Is Intravascular Ultrasound Underutilized in the Management of Deep Vein Thrombosis?

Purpose: To present a case of right lower extremity deep venous thrombosis (DVT) in the setting of May-Thurner–like anatomy

Materials and Methods: A 59-year-old man with no known past medical history presented to our hospital with a 2-day history of right lower extremity pain and swelling. He had traveled to Europe 7 weeks prior and had no recent surgery, immobilization, or prior history of thrombotic events. In the emergency department, he was hemodynamically stable. Doppler ultrasound of the lower extremity revealed extensive thrombosis involving the entire right femoral vein, popliteal vein, and profunda femoris vein.

Results: The patient was experiencing right lower extremity pain at rest and ambulation. A venogram revealed extensive clot extending from the right popliteal vein into the right external iliac vein. Thrombectomy was performed using a Inari ClotTriever device. After thrombectomy, venogram revealed nearly 0% residual clot. Intravascular ultrasound (IVUS) revealed 83% stenosis of the right external iliac vein with compression by the right external iliac artery. Hence, a 16- ´ 90-mm self-expanding stent was deployed at the right external iliac vein with excellent venographic results with a brisk flow. The patient was started on dual antiplatelet therapy with aspirin and clopidogrel and a novel oral anticoagulating agent with rivaroxaban.

Conclusions: Although the incidence of DVT is not precisely known, it is reported by the Centers for Disease Control and Prevention that as many as 900,000 people could be affected each year alone in the United States, with an estimated death toll of 100,000 patients per year because of a DVT or pulmonary embolism (PE). An estimated 33% of people with DVT or PE will have a recurrence within 10 years. Based on Virchow’s triad, patients are at the highest risk of thrombosis if they have stasis, vessel wall injury, and hypercoagulable state. Stasis is often overlooked in the workup of a DVT, despite the fact that one third of the general population has May-Thurner–like anatomy. Breaking this component of the triad could prevent the recurrence of DVTs. The advent of IVUS provides an important diagnostic tool in the identification of these anatomical defects. If these defects can be identified by IVUS early in the course of the DVT, then this can lead to clot retrieval and venous stent placement and ultimately lead to a lower rate of recurrence of DVT and PE.