This case was exempt from the institutional review board. A 35-year-old male with a history of post-operative left lower extremity (LLE) DVT and recurrent right retroperitoneal Ewing sarcoma status post-chemotherapy, radiation, resection, and spinal reconstruction complicated by LCIV injury and repair, presented to our emergency department with severe left groin pain and LLE heaviness/edema. He had been discharged three days prior from an outside hospital, where he had undergone three rounds of catheter-directed thrombolysis for extensive acute on chronic LLE DVT, but multiple attempts to recanalize the LCIV occlusion from above and below using standard catheter and wire techniques had failed. He was on therapeutic enoxaparin and reported no chest or abdominal pain and no fever, cough, or chills. LLE duplex ultrasound demonstrated acute DVT with complete occlusion of the distal left external iliac (LEIV) and common femoral (LCFV) veins, partial occlusion of the left deep femoral vein, and acute-on-chronic DVT with partial occlusion of the proximal LCFV. On follow-up with vascular surgery, he received extensive counseling on treatment options and was referred to interventional radiology (IR) for endovascular recanalization; venous-venous bypass was offered as a second option. Physical exam demonstrated pain to palpation of the left groin, as well as edema, erythema, and tenderness of the left thigh and leg. Range of motion and pulses were intact. His Villalta score of 16 was compatible with severe PTS, and recanalization was attempted (Soosainathan et al. 2013).
The initial LLE venogram confirmed the duplex ultrasound findings, and conventional recanalization attempts were unsuccessful (Fig. 1a), so the patient returned 1 month later for sharp recanalization under general anesthesia in a room equipped with angio-CT (Infinix-i 4DCT, Canon, Tustin, CA). Sheaths (Flexor; Cook Medical, Bloomington, IN) were placed in the right femoral vein (8F), LCFV (14F), and right internal jugular vein (RIJ) (8F) proximal to the iliac bifurcation. A 5F MPA catheter (Cook Medical) and 0.035″ hydrophilic guide wire (Glidewire; Terumo Interventional Systems, Somerset, NJ) could not be advanced further into the LCIV (Fig. 1b). The RIJ sheath was exchanged for a Rösch-Uchida transjugular liver access set (Cook Medical), EN Snare catheter systems (Merit Medical, South Jordan, UT) were placed in the RIJ and LCFV accesses, and the LCIV was recanalized with needle puncture across the surgical clips into the extra-vascular space under fluoroscopy (Fig. 1c-d).
Hybrid-CT confirmed the extra-vascular location, as well as positioning of the snares (Fig. 2a). Under CT guidance, a 21G needle was advanced percutaneously through the snares. Under fluoroscopic guidance, an 0.018″ V-18 wire (Boston Scientific, Marlborough, MA) was advanced and snared through the LCFV access (Fig. 2a-c). Through-and-through “flossing” between the LCFV and RIJ accesses was achieved using a 0.035″ guidewire. Angioplasty (5x20mm Mustang; Boston Scientific) was performed over the LCIV and LEIV, followed by deployment of a Viabahn stent graft (13x50mm; Gore Medical, Flagstaff, AZ) across the extra-vascular connection site with post-dilation (12 × 40 mm Mustang) (Fig. 3a). A Viabahn stent was chosen to cross the extra-anatomic portion as it is self-expanding and can cover any potential area of injury at this point. Additional Venovo stents (16 × 160 mm, 12x60mm, 14x60mm) (BD Bard, Tempe, AZ) were deployed in the LCIV and LEIV across the Viabahn with extension into the LCFV, followed by angioplasty (14x40mm Atlas; BD Bard) (Fig. 3b). Rheolytic thrombectomy (AngioJet; Boston Scientific) was performed for acute thrombus throughout the LCFV and LEIV, with patency and restoration of normal luminal caliber on post-thrombectomy venogram (Fig. 3c).
The patient tolerated the procedure well without major complications. Serial creatinine remained at baseline, and hematocrit returned to normal after 24 h. The patient received a 300 mg loading dose of clopidogrel, in addition to heparin drip for 36 h, and was discharged on post-procedure day two on therapeutic enoxaparin and 75 mg clopidogrel daily. He reported marked clinical improvement in leg swelling at one-week follow-up phone call. On three-month follow-up he underwent IVC filter removal and LLE venogram, demonstrating widely-patent LCIV and LEIV stents. His Villalta improved to 6. He is currently scheduled for six-month venous duplex ultrasound follow-up.