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CASE REPORT
Vascular Disease Management® March 2017 E78
Revascularization of Chronic Venous Occlusion in the Setting of Post-Thrombotic Syndrome
Jon George, MD; Deepakraj Gajanana; Sean Janzer; Vincent Figueredo; Dennis MorrisFrom the Einstein Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
Post-thrombotic syndrome (PTS), often the
sequelae of deep vein thrombosis (DVT) in
lower extremities, carries high morbidity and
often mortality. Timely intervention is critical for
preventing complications and salvaging the extremity.
Of late, there is growing interest in endovascular
techniques, including percutaneous angioplasty with
stent placement. We describe a unique case of May-
Thurner syndrome complicated by PTS that was
successfully treated using an endovascular approach.
Figure 1. Venous duplex showing occlusive thrombus in the left common femoral vein (CFV), near-total occlusion of the left superficial femoral (SFV) with non-compressibility of left greater saphenous vein (GSV).
ABSTRACT: Post-thrombotic syndrome is a complication that may follow deep vein thrombosis, and is
associated with significant morbidity. There is growing interest in endovascular techniques to treat this
complication. We present a case of May-Thurner syndrome complicated by post-thrombotic syndrome
that was successfully treated using an endovascular approach.
VASCULAR DISEASE MANAGEMENT 2017;14(3):E78-E84
Key words: post-thrombotic syndrome, endovascular technique
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CASE PRESENTATIONA 66-year-old male with past medical history of
colon cancer with subtotal colectomy and ileostomy,
left atrial myxoma with resection 4 months prior, and
concurrent left lower-extremity DVT, presented for
routine office visit. He was found to have persistent
bilateral lower-extremity edema, left greater than right
for 4 months despite appropriate anticoagulation with
warfarin and compression stockings. Upon evaluation,
his initial vital signs revealed blood pressure of 109/90
mm Hg, heart rate of 71 bpm, and pulse oximetry of 99%
on room air. He had unremarkable cardiopulmonary
and abdominal examination. He was found to have
significant left lower-extremity edema, extending up
to the upper thigh level with chronic venous stasis skin
changes and varicose veins. His hemoglobin was 11.8
g/dL and international normalized ratio (INR) was 2.0.
Figure 2. Chronic total occlusion of the femoral vein with collateral branches filling the distal common femoral vein and proximal common femoral vein.
Figure 3. Intravascular ultrasound image confirming severe compression of the left common iliac vein up to 60.4% area compression.
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An echocardiogram revealed mild mitral regurgitation
and normal biventricular function, with left ventricular
ejection fraction of 55% without any pericardial
effusion. A computed tomography scan of abdomen
and pelvis 4 months prior showed no organomegaly
or lymphadenopathy.
The presentation was consistent with PTS, despite
being compliant with warfarin therapy and therapeutic
INR. Venous duplex of bilateral lower extremities
revealed occlusive thrombus in the left common femoral
vein (CFV), near-total occlusion of left superficial
femoral (SFV), and popliteal vein with thickening of
greater saphenous vein (Figure 1). The patient was
then referred for venography of left lower-extremity
for further assessment and definitive therapy.
Selective left lower-extremity venography was
performed with the patient placed in supine frog-legged
position and ultrasound-guided 6 Fr sheath placement
in left popliteal vein using micropuncture access kit.
Selective venogram confirmed left popliteal scarring
with 50%-60% stenosis, with 100% occlusion of the
femoral vein with collateral branches filling the distal
Figure 4. Stenting and postdilation of left common femoral vein, proximal and distal femoral vein.
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CFV above the femoral head (Figure 2). A TriForce
coaxial crossing system (Cook Medical) was then
advanced over a stiff Glidewire to cross the occlusion
in the femoral vein to enter the reconstituted segment
in the CFV. Intravascular ultrasound confirmed severe
compression of the left common iliac vein (CIV) up to
60.4% area compression (Figure 3). A 24 x 45 mm self-
expanding Wallstent (Boston Scientific) was deployed
in the left CIV and postdilated using a 16 x 40 mm
Mustang XXL balloon (Boston Scientific) with good
expansion (Figure 4). Following this, 14 x 80 mm, 10 x
80 mm, and 8 x 150 mm self-expanding Protégé stents
(Medtronic) were deployed in the left CFV, proximal
to mid femoral vein, and mid to distal femoral vein,
respectively. The CFV was postdilated using a 12 x 40
mm Mustang balloon and the remainder of the stented
segment was postdilated using a 6 x 200 mm EverCross
balloon (Medtronic) with good expansion. Final
venogram revealed excellent angiographic result with
brisk flow through the entire stented segment (Figure
5), with excellent stent apposition under intravascular
ultrasound imaging. Hemostasis was achieved using
manual compression and the patient was discharged
home the next day with marked improvement in his
symptoms. His medical regimen at discharge included
aspirin 81 mg indefinitely, clopidogrel 75 mg for 1
month, and warfarin for 3 months.
DISCUSSIONDVT of the lower extremities occurs in about 1 per
1000 people/year and is associated with significant
morbidity.1 PTS is the development of symptoms
and signs of chronic venous insufficiency following
DVT.2 Despite adequate anticoagulation, PTS occurs
Figure 5. Final venogram revealing excellent angiographic result with brisk flow through the entire stented segment with excellent stent apposition under intravascular ultrasound imaging.
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in 20%-50% of patients with history of DVT.3 PTS
might develop over a matter of a few months, and in
some instances a few years after symptomatic DVT.4
A few identified risk factors include older age, obesity,
recurrent ipsilateral DVT, extensive DVT, symptoms
beyond 1 month, and subtherapeutic anticoagulation.
It carries significant morbidity and mortality, with a
significant economic burden to health-care systems.5
Usually, patients present with pain, venous varicosities,
edema, skin pigmentation, and eventually venous ulcers.
The patient described above had a history of DVT,
was on therapeutic anticoagulation with warfarin, and
had persistent symptoms beyond 3 months; thereby,
he had PTS by definition. There was no discussion of
switching the mode of anticoagulation, since there was
no recurrence of DVT on warfarin therapy but rather
onset and progression of PTS related to occlusive DVT.
Presence of unilateral DVT and PTS should often raise
suspicion for any extrinsic compression of the iliofemoral
system. May-Thurner syndrome is an often unrecognized
etiology of DVT, due to left CIV compression from the
right common iliac artery, first described by May and
Thurner in 1956.6 There is lack of awareness regarding
this entity and if not treated in a timely fashion, ulceration
and possible infection may result in amputation of the
affected extremity.
Once PTS is suspected, there are several classification
systems to clinically stage the extent of the disease,
which in turn determines treatment strategy. One such
classification is the CEAP (clinical, etiological, anatomic,
pathophysiological) system.7 Our patient was CEAP class
4a (associated with pigmentation/eczema). Since PTS is
a clinical diagnosis, any imaging modality would provide
additional information with regard to management.
Doppler ultrasound and plethysmography have been used
to measure venous reflux, venous obstruction, and calf
muscle dysfunction. However, it is limited in its assessment
of iliac veins. Thus, an additional imaging modality such
as intravascular ultrasound during venography is essential
to rule out May-Thurner syndrome. Our patient had
significant thrombus burden on ultrasound and changes
consistent with chronic inflammation of the affected veins
with significant secondary skin changes. The patient
described above had intravascular ultrasound imaging
during venography, which confirmed May-Thurner
syndrome. Treatment for May-Thurner syndrome has
evolved over the years, from conservative approach
with compression stockings8 to surgical veno-venous
bypass.9 The advancement of endovascular techniques,
including percutaneous iliac vein angioplasty with stent
placement, has revolutionized the treatment for May-
Thurner syndrome.10
Despite adequate anticoagulation, nearly one-half of
the cases develop PTS due to mechanisms less clearly
understood, as mentioned above. Treatment of PTS
and chronic DVT has evolved over years, with greater
emphasis on mechanical thrombectomy, thus focusing
on restoration of normal flow over anticoagulation.
One of the arguments for pharmacological thrombolysis
or surgical thrombectomy is the fact that residual
thrombus11 is a strong risk factor for recurrent DVT
and hence PTS. In a study comparing systemic
thrombolysis to heparin, PTS developed less frequently
in those treated with plasminogen activators rather than
heparin. However, at the cost of increased bleeding
risk (risk ratio, 2.9; 95% confidence interval, 1.1–8.1;
P=.04) than in those treated with heparin alone.12 In
another randomized trial comparing anticoagulation to
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surgical thrombectomy, improved venous patency and
a reduction in PTS was demonstrated in the surgical
arm,13 at the expense of surgical and anesthetic risks.
Other preventive strategies that have been proven to
be beneficial are elastic compression stockings and
exercise therapy.
In chronic DVT with persistent PTS, standard
endovascular chronic total occlusion revascularization
techniques are employed to traverse the occlusion. One
such catheter is the Wildcat catheter system, which
has been successfully used to cross the chronic venous
occlusion and has been reported previously.14 In our
patient, we used the TriForce Peripheral Crossing
system to successfully traverse the chronically occluded
venous segment. Thrombolysis has no perceived role
in chronic DVT due to the chronic nature of the
coagulation cascade; however, its role in acute DVT will
be dictated by the results of the pending ATTRACT
(Acute Venous Thrombosis: Thrombus Removal
with Adjunctive Catheter-Directed Thrombolysis)
multicenter, randomized, phase 3 trial.
In a study by Raju et al,15 chronic occlusion affecting
ilio-femoral segments treated with large-caliber, self-
expanding stents extending below the groin crease
were studied for the ease of deployment and long-
term patency. Actuarial primary, primary-assisted,
and secondary patency rates of stents at 24 months
were 49%, 62%, and 76%, respectively. The stented
group had significant symptomatic improvement with
minimal morbidity. The same group in another review
reported excellent results with iliac vein interventions
with better long-term patency results. Thus, our
patient underwent stenting of the chronically occluded
venous segments in order to mitigate the symptoms of
PTS, with excellent result post procedure. The patient
was seen in the follow-up clinic and had excellent
symptom improvement.
This case highlights endovascular management of
May-Thurner syndrome complicated with PTS. We
describe the technique of crossing chronic venous
occlusion and revascularization with stenting. The
importance of post-interventional care including an-
tiplatelet therapy, anticoagulation, and early ambula-
tion, should not be underestimated. n
Editor’s Note
Disclosures: Manuscript submitted July 17, 2016; pro-
visional acceptance given August 2, 2016; final acceptance
given November 8, 2016.
Address for correspondence: Jon C. George, MD, Einstein
Medical Center, Interventional Cardiology and Endovascular
Medicine, 5501 Old York Road, Philadelphia, PA 19141.
Email: jcgeorgemd@gmail.com
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