Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 58 years-old gentleman Mr. RA with past history of Ischemic stroke 15 years back, operated and received radiotherapy for carcinoma of vocal Cord 4 years back, presented now with pain and swelling in left leg for 1 month.
Relevant test results prior to catheterization
CT Pulmonary angiography showed no evidence of pulmonary embolism. His echocardiography was essentially normal. CT venography demonstrated Thrombus extending from lower IVC to left popliteal vein; Right common iliac artery compressing left common iliac vein against lumbar vertebrae suggestive of May-Thurner syndrome (MTS).
Relevant catheterization findings
Thrombus extending from lower IVC to left popliteal vein.
CT venography rather than ultrasonography helps in establishing the diagnosis of MTS. Systemic anticoagulation alone is insufficient, more aggressive approach is necessary to prevent recurrent deep venous thrombosis (DVT) in the presence of anatomical substrate like MTS. Three practical steps are involved in the treatment of MTS namely deployment of IVC filter, Catheter Directed Thrombolysis (CDT) and Iliac vein Stenting.
Optease retrievable IVC filter deployed prior to lower extremity intervention in order to prevent further embolization during lytic therapy. With patient lying in prone position and USG Doppler, guided puncture of left popliteal vein was performed. 6F sheath inserted; 5F JR 3.5 catheter advanced 0.035” 150 cm J tipped Terumo wire and Venogram performed which revealed large clot burden. Terumo wire was exchanged to 0.035” Magic torque wire and Balloon dilated with 9 x 30 mm over the wire peripheral balloon at 2-6 atm. CDT was started with Urokinase using 4F Fountain infusion catheter. Venogram repeated after 72 hours of CDT. Most of the clot had resolved by then. Large self-expanding stent (Bard E-Luminexx Vascular Stent 14 x 60 mm) positioned in Left Common Iliac vein across the extent of the stenosis and extending into the inferior vena cava to prevent migration. Systemic long-term anticoagulation recommended for at least 6 months.
Actively look for May-Thurner Syndrome in left sided deep venous thrombosis. Percutanoeus interventional therapy is advised for deep venous thrombosis caused by May-Thurner Syndrome. Preprocedure CT venography helps in establishing the diagnosis.