Iliofemoral DVT

Physician

Michael Taylor, M.D.
Interventional Radiologist
St. Mary’s Medical Center
San Francisco, CA

Background

A 75 year old female presented into the St. Mary’s Emergency Department with significant pain, swelling, and discoloration in her left leg. She had a 60-day history of deep vein thrombosis (DVT) and was on anticoagulation (Coumadin) therapy. Vascular ultrasound was positive for thrombosis in the leg and thigh. An occlusion was suspected in the pelvis. Isolated pharmacomechanical thrombolysis was identified as a potential therapy to re-establish patency and resolve the patient's symptoms of pain and swelling.

Procedure

The patient was placed in the supine position on the procedure table. A 6Fr sheath was used to access the jugular vein and a contrast injection indicated the vena cava was fully patent with no thrombus. A removable filter was placed in the vena cava (Figure 1).

The patient was then placed in the prone position. An 8Fr sheath was used to access the popliteal vein and a contrast injection indicated a chronic occlusion in the iliac vein, an acute thrombus in the common femoral vein, and patency in the femoral and popliteal veins (Figure 2).

A Trellis®-8 (80 x 15cm) was placed in the left common iliac vein. Isolated pharmacomechanical thrombolysis was performed using 6mg of t-PA with a 10-minute dispersion time. A follow-up contrast injection revealed partial antegrade flow through the treated area with an identified chronic obstruction in the iliac vein (Figure 3).

A self-expandable stent was placed in the iliac occlusion and post-dilated with an angioplasty balloon (Figure 4). The Trellis-8 (80 x 15cm) was reinserted and placed in the left common femoral vein. Isolated pharmacomechanical thrombolysis was performed using 6mg of t-PA for 10 minutes. The acute thrombus was fully resolved.

A full contrast injection identified complete restoration of flow from the left popliteal to the vena cava (Figure 5).

Conclusion

Full patency of the left femoral and iliac vein was restored in a single procedure. The patient’s pain and swelling had dramatically improved the next day. The patient was discharged on Heparin therapy then prescribed anticoagulation (Coumadin) therapy. The vena cava filter was removed one week later.