ILIOCAVAL

RECONSTRUCTION
IN A PATIENT WITH HEREDITARY HEMORRHAGIC
TELANGIECTASIA
Fellow: Saba Gilani, MD
Attendings: Ian J. Wilson, MD; David L. Waldman
MD, FSIR
Program/Dept: Vascular and Interventional
Radiology, University of Rochester

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation
57 year old female with history of hereditary hemorrhagic telangiectasia
(HHT) with recurrent epistaxis, prior history of stroke, and known
pulmonary AVMs admitted with headache, worsening confusion, back
pain, and bilateral leg swelling.
VIR was consulted for possible venous thrombolysis.

RELEVANT HISTORY
Past Medical History
HHT
manifesting with recurrent epistaxis
multiple pulmonary AVMs
Patent foramen ovale
Pulmonary Embolism
prior IVC filter placement
CVA
HTN, DM, hypercholesterolemia,
hypothyroidism
Past Surgical History
Cauterization for epistaxis

Family & Social History

Both parents and 2 sisters with HTN.
2 deceased brothers sudden death from
brain bleed.
Former smoker (quit 2006)
Review of Systems
positive for headache, back pain, leg
swelling
negative for chest pain, SOB
Medications
Levothyroxine, lisinopril, simvastatin
Allergies
NSAIDs - contraindicated

DIAGNOSTIC WORKUP
Physical Exam

Positive for skin telangiectasias, severe bilateral lower extremity leg swelling with edema, patchy
areas of reddish discoloration, and blistering.

Laboratory Data

INR 1.2, PTT 43.3, Platelets 88

CK 27498

Non-Invasive Imaging
CT head: acute on chronic right frontoparietal infarct.
CTA chest: showed segmental pulmonary embolus and multiple bilateral AVMs
(largest measuring 1.3 cm).
Doppler US of the lower extremities: thrombus from the calf veins to the common
femoral veins bilaterally.

DIAGNOSIS
Extensive deep venous thrombus with developing post
thrombotic syndrome and phlegmasia cerulea dolens.

CLINICAL QUESTION
1) What is post thrombotic syndrome (PTS)?
A: CVA following DVT.
B: Chronic pain and swelling following DVT.
C: Venous sinus thrombosis following DVT.
D: None of the above.

CORRECT!
1) What is post thrombotic syndrome (PTS)?
A: CVA following DVT.
B: Chronic pain and swelling following DVT. PTS is a constellation of
debilitating lower extremity symptoms following DVT including leg swelling,
pain, edema, discoloration.
C: Venous sinus thrombosis following DVT.
D: None of the above.

CONTINUE WITH CASE

SORRY, THATS INCORRECT!

1) What is post thrombotic syndrome (PTS)?
A: CVA following DVT.
B: Chronic pain and swelling following DVT. PTS is a constellation of
debilitating lower extremity symptoms following DVT including leg swelling,
pain, edema, discoloration.
C: Venous sinus thrombosis following DVT.
D: None of the above.

CONTINUE WITH CASE

TREATMENT QUESTION
2) What are the treatment options for symptomatic iliocaval DVT?
A: Mechanical thrombectomy.
B: Pharmacologic thrombolysis.
C: Pharmacomechanical thrombolysis.
D: All of the above.

CORRECT!
2) What are the treatment options for symptomatic iliocaval DVT?
A: Mechanical thrombectomy. Yes, can use devices such as Angiojet or Trellis.
B: Pharmacologic thrombolysis. Yes, can use catheter directed tPA infusion
therapy.
C: Pharmacomechanical thrombolysis. Yes, can use Angiojet with tPA.
D: All of the above.

CONTINUE WITH CASE

SORRY, THATS INCORRECT!

2) What are the treatment options for symptomatic iliocaval DVT?
A: Mechanical thrombectomy. Yes, can use devices such as Angiojet or Trellis.
B: Pharmacologic thrombolysis. Yes, can use catheter directed tPA infusion
therapy.
C: Pharmacomechanical thrombolysis. Yes, can use Angiojet with tPA.
D: All of the above.

CONTINUE WITH CASE

INTERVENTION
Venous thrombolysis contraindicated due to CVA, pulmonary AVM/PFO.
Mechanical thrombectomy offered to help diminish clot burden.

INTERVENTION: DAY 1
Venogram demonstrating multiple
filling defects in the bilateral
common iliac veins and near
complete occlusion of the distal IVC.
An IVC filter is noted (circle).

INTERVENTION: DAY 1 (CONT.)

Post venous angioplasty and
thrombectomy venogram
demonstrated minimally increased
patency of the IVC and bilateral
common iliac veins.
Access into the common femoral
veins could not be obtained
bilaterally.
Dialysis catheter was placed.
Treatment was limited due to
contraindication for catheter
directed thrombolysis overnight.
Percutaneous transluminal venous angioplasty
of the common iliac veins and distal IVC was
performed. This was followed by mechanical
thrombectomy using Angiojet.

INTERVENTION: DAY 2
Pre-Intervention Angiograms

Post-Intervention Angiograms

Patient returned to IR for repeat intervention, this time with access distal to the
bilateral common femoral veins was achieved and extensive thrombus, left greater than
right, was seen.
This was treated with percutaneous angioplasty and mechanical thrombectomy.

INTERVENTION: DAY 3
A
B

A: Cavagram demonstrating
increased patency of the IVC.
B: A suprarenal IVC filter was
placed (red circle).
C: The old IVC filter was
removed using wire-loop-snare
technique (arrow).

INTERVENTION: DAY 3 (CONT.)

Repeat percutaneous angioplasty and
mechanical thrombectomy of the distal
IVC, bilateral common iliac, common
femoral, and superficial femoral veins
was performed.
This was supplemented by mechanical
thrombolysis from the common iliac vein
to the popliteal vein bilaterally using
Angiojet with tPA in pulse spray mode
during which the patient developed
epistaxsis.

INTERVENTION: DAY 3 (CONT.)

A

A: After thrombolysis, iliocaval

reconstruction was performed using
10 mm self expanding stents.
B: Post stent deployment venogram
demonstrated significantly increased
patency in the IVC and bilateral
common iliac veins.

QUESTION SLIDE
3) What type of filter did this patient have?
A: Birds Nest.
B: Greenfield.
C: TrapEase.
D: G2.

CORRECT!
3) What type of filter did this patient have?
A. Birds Nest.
B: Greenfield.
C: TrapEase. Permanent filter; high rate of thrombosis (25.2 %, Kalva SP, et al.
2006)
D: G2.

CONTINUE WITH CASE

SORRY, THATS INCORRECT!

3) What type of filter did this patient have?
A. Birds Nest.
B: Greenfield.
C: TrapEase. Permanent filter; high rate of thrombosis (25.2 %, Kalva SP, et al.
2006)
D: G2.

CONTINUE WITH CASE

QUESTION SLIDE
4) What is the most common complication of IVC filters?
A. Occlusion.
B: Migration.
C: Fracture.
D: IVC penetration.

CORRECT!
4) What is the most common complication of IVC filters?
A: Occlusion. Long term studies estimate 13-30% rates of IVC thrombosis after
filter placement attributable to three factors: 1. thrombogenicity of the
filter, 2. trapped embolus from a distal source, 3. cephalad extension of
distal DVT.
B: Migration.
C: Fracture.
D: IVC penetration.

CONTINUE WITH CASE

SORRY, THATS INCORRECT!

4) What is the most common complication of IVC filters?
A: Occlusion. Long term studies estimate 13-30% rates of IVC thrombosis after
filter placement attributable to three factors: 1. thrombogenicity of the
filter, 2. trapped embolus from a distal source, 3. cephalad extension of
distal DVT.
B: Migration.
C: Fracture.
D: IVC penetration.

CONTINUE WITH CASE

CLINICAL FOLLOW UP
Patient returned to the MICU, was extubated, and had decreased lower
extremity swelling over time.
She developed acute renal failure requiring dialysis.
Bivalirudin (specific and reversible direct thrombin inhibitor) was used for
anticoagulation.
She began receiving inpatient physical therapy and was able to ambulate 8
days post IR procedure.
22 days post procedure lower extremity doppler US demonstrated resolved
lower extremity thrombus.

SUMMARY & TEACHING POINTS

A 57 year old female with HHT developed extensive iliocaval thrombus with
manifestations of post thrombotic syndrome. Her management was
complicated by the presence of a thrombogenic IVC filter and the inability
to anticoagulate due to acute CVA, recurrent epistaxsis, and multiple
pulmonary AVMs.
Mechanical thrombectomy without thrombolytics may have limited value
when there is a large clot burden.
Iliocaval reconstruction can result in successful venous recanalization and
may prevent the progression of post thrombotic syndrome.

REFERENCES & FURTHER READING

Kalva SP, et al. TrapEase vena cava filter: experience in 751 patients. J Endovasc Ther.
2006 Jun;13(3):365-72.
Nayak L, et al. Postthrombotic Syndrome: Feasibility of a Strategy of Imaging-
guided Endovascular Intervention. JVIR. 23(9):1165 1173.
Patel RT, et al. Endovascular treatment of iliocaval DVT. Endovascular Today. 2013
Sept: 36-43.
Williams DM. Iliocaval reconstruction in chronic deep vein thrombosis. Tech Vasc
Interv Radiol. 2014 Jun;17(2):109-13.