49 yo female referred to IR with bilateral extremity pain an | Figure 1

SIRRFS

49 yo female referred to IR with bilateral extremity pain and swelling for several months. Pmhx: NKDA, No medications, No relevant pelvic or other surgical history.

Physical: BP 111/76 RR 14, BMI 22, BSA 1.5

RRR, Equal breath sounds, no abd pain.

Bilateral non pitting edema with tenderness and varicosities. Pain improved with elevation.

Figures 1, 2 and 3 demonstrate #venogram obtained via left popliteal v. access in prone position. Figure 1 green arrow shows nonopacification of the #IVC. Figure 2 arrow demonstrates collaterals entering right common iliac v., delayed flow into IVC is demonstrated.

What is the #angiographic diagnosis?

Figures 4 and 5 demonstrate placement of A 14F self expandable wall #stent (Red) placed in the left common iliac vein and venogram demonstrates patency without retrograde flow.

Which of these best describes anatomical relationship in #May-Thurner’s Syndrome?

A: Right common iliac artery crosses over the right common iliac vein. B: Right common iliac artery crosses over the left common iliac vein. C: Left common iliac artery crosses over the right common iliac vein. D: Left common iliac artery crosses over the left common iliac vein.

What is a possible late complication of venous stenting? What is demonstrated by CT at 1.5 year follow up?

IVC thrombosis has developed below indwelling Optease IVC filter, extending below the common iliac veins. A plethora of abdominopelvic collateral pathways have developed.
IVC thrombosis can lead to lower extremity DVT, chronic venous insufficiency, post-thrombotic syndrome, and limb ischemia.
Recurrent VTE after adequate anticoagulation, VTE with contraindications to anticoagulation, VTE with complication from anticoagulation, and inability maintain anticoagulation for VTE. Lower extremity symptoms from venous hypertension were treated with IVC filter retrieval followed by cavo-iliac reconstruction. Venography of the common iliac veins and IVC demonstrates occlusion at the cavo-iliac bifurcation with prominent collateral pathways. Note indwelling IVC filter. The IVC filter was successfully recaptured with using a laser excimer sheath. Next, a Gianturco stent was deployed just inferior to the right renal vein, followed by an overlapping Gianturco stent in the peripheral IVC. Kissing Wall-stents were deployed at the cavo-iliac bifurcation. Completion venography demonstrates patent IVC and common iliac veins with preferential blood flow through the reconstructed iliocaval system. Case courtesy of Dr. Doug McDonald and Dr. Lauren Evans from Scott and White Medical Center, Department of Interventional Radiology, Texas A&M University.

38 year old pregnant female presents with acute LLE DVT diagnosed by MRI. Due to the extreme pain, risk of PE and for prevention of post-thrombotic syndrome, she was treated with balloon venoplasty, AngioJet thrombectomy and overnight catheter directed lytics infusion. A self expanding stent was then deployed across the narrowing. Repeat venoplasty was performed within the stent. IVUS post intervention demonstrates that at the IVC bifurcation, the right common iliac artery (red arrowhead) no longer compresses the open left common iliac vein (yellow arrowhead). (Courtesy Feraz N Rahman MD)

May-Thurner is correct. A self expandable stent was placed in the left common iliac vein and venogram demonstrates patency without retrograde flow. CT abdomen and pelvis demonstrates patent left internal iliac vein with self expanding stent in place. 1 year later patient had recurrence of symptoms and CT showed mural thrombus with in-stent stenosis.

Patient with occlusive #DVT extending from IVC to the left external iliac vein (red arrow). The DVT is likely secondary to compression of the left common iliac vein secondary to the right common iliac artery (red arrow), known as May-Thurner syndrome. The patient was brought to #InterventionalRadiology where they had thromblysis using Angiojet, angioplasty and stent placement utilizing IVUS for measurements.