A 46 year old female presented to the Emergency Department with complaint of left lower extremity pain of two days duration. Swelling originated around the ankle with progression to the groin. Medical history was significant for oral contraceptive use and a known uterine leiomyoma, approximately 10cm at last evaluation. Physical exam revealed left lower extremity swelling extending from foot to mid-thigh with erythematous discoloration of skin (fig 1). Biphasic doppler signals in left posterior tibial and dorsalis pedis arteries were present with triphasic signals on the right side. Motor and sensory function was intact in both lower extremities.
Duplex venous imaging showed extensive acute DVT of the left common femoral, femoral, popliteal, gastrocnemius, posterior tibial, peroneal, and great saphenous veins. The left external iliac vein (EIV) close to the junction with the common femoral vein (CFV) showed evidence of thrombosis. However, the left common iliac vein (CIV) could not be evaluated with duplex venous imaging. Computed tomography(CT) pulmonary embolism protocol showed right lower lobe segmental and subsegmental emboli. CT venogram of abdomen and pelvis showed a large heterogenous mass which measured 18.6 x 15.5 x 9.9 cm (fig 2). Mass effect was noted on the inferior vena cava (IVC) and left CIV with evidence of thrombus in the left EIV, Internal iliac vein, and CIV. Ankle-brachial indices were not obtained. She was started on intravenous heparin.
A left lower extremity venogram with access through the left popliteal vein, demonstrated thrombus within left femoral and common femoral veins and chronic near complete occlusion of the left EIV and the entire portion of the left CIV. A 30cm infusion length UniFuse catheter (Queensbury, N.Y.) was placed with the treatment area from proximal IVC to the distal femoral vein. Overnight, thrombolysis was initiated with Tissue Plasminogen Activator(tPa).
The Infusion catheter was removed after 12 hours. Left lower extremity venogram demonstrated persistent thrombus within the left femoral vein. There was persistent lack of flow within the distal left external iliac vein and the left CIV.
Angioplasty, with a 4 x 40 mm Armada balloon (Abbott Park, IL.) was performed within the IVC, left CIV and EIV for purposes of pre-dilatation prior to mechanical thrombectomy with the Inari, a 105 cm x 16 mm Clottriever (Irvine, CA.), in order to gain access into the lumen. Mechanical thrombectomy of the proximal IVC, left CIV, EIV, common femoral and femoral veins with retrieval of a large amount of acute, subacute and chronic appearing clot (Fig 3).
A completion venogram demonstrated complete removal of the thrombus within the left femoral, common femoral and the visualized portions of the proximal EIV. Flow was present within the left CIV with contrast seen entering the IVC. There was chronic stenosis of the left CIV and EIV secondary to mass effect of the uterus.
A suprarenal Option-Elite IVC filter (Athens, TX.) was placed prior to surgery for excision of pelvic mass. Systemic heparin was held 6 hours prior to surgery. She underwent total abdominal hysterectomy with bilateral salpingectomy, with preservation of normal ovaries. Pathology showed the mass to be a large benign leiomyoma measuring 18x 18cm.
Approximately eight hours postoperatively the patient started complaining of recurrent left calf tightness and swelling. Increased pitting edema with palpable pulses, compartments were soft and no pain with passive range of motion. Repeat US duplex showed acute DVT of left common femoral, femoral, posterior tibial, and peroneal veins.
Venogram showed diffuse thrombosis of the left femoral, common femoral, external and common iliac veins with high-grade stenosis involving the common iliac vein. Mechanical thrombectomy was repeated with the Inari Clottriever. The venogram did not show residual thrombus. Intravascular ultrasound demonstrated an 80% stenosis involving the mid to distal left CIV, that was likely missed on prior imaging due to overlying thrombus. Balloon angioplasty with a 14 mm Atlas balloon was performed within the common iliac vein, followed by placement of a 16 x 120 mm Boston Scientific Vici stent (Marlborough, MA.). Completion venogram demonstrated adequate inflow and outflow through the left common iliac vein stent with no significant residual thrombus or stenosis, (Fig 4).
Her post-operative course was complicated by adynamic ileus that resolved with conservative management. She required blood transfusion due to steady drop in her hematocrit. CT arteriogram of abdomen and pelvis showed large pelvic hematoma with extravasation. However, angiography failed to show active bleed, likely caused by missed bleed during hysterectomy. Anticoagulation was held until hemoglobin stabilized. She was discharged on hospital day 15 on oral Apixaban 5mg twice daily. Her left lower extremity edema had much improved, (Fig 5). She returned two months later and had the IVC filter retrieved. Follow up office visit three months later showed patient left CIV and EIV stent.