Excerpt

A 69-year-old woman without a history of venous thromboembolism was admitted to our hospital with a chief compliant of a red swollen left lower extremity that persisted for 3 months. Doppler ultrasound revealed occlusive thrombi from the left popliteal vein to the common iliac vein and computed tomographic venography revealed suspected iliac vein compression syndrome (May-Thurner syndrome; MTS). Diagnosed as subacute deep vein thrombosis (DVT), she received oral anticoagulation with rivaroxaban, an oral factor Xa inhibitor, 15 mg twice daily for 5 days (Day 0–4). Given that the degree of the symptoms was remarkable, suggesting the presence of insufficient collateral flow and acute-on-chronic DVT factors, we decided to perform a catheter-directed thrombolysis (CDT). After placement of an inferior vena cava filter, intravascular ultrasound (IVUS) confirmed the diagnosis of MTS. CDT via the left saphenous vein (Day 4) and that via the left popliteal vein 3 days later (Day 7) using an infusion catheter (5-Fr Fountain catheter, Merit Medical, South Jordan, Utah) with a continuous infusion of urokinase (240,000 IU per day) and oral anticoagulation with rivaroxaban (15 mg once daily) did not improve her symptoms sufficiently. Although venography (Day 11) confirmed sufficient inflow from the left femoral vein, venography and IVUS revealed a lot of organized thrombi in the iliac vein, and a subsequent venous thrombectomy was performed (Fig. 1a). A 22-Fr DrySeal sheath (W. L. Gore, Flagstaff, Arizona) was placed in the left femoral vein without a skin incision, and a successful thrombectomy using a 4-Fr Fogarty balloon catheter (Edwards Lifesciences, Irvine, California) was performed (Fig. 1b, c). Despite being on anticoagulation therapy, complete hemostasis was achieved by manual compression for 20 min after removing the sheath, followed by one stitch suture and 5-h gauze compression. There were no access-site complications such as an arteriovenous fistula. After oral anticoagulation with rivaroxaban (15 mg twice daily) for 3 days, venography (Day 14) revealed the successful revascularization of the iliac vein without a stent implantation (Fig. 1d), and the filter was removed. Her symptoms were completely relieved without any recurrence within 30-days.

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