Venous intervention for severely stenotic IVC filter

A male in his sixties presented with bilateral severe lower extremity pain with ambulation consistent with venous claudication. On physical examination, he had bilateral severe lower extremity swelling, signs of venous stasis, and a Villalta score of 7. His history was significant for chronic bilateral lower extremity DVT with prior IVC placement and left iliac venous stents. On duplex examination, he had severe bilateral common femoral vein reflux (3.6 on the right, 5.5 seconds on the left).
A bilateral popliteal vein approach (prone positioning) was used because of severe common femoral venous stenoses bilaterally. The popliteal veins were cannulated bilaterally using micropuncture sheaths, upsized to 8 French sheaths. Initial imaging showed near occlusion of the prior IVC filter (A; arrow) and severe iliofemoral venous disease bilaterally (A, B). IVUS (Philips Volcano) was used to characterize the lesions. The IVUS image (C) demonstrates the near occlusion of the IVC in the region of the previously placed IVC filter. The crushed IVC filter is demonstrated on fluoroscopic imaging (D). The right common iliac vein was also occluded (E).
Glidewires and glide catheters from both sides were used to cross the iliac vein and IVC lesions (F). Angioplasty was completed using 16 x 40 mm balloons, after which 18 x 60 mm stents (Wallstent) were deployed in the iliac veins bilaterally; the stent in the right iliac vein (dashed arrow) is shown (G). A stent was placed into the infrarenal IVC (Wallstent), but it maldeployed (H). The initial stent was manipulated with a balloon, collapsing the filter, which was subsequently crushed by placing a second stent (Palmaz). On completion venography, successful placement of the IVC stent and bilateral iliac vein stents can be seen with good blood flow throughout (I).