hypertension by reconstructing the iliac vein. Do you think this was appropriate? Related cases: Case 1097_08 --External iliac vein occlusion: treatment with endovascular stents MM#96-32 Caval thrombosis and thrombolysis after filter placement | ||
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