This is a 25-year-old male with no pertinent hypercoagulable conditions or prior thromboembolic events, who was referred to our clinic in early July with an extensive left lower extremity deep vein thrombosis. Patient is a truck driver and had been at work transporting from Casa Grande, Arizona up to Flagstaff when he started developing pain in his left ankle. This patient was seen at a local hospital, diagnosed with a DVT, given subcutaneous Lovenox, and discharged home without any oral anticoagulants. Patient was then forced to stop driving and was transferred down to another facility in Phoenix, Arizona. There, he was placed on full dose oral Eliquis for anticoagulation. Ultrasound at that time revealed very extensive deep vein thrombosis extending from the left post tibial vein up to the left common femoral vein.
This patient was evaluated in our clinic on July 8, 2022. Patient had severe edema on examination, with very prominent varicosities and extensive reticular veins with erythema of the tibial region. Symptoms include severe pain with immobility. A stat repeat venous Doppler with left iliac vein imaging was performed in our clinic. There was no resolution of the DVT, with high probability of left iliac vein compression. He was also seen by a hematologist and had a hypercoag panel drawn and was negative for any of the hypercoag conditions typically seen.
Due to severe mobility and the risk of posttraumatic syndrome, along with probability of May-Thurner syndrome, he was scheduled for venography with thrombectomy IVC filter placement, along with iliac venography and IVUS.
Initial access was obtained in the right common femoral vein with imaging of the vena cava and deployment of a tulip IVC filter without complications. This patient was placed in the prone position and access was obtained in the left popliteal vein follow by placement of a 8 Fr venous sheath. Due to significant amount of thrombus, I was able to pass a V 18 wire up through the occluded superficial femoral vein into the left common femoral vein up into the left common iliac vein in the vena cava. Intravascular ultrasound was performed revealing intraluminal position along with classic compression of the left common iliac vein. I confirmed 70% compression. Due to the need to treat the left common iliac vein, the 8Fr sheath was upsized to a 10 French sheath. This was successfully treated with deployment of a 16 mm x 90 mm wall stent. Pre and post imaging of the left iliac vein is included.
Through the popliteal venous sheath, we then advanced a 8Fr Zelante Angiojet aspiration thrombectomy catheter into the left superficial femoral vein. A total of 20 mg of alteplase was administered via pulse spray, with a 20-minute dwell time. Aspiration thrombectomy was performed with aspiration of a total of 300 mL of thrombus and blood.
Based on intravascular ultrasound, we then performed venoplasty of the left superficial femoral vein using a 10 mm x 80 mm charger balloon. Repeat venography revealed full resolution of thrombus. Before and after pictures are included below. The venous sheath was removed, pressure was applied and hemostasis was adequate.
In order to prevent hemosiderin deposition in the renal tubules, patient was hydrated with 3 L of normal saline intra-procedure. Patient was also instructed to consume at least 64 to 84 ounces of fluid on the next 24 hours. He was discharged home on Eliquis 5 mg b.i.d. and will be seen in the office in two weeks for follow up.
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