Thrombectomy in a severe case of iliofemoral venous thrombosis involving the deep femoral vein via a single percutaneous access from the jugular vein: case report and description of the technique

Iliac vein thrombectomy is usually performed via access through veins located in the lower limbs, which makes it impossible to treat the deep femoral vein, which in turn is an important inflow route to the iliac vein stent. We describe a clinical case and the previously unpublished technique of percutaneous thrombectomy, angioplasty, and stent implantation performed in a single session and with a single access, obtained via the internal jugular vein.

Keywords:
angioplasty; thrombectomy; iliac vein; thrombosis

Authorship

Fabio Henrique Rossi

Instituto Dante Pazzanese de Cardiologia – IDPC, São Paulo, SP, Brasil.Instituto Dante Pazzanese de CardiologiaBrasilSão Paulo, SP, BrasilInstituto Dante Pazzanese de Cardiologia – IDPC, São Paulo, SP, Brasil.

Instituto de Excelência em Doenças Venosas – IEDV, São Paulo, SP, Brasil.Instituto de Excelência em Doenças VenosasBrasilSão Paulo, SP, BrasilInstituto de Excelência em Doenças Venosas – IEDV, São Paulo, SP, Brasil.

https://orcid.org/0000-0001-9423-3638

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Correspondence Fabio Henrique Rossi Av. Dr. Amâncio de Carvalho, 182, conjunto 511 - Vila Mariana CEP: 04012-080 - São Paulo (SP) – Brazil Tel.: +55 (11) 3368-2975 E-mail: vascular369@hotmail.com

Author information FHR - PhD e postdoctoral, Faculdade de Medicina da Universidade de São Paulo (FMUSP); Instituto Dante Pazzanese de Cardiologia (IDPC).

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (10)

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Figure 1
Abdominal and pelvic angiotomography showing presence and size of the thrombosis and angiotomographic classification at the point of greatest compression (*) in the cavo-ilio-femoral segment. A) Coronal axis; B) Sagittal axis; C) Transverse axis.

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Figure 2
Angiotomography demonstrating presence of thrombus filling the entire lumen of the left common femoral, femoral, and deep femoral vein (*). A) Coronal axis; B) Sagittal axis; C) Transverse axis.

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Figure 3
Digital subtraction venography. A) Tip of the 5F PM catheter positioned at the confluence of the common iliac veins, showing the site of compression by the right iliac artery; B) initial venography conducted with the Angiojet Zelante thrombectomy catheter, positioned in the left popliteal vein; note the presence of collateral flow between this vein and the deep femoral vein, which is obstructed by thrombi; C and D) presence of a large volume of thrombi in the left femoral and deep femoral veins.

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Figure 4
Digital subtraction venography demonstrating A) initial presence of obstruction of left femoral and deep femoral veins by thrombi; in B, C and D) intraoperative control venography after infusion of the thrombolytic agent with the “pulse spray” technique and mechanical aspiration of the left femoropopliteal segment.

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Figure 5
Digital subtraction venography demonstrating the technique for repositioning the Angiojet catheter tip in the caudal extremity of the left deep common femoral vein: A) catheter tip placed in the left common femoral vein without the guidewire; B and C) positioning of the tip of the same catheter over the hydrophilic guidewire in the caudal extremity of the left deep femoral vein.

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Figure 6
Digital subtraction venography of the cavo-ilio-femoral axis: A and B) initial venography demonstrating occlusion of the iliofemoral axis; C) venographic appearance after infusion of thrombolytic with the “pulse spray” technique and mechanical aspiration. At the arrow, we can observe the anatomic obstruction that occurs at the “mouth” of the left common iliac vein, provoking compression by the right common iliac artery and used as the cranial limit of advancement of the thrombectomy catheter, with the objective of preventing fragments of thrombus entering the inferior vena cava.

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Figure 7
Image acquired when crossing the entire treated segment with the intravascular ultrasonography catheter (Vision PV.035 – Philips) with the objective of identifying remnant thrombi and residual points of compression and/or obstruction: A) left femoral vein; B) left common femoral vein below the inguinal ligament; C) mid third of the left common iliac vein; D and E) severe compression and obstruction (>80%) at the confluence of the iliac veins and the caudal extremity of the inferior vena cava; D) inferior vena cava in mid infrarenal third.

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Figure 8
A) Digital subtraction venography demonstrating controlled-release of the Wallstent 18 x 90 mm; and B) post-ballooning of the stent with an 18 x 40 mm XXL catheter balloon.

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Figure 9
Digital subtraction venography and final intravascular ultrasonography control along the femoral (A), iliofemoral (B), and vena cava segments (C), demonstrating adequate flow and recovery of the cross-sectional area of the segments treated.

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Figure 10
Postoperative control Doppler ultrasonography demonstrating (A) patency of the inferior vena cava (VCI), the stent venous positioned in the left common iliac vein (VICE), from its cranial segment over the right common iliac artery (AICD), and in the left external iliac vein (VIEE), and the right common iliac vein (VICD); B) Venous flow in phase with respiratory movements in the left (VFCE) and right (VFCD) common femoral veins; C) diameters of the stent in the VCI, VICE, and VIEE.

Figure 1 Abdominal and pelvic angiotomography showing presence and size of the thrombosis and angiotomographic classification at the point of greatest compression (*) in the cavo-ilio-femoral segment. A) Coronal axis; B) Sagittal axis; C) Transverse axis.

Figure 2 Angiotomography demonstrating presence of thrombus filling the entire lumen of the left common femoral, femoral, and deep femoral vein (*). A) Coronal axis; B) Sagittal axis; C) Transverse axis.

Figure 3 Digital subtraction venography. A) Tip of the 5F PM catheter positioned at the confluence of the common iliac veins, showing the site of compression by the right iliac artery; B) initial venography conducted with the Angiojet Zelante thrombectomy catheter, positioned in the left popliteal vein; note the presence of collateral flow between this vein and the deep femoral vein, which is obstructed by thrombi; C and D) presence of a large volume of thrombi in the left femoral and deep femoral veins.

Figure 4 Digital subtraction venography demonstrating A) initial presence of obstruction of left femoral and deep femoral veins by thrombi; in B, C and D) intraoperative control venography after infusion of the thrombolytic agent with the “pulse spray” technique and mechanical aspiration of the left femoropopliteal segment.

Figure 5 Digital subtraction venography demonstrating the technique for repositioning the Angiojet catheter tip in the caudal extremity of the left deep common femoral vein: A) catheter tip placed in the left common femoral vein without the guidewire; B and C) positioning of the tip of the same catheter over the hydrophilic guidewire in the caudal extremity of the left deep femoral vein.

Figure 6 Digital subtraction venography of the cavo-ilio-femoral axis: A and B) initial venography demonstrating occlusion of the iliofemoral axis; C) venographic appearance after infusion of thrombolytic with the “pulse spray” technique and mechanical aspiration. At the arrow, we can observe the anatomic obstruction that occurs at the “mouth” of the left common iliac vein, provoking compression by the right common iliac artery and used as the cranial limit of advancement of the thrombectomy catheter, with the objective of preventing fragments of thrombus entering the inferior vena cava.

Figure 7 Image acquired when crossing the entire treated segment with the intravascular ultrasonography catheter (Vision PV.035 – Philips) with the objective of identifying remnant thrombi and residual points of compression and/or obstruction: A) left femoral vein; B) left common femoral vein below the inguinal ligament; C) mid third of the left common iliac vein; D and E) severe compression and obstruction (>80%) at the confluence of the iliac veins and the caudal extremity of the inferior vena cava; D) inferior vena cava in mid infrarenal third.

Figure 8 A) Digital subtraction venography demonstrating controlled-release of the Wallstent 18 x 90 mm; and B) post-ballooning of the stent with an 18 x 40 mm XXL catheter balloon.

Figure 9 Digital subtraction venography and final intravascular ultrasonography control along the femoral (A), iliofemoral (B), and vena cava segments (C), demonstrating adequate flow and recovery of the cross-sectional area of the segments treated.

Figure 10 Postoperative control Doppler ultrasonography demonstrating (A) patency of the inferior vena cava (VCI), the stent venous positioned in the left common iliac vein (VICE), from its cranial segment over the right common iliac artery (AICD), and in the left external iliac vein (VIEE), and the right common iliac vein (VICD); B) Venous flow in phase with respiratory movements in the left (VFCE) and right (VFCD) common femoral veins; C) diameters of the stent in the VCI, VICE, and VIEE.

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Thrombectomy in a severe case of iliofemoral venous thrombosis involving the deep femoral vein via a single percutaneous access from the jugular vein: case report and description of the technique

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.