Fig. 1. Severe venous stenosis over long segments due to radiation treatment.

Fig. 2. Venous webs secondary to radiation treatment.

A 48-year-old female patient with a past medical history of Hodgkin’s Lymphoma treated with total body radiation was referred to our department for evaluation of venous claudication. The patient’s symptoms currently included 45-foot venous claudication with right sided leg pain and discoloration, which would improve with rest and elevation of the right leg. The patient had recently recovered from similar symptoms and an episode of phlegmasia cerulea dolens on the right.

With the patient in the prone position, ultrasound guidance was used to puncture the right popliteal vein. A 5 French sheath was placed into the popliteal vein and a 0.018 inch guidewire was used to guide various catheters through the venous system into the inferior vena-cava. Venography was performed throughout the venous system, demonstrating threadlike deep veins with chronic venous thrombosis and multiple collateral vessels (see figure 1). Senechia and venous webs were demonstrated within the common iliac and external iliac veins (see figure 2). The inferior vena-cava was patent. Mechanical thrombolysis was performed through the venous webs and chronic thromboses multiple times yielding improved flow through the deep venous system. An infusion catheter was then placed from the superficial femoral vein into the common iliac vein (see figure 3) and tissue plasminogen activator was pulse sprayed for four hours at a rate of 2 mg/hr.

Fig. 3.Status post tissue plasminogen activator infusion with an infusion catheter in the common iliac vein.

Fig. 4. Final result status post tissue plasminogen activator infusion, angioplasty, and stent placement.

The patient's calf and thigh swelling improved after the procedure. A 3 months follow up, the stents remain widely patent (and have fully expanded)--confirmed by ipsilateral femoral venography.

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