28-year-old female admitted with acute-onset left lower extremity swelling and pain. Ultrasound demonstrates occlusive thrombus extending from the left common iliac vein through the calf veins. VIR consulted for DVT catheter-directed thrombolysis.
Initial venogram
Extensive thrombus throughout the left superficial femoral vein into the pelvis.
post-lysis image 1
A 135 x 50 cm infusion length thrombolysis catheter was placed and positioned within the femoral vein extending to the iliocaval bifurcation. Overnight lysis was performed and a repeat venogram (left image) was performed demonstrating resolution of femoral thrombus.
post-lysis image 2
A pelvic venogram performed after overnight lysis demonstrates significant reduction in iliac thrombus, however with residual chronic thrombus and/or stenosis involving the common iliac vein.
Post-lysis image 3
Intravascular ultrasound (IVUS) was performed, which demonstrated the presence of a severe stenosis of the left common iliac vein due to mass effect from the crossing right common iliac artery. This finding is diagnostic of a May-Thurner lesion, which was the underlying anatomic abnormality predisposing this young patient to an extensive DVT.
post-lysis image 4
Given the residual stenosis within the common iliac vein following thrombolysis, the decision was made to place a stent as this has been shown to be the most durable long-term management approach to patients with May-Thurner syndrome. The final venogram demonstrates optimal positioning of the stent and no residual stenosis. The patient was completely asymptomatic within 48 hours of the procedure.