Fig. 1.  Doppler examanation showing thrombosis within the right common femoral vein (CFV). Case Reference No. CC-0998-02 A 21-year-old male presented with 5 days of right leg swelling and pain. He denied a history of trauma, malignancy, recent surgery, or shortness of breath. Lower extremity ultrasound demonstrated right common femoral vein (CFV) and upper superficial femoral vein (SFV) thrombus. A chest CT revealed thrombus in several of right lower lobe branch pulmonary arteries. He was started on heparin, but because of his and his family's concern about the possibility of additional pulmonary emboli, we were consulted for inferior vena cava (IVC) filter placement. Taking into account the patient's age, life expectancy, excellent health, the future risk of post-phlebitic syndrome, and the acute nature of his symptoms, thrombolytic therapy was initiated. The right popliteal vein was punctured under ultrasound guidance. Venography revealed a large, non-occlusive thrombus in the upper SFV and CFV (Fig. 2). The iliac veins and IVC were normal in appearance. A local urokinase infusion was started at 240,000 u/h; this was decreased to 120,000 u/h after 4 hours. Heparin was continued at 800 u/h through the popliteal vein sheath. After 15 hours, venography revealed a moderate decrease in clot burden. After 23 hours, the patient experienced asymptomatic sinus tachycardia and a low grade fever. There was no evidence of infection of the right leg so additional tylenol and benadryl were given and the infusion was continued. After 26 hours, there was a further decrease in clot burden but persistent mural thrombus remained (Fig. 3). Venoplasty was performed to 10 mm with some improvement. However, the presence of residual mural thrombus prompted us to consider the use of the Trerotola-Arrow Percutaneous Thrombectomy Device in order to further decrease the clot burden and allow us to discontinue the urokinase infusion in the face of the persistent tachycardia. Two passes through the CFV were made with the PTD and venography revealed near complete resolution of thrombus with good flow through the treated vein (Fig. 4). Post-procedure ultrasound demonstrated normal flow with minimal, residual mural thrombus (Fig. 5). A hypercoagulable workup was positive for anti-cardiolipin antibodies. He was discharged on Coumadin without evidence of leg swelling. One week post procedure, he had resumed normal activity.		Fig. 2. Ascending venography from a popliteal approach demonstrates non-occlusive SFV and CFV clot. Fig. 3. After 26 hours of urokinase, residual mural thrombus remains. Fig. 4. Use of the percutaneous thrombectomy device has removed the thrombus. Fig. 5. Sonography demonstrates minimal residual mural thrombus.
Questions: 1) Should we have placed a vena caval filter in this case? In what DVT lysis cases do you place permanent or temporary filters, if any? 2) In light of the unexplained tachycardia during urokinase infusion, should the urokinase without thrombectomy been continued, given the fact that progress was demonstrated with each venogram? 3) What should be the long-range therapeutic plan, follow-up plan, and overall prognosis for the patient? Related cases: Case 0298 10 Mechanical thrombolysis for effort vein thrombosis Case 1097 08 External iliac vein occlusion treatment with endovascular stents Case 697_05 -- Lower extremity venous thrombolysis MM 96 32-Caval Thrombosis and Thrombolysis after Filter Placement