O caminho das pedras no diagnóstico e tratamento da síndrome obstrutiva ilíaca venosa crônica / Best practices in diagnosis and treatment of chronic iliac vein obstruction

Resumo A obstrução venosa ilíaca ocorre em 20% a 30% da população. Nos portadores de insuficiência venosa crônica grave, essa prevalência é ainda maior, podendo chegar a 50% a 90% dos pacientes, situação em que essa obstrução é investigada pelo ultrassom intravascular. Métodos diagnósticos menos invasivos, como o Doppler vascular, ou mesmo invasivos, como a flebografia, podem falhar em seu diagnóstico. O tratamento endovascular dessas obstruções tem se demonstrado eficaz, seguro e associado a excelente resultado clínico e de perviedade, desde que princípios anatômicos e técnicos fundamentais sejam considerados e aplicados.

Abstract Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

Surgical Thrombectomy, Fibrinolysis, Angioplasty and Stenting: A Combined Approach for Treatment of a May-Thurner Syndrome Presenting as Phlegmasia Cerulea Dolens.

INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a rare complication of deep venous thrombosis (DVT). Massive ileo-femoral DVT is usually the cause and prompt treatment is mandatory as it represents a medical emergency. Reported amputation rates range from 12% to 25% and mortality ranges from 25% to 40%. Limb ischemia results from obstruction to arterial inflow secondary to extreme levels of venous hypertension. Primary treatment goal is restoration of venous outflow and can be achieved by endovascular or surgical techniques. After thrombus removal an underlying iliac vein stenosis may be present. May-Thurner syndrome, a condition where the left common iliac vein is compressed by the right iliac artery, is the most prevelant iliac stenotic lesion. METHODS: We report a case of a 57 years-old male, smoker, with no significant medical history, who presented to the emergency department with excruciating sudden left limb pain and swelling, with no trauma history, with a 2-hour onset. On physical examination he showed significant edema, purplish discoloration of the entire leg and absent dorsalis pedis artery pulse. RESULTS: Hipocoagulation with intravenous heparin was immediately initiated and emergent surgical venous thrombectomy was performed associated with direct intravenous fibrinolytic agent injection. Postprocedure phlebography showed a left common iliac vein lesion which was treated with angioplasty and venous stent placement. Pain, edema and coloration improved markedly after procedure without any complications. The patient was discharged home with anticoagulation treatment and compression stocking. CONCLUSION: Endovascular approaches such as catheter-directed thrombolysis (CDT) or pharmacomecanical thrombolysis (PMT) are becoming the treatment of choice to achieve venous outflow in DVT. In cases of PCD, when rapid restauration of venous outflow is mandatory, CDT has the disadvantage of having a long mean treatment time. This way, surgical thrombectomy still plays an important role in cases of PCD, especially if PMT is not available. In our case, the combined used of surgical thrombectomy with direct intravenous thrombolytic infusion provided effective treatment of PCD and uncovered an underlying left common iliac vein stenosis, which was successfully managed by angioplasty and stenting.

Anticoagulant Therapy in a Pregnant Woman with May-Thurner Syndrome.

A 39-year-old woman with a 9-week abdominal pregnancy noted pain in her lower abdomen and left leg. Since successive thrombi were observed extending from the left common iliac vein to the popliteal vein along with a thrombus in the left pulmonary artery, we diagnosed her with pulmonary thromboembolism with deep venous thrombosis (DVT). May-Thurner syndrome may have contributed to DVT in the left leg when the left iliac vein was compressed by the right iliac artery. She underwent anticoagulant therapy with heparin, followed by the subcutaneous injection of heparin at home after discharge. We herein report the case of a pregnant woman with May-Thurner syndrome who safely gave birth.

Combined catheter-directed thrombolysis and iliac vein recanalization for iliac vein compression syndrome with secondary acute deep vein thrombosis: effectiveness and long-term outcome.

BACKGROUND: The aim of this paper was to evaluate the effectiveness and long-term outcome of combined catheter-directed thrombolysis (CDT) and iliac vein recanalization in management of iliac vein compression syndrome (IVCS) with secondary acute deep vein thrombosis (DVT). METHODS: From January 2006 to February 2014, consecutive patients with IVCS and secondary acute DVT were treated with combined CDT and iliac vein recanalization. Data on technical success, clinical success, and follow-up were analyzed respectively. RESULTS: A total of 55 patients were included in this retrospective study. Technical success was achieved in all patients. The filter was placed in 24 patients and all filters were successfully retrieved after treatment. The total dose of urokinase ranged from 1.6×106 to 6.6×106 units (mean, 3.72±0.13×106 units). The thrombus were totally dissolved in all patients. The iliac venous stents were placed in 7 patients. Clinical success was achieved in all patients. During the follow-up of 6-103 months (mean, 35.87±27.86 months), eight patients experienced the recurrence of DVT 1-39 months (mean, 13.13±12.25 months) after treatment. The cumulative 1-, 3-, and 6-year primary patency rates were 88.5, 85.3 and 80.0%, respectively. The cumulative 1-, 3-, and 6-year secondary patency rates were 98.0, 94.2, and 88.7%, respectively. At univariate and multivariate analysis, the independent predictor of recurrence of DVT was INR<2 after treatment. CONCLUSION: Combined CDT and iliac vein recanalization could provide a favorable effectiveness and long-term outcome for patients with IVCS and secondary acute DVT.

CT venography for deep venous thrombosis: can it predict catheter-directed thrombolysis prognosis in patients with iliac vein compression syndrome?

To evaluate the prognostic value of CT venography for catheter-directed thrombolysis (CDT) in iliac vein compression syndrome (IVCS) patients with deep venous thrombosis (DVT). The institutional review board approved this retrospective study and waived informed consent. Among the 201 consecutive patients treated in our interventional suite for DVT from January 2001 to June 2013, 48 IVCS patients (12 men, 36 women) who underwent pre-procedural CT venography, CDT with stenting, and follow-up imaging were analyzed. To identify possible determinants of 6-month patency, CT venography was evaluated with Fisher's exact test and logistic regression analyses. Based on the analyses, image-based criteria were established and compared to the current symptom duration-based approach by receiver-operating-characteristic curve analyses and the McNemar test. Recoiling of external iliac vein (EIV) diameter (<120 %) [hazard ratio (HR) 28.652, p = .007] and severe rim enhancement (HR 20.545, p = .016) were significant risk factors for venous occlusion within 6 months of CDT. The dual-parameter image-based criteria were significantly superior to the current symptom duration-based approach in terms of area under the curve value (p = .010) and predictive accuracy (p = .031). With a 2-point cut-off, the proposed criteria demonstrated a 66.7 % sensitivity, 100.0 % specificity, and 92.9 % predictive accuracy for identifying non-responders of CDT. CT venography may be useful in assessing CDT prognoses in IVCS patients, particularly to identify non-responders who demonstrate recoiling of EIV diameter and rim enhancement on CT venography.

An unusual presentation of May-Thurner syndrome in a pediatric patient with a pelvic kidney.

We report a case of an adolescent who presented with a deep vein thrombosis (DVT) and clinical findings consistent with May-Thurner Syndrome. Specific imaging demonstrated direct compression of the left common iliac vein by an overlying pelvic kidney. The patient's history and clinical presentation is detailed. The discussion focuses on the potential implications for care and management of a patient with an ectopic left pelvic kidney.