Intervention for bilateral iliac venous obstruction

A 62-year-old woman presented with a three-week history of bilateral lower extremity swelling following prior IVC filter placement 10 years previously. Venous duplex confirmed acute thrombus involving the distal inferior IVC and left iliac vein, as well as chronic DVT of the right common femoral vein. Venography (prone positioning) demonstrated extensive left iliofemoral thrombosis (A). The previously placed IVC filter was seen (B, arrow). The occluded segments were successfully crossed using a stiff glidewire and Navicross catheter (C) and intraluminal positioning confirmed by venography and intravascular ultrasound (Philips Volcano). Following sequential ballooning using 8 × 40 and 10 × 40 mm balloons, a 50 cm catheter (UniFuse) was placed, and thrombolysis with tPA was initiated. After 24 hours, the patient was returned to angiography and placed supine, and the right common femoral vein was cannulated with an 8 Fr sheath using ultrasound guidance. The IVC and iliac veins were angioplastied using a 12 × 40 mm balloon (Conquest) (D). The sheath was upgraded to 16 Fr (DrySeal) to pass a 20 × 55 mm stent (Wallstent), which was deployed within the prior IVC filter and expanded with a 20 × 40 mm balloon (Maxi LD). Reconstruction of the iliofemoral segments bilaterally was performed with the deployment of a combination of 12 × 80 mm stents (Smart) bilaterally, 14 × 80 mm stents (SMART) bilaterally, and finished with 16 × 60 mm "kissing" stents (Wallstent) bilaterally (E). Completion venography and intravascular ultrasound (Philips Volcano) confirmed the patency of both iliocaval and femoral venous segments (F, G, H). The sheaths were removed. Postoperatively, the patient remained fully anticoagulated. Clopidogrel was initiated within four hours. Postprocedure, the patient did not have any complications and was discharged to home on warfarin and clopidogrel.