PMC3590570_01
The left common femoral (a); left femoral (b); left popliteal (c); left great saphenous (d); left posterior tibial (e); left peroneal veins (f) demonstrate extensive thrombosis, loss of flow on Doppler. Veins also demonstrate an increase in the size and noncompressibility with ultrasound probe which are consistent with DVT.
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Lower extremity doppler was significant for extensive thrombosis of left common femoral, femoral, great saphenous, posterior tibial, popliteal, and peroneal vein as shown in Figures 1(a)-1(f).
Massive bilateral PE noted in (a), right common iliac artery crossing in front of left common iliac vein noted in (b), (c), and (d), and features consistent with the May-Thurner syndrome.
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CT scan of chest with intravenous contrast revealed massive bilateral PE (Figure 2(a)). CT abdomen supported the diagnosis of MTS as shown in Figures 2(c) and 2(d) and showed extension of the clot all the way through left common iliac vein (Figure 2(b)) into inferior vena cava (IVC).
Venography at the day of presentation shows complete thrombotic occlusion of the veins in left leg, dye is not passing beyond popliteal vein ((a) and (b)), (c) demonstrates duplication of the femoral vein. (d), (e), and (f) demonstrate venography at day 3 before and after stent placement, respectively.
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Subsequently the patient underwent interventional radiology (IR) guided venography (Figures 3(a) and 3(b)) and local thrombolysis with the alteplase followed by continuous infusion of alteplase and heparin through catheter laid across femoral and iliac veins with a closer monitoring of CBC and coagulation profile. On a subsequent day patient underwent IR guided venography revealing duplicate femoral veins (Figure 3(c)), pharmacomechanical thrombolysis, and thrombectomy of left iliofemoral veins. On the subsequent day patient underwent repeat venography which showed no significant thrombus burden but revealed narrowing of the left common iliac vein (Figures 3(d) and 3(e)) which confirmed the diagnosis of MTS, venoplasty was done, and two stents made of nitinol (nickel-titanium alloy) measuring 14 mm x 8 cm and 14 mm x 3 cm were deployed in iliocaval junction with a good flow through stent into IVC (Figure 3(f)).