Author + information
- Received January 16, 2018
- Accepted January 23, 2018
- Published online May 21, 2018.
- Wai Kin Chi, MBChB and
- Bryan P. Yan, MBBS∗ ()
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China
- ↵∗Address for correspondence:
Prof. Bryan P. Yan, Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F Clinical Science Building, Prince of Wales Hospital 30-32 Ngan Shing Street, Shatin, NT, Hong Kong SAR, China 20037.
A 69-year-old man presented with acute left thigh pain and swelling 1 day after successful left superficial femoral artery balloon angioplasty and stenting for claudication via contralateral right common femoral artery access with a 45-cm 6-F crossover sheath. Physical examination revealed palpable pedal pulses, and left thigh and calf circumference 3 cm greater than the right. Venous duplex ultrasound revealed nonocclusive thrombus in the left common femoral vein extending proximally into the external iliac vein. The left common iliac vein (CIV) was obscured and not imaged.
The patient was started on standard dose subcutaneous low-molecular-weight heparin and underwent invasive venography within 24 h (Figure 1A). Venography performed via left popliteal vein access with the patient lying prone demonstrated a filling defect in the left CIV. Peripheral intravascular ultrasound (Vision PV 0.35, Philips Volcano, San Diego, California) revealed severe extrinsic compression of the left CIV (Figure 1B) by the right common iliac artery, consistent with May-Thurner syndrome (1). Three overlapping 16 mm × 120 mm, 14 mm × 120 mm, and 14 mm × 60 mm dedicated nitinol venous stents (Vici, Veniti, Fremont, California) were deployed from the inferior vena cava to the left common femoral vein with an excellent angiographic result (Figure 2A) and significant luminal gain by intravascular ultrasound (Figure 2B). Patient’s left lower limb swelling rapidly improved and resolved by 3-month follow-up.
During subsequent staged angioplasty to the right superficial femoral artery via left common femoral artery puncture, fluoroscopy demonstrated the crossover sheath crossed over the left CIV at the point of occlusion (Figures 3A and 3B).
The proposed mechanism of acute left DVT in this case was exacerbation of the left CIV compression (i.e., May-Thurner syndrome) by the overriding arterial crossover sheath causing increased obstruction of venous outflow. Our case also demonstrated venography alone may underestimate the extent of CIV compression in May-Thurner syndrome. Peripheral intravascular ultrasound is recommended for better assessment of CIV compression pre- and post-intervention (2).
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 16, 2018.
- Accepted January 23, 2018.
- 2018 American College of Cardiology Foundation
- Hager E.S.,
- Yuo T.,
- Tahara R.,
- et al.
- DeRubertis B.G.,
- Lew W.,
- Jabori S.,
- Barleban A.,
- Jimenez J.C.,
- Lawrence P.F.