PMC8260863_01
Pre-procedural axial CT venogram images proceeding from a caudal to cranial direction. (A) The bilateral common iliac veins (arrows) are dilated by acute thrombus. (B) At the expected location of the confluence of the common iliac veins, there are enlarged, thrombosed paraspinal venous collaterals (arrows). (C) These collaterals eventually drain into the azygos system (arrows). (D) Superiorly, the azygos vein is patent, but distended (small arrows). The hemiazygous vein is also engorged (large arrow). (E) The IVC is only identified at the superior aspect of the liver, at the confluence of the hepatic veins (arrow).
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Pre-intervention CT venogram confirmed extensive lower extremity DVT, partial absence of the intrahepatic IVC, complete absence of infrahepatic IVC, and dilated thrombosed paraspinal collateral veins draining into enlarged azygos and hemiazygous veins (Fig. 1). At the one month clinic visit, CT venography demonstrated a patent reconstructed IVC and bilateral iliac veins (Fig. 5, Supplemental Video 1).
Digital subtraction angiography images from Day 1 thrombolysis and thrombectomy. (A) Initial venography from the left posterior tibial vein demonstrates clot through the femoral veins (arrows). (B) Extensive clot burden is also seen in the bilateral common iliac veins (white arrows). The IVC is absent at its expected location (black arrow).
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On the first day, bilateral lower extremity venography was performed via posterior tibial vein access, demonstrating a clot burden from the bilateral posterior tibial veins to the common iliac veins (CIVs) (Fig. 2A). The IVC was not visualised from the confluence of the CIVs and no significant abdominopelvic collaterals were identified (Fig. 2B).
Digital subtraction angiography images from Day 2 lysis check. (A) Following 24 hours of catheter directed thrombolysis, there is near complete resolution of thrombus, and a large outflow azygos vein (arrows) is identified. (B) However, within 10 minutes of terminating the tissue plasminogen activator infusion, the azygos vein is no longer seen on repeat venography. Re-thrombosis also occurred in the right common iliac vein (white arrow). The IVC remained absent at its expected location (black arrow).
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On the second day, repeat venography demonstrated near complete resolution of thrombus throughout both lower extremities and the outflow azygos vein (Fig. 3A). Within 10 minutes of terminating tPA, there was re-thrombosis of the azygos and CIVs (Fig. 3B).
IVC reconstruction on Day 3. (A, B) Fluoroscopic images demonstrate abrupt termination of the proximal IVC at the level of the hepatic veins (black arrow). A small remnant of the IVC (white arrow) is now identified at the confluence of the common iliac veins. The dashed lines outline the expected course of the atretic IVC and the length to be reconstructed. (C) Using several recanalisation techniques and after traversing the atretic IVC (black arrow), venography of the right renal vein (white arrow) confirmed that the recanalised vessel was the IVC. (D, E) After extensive venoplasty, intravascular ultrasound evaluation, and deployment of Wallstents in the IVC and common iliac veins, the final venogram demonstrates a patent, fully reconstructed IVC. (F, G) Intravascular ultrasound demonstrates a recanalised IVC with a patent IVC stent (open red arrow) and well apposed kissing iliac stents (solid red arrows) at the inferior aspect.
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On the third day under general anaesthesia and with the patient in the supine position, venography of the proximal intrahepatic IVC was performed via a right internal jugular vein access, demonstrating complete occlusion of the infrahepatic and distal intrahepatic IVC (Fig. 4A). Venography was performed at the confluence of the CIVs via bilateral common femoral vein access, revealing a small remnant of the IVC (Fig. 4B). The right renal vein was catheterised and venography was performed, confirming that the recanalised vessel was the IVC (Fig. 4C). The IVC end of the 18 mm Wallstents was dilated to 14 mm and the common iliac end was dilated to 16 mm (Fig. 4D and E). Final venography and IVUS demonstrated a widely patent reconstructed IVC with good wall apposition of the stents (Fig. 4F and G).
Post-procedural CT venogram images at one month. Representative axial images (A-D) and coronal image (E) at the iliac veins (A), distal IVC (B), renal IVC (C), and intrahepatic IVC (D) demonstrate patency of the kissing 18 mm Wallstents and 24 mm Wallstent, which are free of thrombus.
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At the one month clinic visit, CT venography demonstrated a patent reconstructed IVC and bilateral iliac veins (Fig. 5, Supplemental Video 1).