Author + information
- Received June 20, 2016
- Accepted June 30, 2016
- Published online October 10, 2016.
- aDepartment of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- bDepartment of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- ↵∗Reprint requests and correspondence:
Dr. Syed Y. Naqvi, Pennsylvania Hospital, Department of Internal Medicine, 800 Spruce Street, Philadelphia, Pennsylvania 19107.
A 65-year-old woman with a history of pulmonary embolism and venous stasis presented to her doctor’s office reporting leg edema. In 1969, she developed a massive spontaneous pulmonary embolism that was treated with surgical clot removal. She was unable to be anticoagulated because of warfarin allergy and underwent Adams-DeWeese inferior vena cava (IVC) clip placement for prevention of pulmonary embolism (1). Over 10 years, she developed worsening bilateral leg edema that was managed with compression stockings and high-dose oral diuretic agents. Her edema progressed to the point at which she lost her job and became wheelchair bound. A computed tomographic scan with contrast revealed an IVC diameter of 5 mm at the level of the clip, extensive bilateral external iliac vein compression from large uterine fibroids, and extensive superficial abdominal venous collateralization (Figure 1A). The patient was declined for hysterectomy because of extensive pelvic venous congestion. The patient was recommended to undergo percutaneous IVC and bilateral external iliac venous stenting. The initial venograms using intravascular ultrasound demonstrated IVC and bilateral iliac vein narrowing from external compression (Figure 1B). The patient underwent successful placement of Palmaz-Schatz balloon-expandable stent at the site of IVC clip and balloon-expandable Express LD stents for the iliac veins. The final venogram revealed widely patent IVC and external iliac veins with good flow (Figure 1C). Post-operatively, the patient developed some mild lower abdominal pain, and a repeat computed tomographic scan of the abdomen revealed no acute findings, widely patent external iliac stents, and an increase in IVC diameter to 1.2 cm (Figure 1D). The patient was started on rivaroxaban 20 mg/day and was discharged home on postoperative day 3. The patient had significant improvement of her edema and lost 50 lb within 3 weeks. She returned to work and was able to ambulate by herself. She underwent successful hysterectomy at 6 months and was asymptomatic at a 12-month follow-up visit.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 20, 2016.
- Accepted June 30, 2016.
- American College of Cardiology Foundation