my worst venous complication - login - nmsuite
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My Worst Venous Complication
Daniela Branzan, MD,
Department of Vascular Surgery
University Hospital Leipzig
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Disclosure
I do not have any potential conflict of interest.
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Clinical Findings
• 18-year-old man
• back pain
• worsening painful swelling in his both legs, severely limiting his mobility within the last 3 weeks
• no shortness of breath, cough or chest pain,
• afebrile and HD stable
• past medical history unremarkable
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Clinical Findings
• no familial history for venous thromboembolism
• US: extensive clot, with complete occlusion of the external iliac vein, and common, deep and superficial femoral veins
• CT pulmonary angiogram excluded pulmonary embolism (PE).
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CT scan of the abdomen (coronal view)
extensive thrombosis of the IVC
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CT scan of the abdomen
Infrarenal IVC extensively thrombosed
Thrombosis of the CIV, EIV on both sides Patent renal veins
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CT scan of the abdomen
marked hypoplasia of the intrahepatic tract of the IVC
Venous drainage from the inferior part of the body
accomplished by a dilated azygos and paravertebral
veins
Intrahepatic IVC thrombosed
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Subacute IVC Thrombosis
Treatment Modalities
• Anticoagulation alone->disabling PTS
• CDT
• Phamacomechanical catheter directedthrombolysis
• PTA and Stenting
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Intervention # 1
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Mechanical Thrombus Removal(10,5 Fr. Aspirex, Straub Medical AG)
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Cragg-McNamara (Medtronic, Minneapolis, Minn) infusion catheters inserted through each popliteal vein
Alteplase (10 mg mixed in 1,000 ml of 0.9% NaCl), infused at a rate of 0.01 mg/kg/h
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Intervention # 2: 24 h later
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Mechanical Thrombus Removal(10,5 Fr. Aspirex)
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PTA of a suprarenal collateral
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Significant residual stenosis due to the chronicity of the thrombosis of CIV&IVC
Good Flow in the Azygos System
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3 Days later
• Symptomatic Re-Occlusion of IVC, iliac Veins. CFV, VF on both sides despite
– anticoagulation with UFH and
– graduated compression stockings
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Intervention # 3: 4 Days later
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Iliofemoral Thrombectomy
Femoral venotomy and surgical thrombectomy: combination of acute soft thrombus and a chronic fibrotic thrombus
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Surgical Thrombectomy
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IVC and CIV Flow after Thrombectomy
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CART of IVC Occlusion via IJV and CFVEstablish a through-and-through wire
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High Preassure PTA of the IVC Occlusion(Conquest® 40 - Bard PV )
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Sinus XL 22/100, 22/80mm(Optimed)
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Surgical Thrombectomy of left CIV
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Final Phlebography
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Discharge
• Graduated compression stockings
• Ass 100mg/die, Clopidogrel 75mg/die for 1 month, NOAK
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• Collateral veins on the left side of the abdomen
• Small varicose veins on the calf
• Discrete edema BTK
• Plays Volleyball regularly
FU@4 Mo
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Phlebography@4 Mo
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Phlebography@4 Mo
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Things we might have considered to improve Patency
• Stenting across the iliocaval bifurcation?
• IVUS?
• AV-Fistula at the groin?
• Inferior vena cava thrombectomy?
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My Worst Venous Complication
Daniela Branzan, MD,
Department of Vascular Surgery
University Hospital Leipzig