Iliofemoral deep vein thrombosis - treated with thrombolysis and thrombectomy

Case contributed by Dr Seamus O'Flaherty

Presentation

One week of right thigh pain, worse with walking, and pallor of right foot. Past history of unprovoked left iliofemoral DVT, on lifelong anticoagulation.

Patient Data

Age: 25 years
Gender: Male

This is a section of the original study at the region of interest. The original study included chest, abdomen and bilateral lower limbs.

There is asymmetrical dilatation of the right femoral vein and external iliac vein with associated surrounding edema, which raises concern for deep venous thrombosis. The right common iliac vein is symmetrical to the left.

There was no evidence of any arterial occlusion throughout the study. There was no evidence of any pulmonary embolus. 

This patient presented with symptoms and signs suggestive of arterial claudication in his right lower limb. CT angiogram showed patent arteries in both lower limbs; however, dilation of the right iliofemoral veins; suggestive of DVT.

The next study to consider is a Duplex ultrasound, which has high sensitivity (95%) and specificity (96%) for DVT.

Duplex ultrasound right lower limb

Ultrasound

Extensive occlusive thrombus commencing in the popliteal vein, with proximal extension into the common femoral vein and common iliac vein (non-compressible on imaging).

Further non-occlusive proximal extension is seen into the common iliac vein and IVC with only partial color flow demonstrated. 

Following the above imaging, the patient proceeded to undergo catheter-directed thrombolysis with urokinase. Residual clot was retrieved by thrombectomy. 

Ultrasound guided access to the popliteal vein.

Angiogram of the femoral and iliac venous system demonstrates extensive occlusive thrombus. Wire and catheter advanced to the iliac bifurcation. Bolus of urokinase was injected via an infusion catheter.

Angiojet thrombolysis performed with further urokinase. Thrombectomy performed.

DSA then demonstrates improved appearance with resolution of thrombus in the femoral vein.

Aspiration thrombectomy performed for internal and external iliac veins.

Final angiogram demonstrated small volume residual thrombus in the internal iliac, but flow in the system.   

Case Discussion

This young adult male presented with symptoms and signs suggestive of arterial claudication. Interestingly, he did not have any lower limb swelling despite a chronic extensive lower limb DVT. 

He reported non-compliance with his anticoagulation in the months preceding admission. He has a strong family history of venous thromboembolism; however, a negative thrombophilia screen. His past history included mild cerebral palsy; although, no known medical conditions to predispose him to thrombosis. 

Due to the residual clot burden after thrombolysis and thrombectomy, the catheter sheath was left in-situ and the patient had an overnight infusion of urokinase and therapeutic heparin.  

The following day he had a repeat ultrasound, which unfortunately showed recurrence of occlusive iliofemoral DVT. He underwent repeat catheter-directed thrombolysis and thrombectomy with a good result and no residual clot burden. 

He did not have any signs, symptoms or imaging findings of pulmonary emboli. 

He made a good recovery and was discharged home on therapeutic anticoagulation. 

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