ABSTRACT: Inferior vena cava (IVC) thrombosis can present progressively with symptoms of leg pain, swelling, ulcer formation, and impaired quality of life. The presence of an IVC filter is an independent risk factor for IVC thrombus formation. We present a clinical case of chronic IVC occlusion in the setting of prior IVC filter placement that was successfully crossed using a novel device and ultimately treated with stent angioplasty. 

VASCULAR DISEASE MANAGEMENT 2017;14(4):E106-E109.
Key words: chronic deep vein thrombosis, inferior vena cava, venous occlusion, post-thrombotic syndrome, venous angioplasty, IVC filter, chronic total occlusion, Wingman catheter

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Inferior vena cava (IVC) thrombosis is a rare but clinically relevant disease process that is frequently underdiagnosed.¹ Occlusive IVC disease can present acutely or chronically with a diversity of symptoms. Acute manifestations are similar to acute deep vein thrombosis (DVT); ie, leg pain, heaviness, swelling, and cramping. Conversely, chronic venous occlusions are generally indolent in nature and can have delayed presentations. Chronic venous outflow obstruction can lead to venous hypertension, skin ulceration, post-thrombotic syndrome (PTS), and limb loss from venous gangrene.^2-4 Symptoms of PTS consist of persistent leg pain, swelling, heaviness, skin changes, and ulcerations, which significantly impair quality of life and decrease life expectancy.¹ Numerous studies have demonstrated a reduction in the development of PTS by providing early treatment and preventing recurrent thrombotic events.⁵  

In spite of their various presentations, both acute and chronic venous occlusive disease share common etiologies, such as inherited and acquired thrombophilia, external compression (May-Thurner’s syndrome), idiopathic, and iatrogenic causes. During the veno-occlusive process, conversion from a soft thrombus to fibrotic lesion may occur as early as 2 weeks.⁴ Over time, the lesion can become calcific, increasing the complexity and difficulty in crossing a chronic total occlusion (CTO) lesion. In the peripheral arterial circulation, 20% of CTO endovascular revascularization attempts end in failure due to difficulty in crossing the lesion.⁶ Fortunately, advances in technology have aided the operator in offering more extensive endovascular treatment options as first-line therapy in complex veno-occlusive disease.⁷ Herein, we describe the case of a 65-year-old female with PTS as a result of chronic venous outflow obstruction and thrombosis of the iliocaval venous system likely related to the presence of an IVC filter. The CTO lesion was successfully crossed using the Wingman crossing catheter (Atrium Maquet Getinge) followed by definitive treatment with stent angioplasty.

Case Report

A 65-year-old female with history of unprovoked DVT in the left popliteal vein 15 years ago, chronic venous stasis skin changes of both legs, and morbid obesity was seen for evaluation of gradually worsening bilateral leg edema with associated pain. She was previously on warfarin therapy for her DVT until last year, when anticoagulation was interrupted for removal of her lap-band, which was causing gastric obstruction. Prior to interruption of her anticoagulation, she underwent IVC filter implantation. After her surgery, coumadin was discontinued indefinitely.

Her evaluation included venous Doppler ultrasound, which demonstrated right external iliac and common femoral vein occlusive DVT. She was restarted on warfarin therapy and prescribed graded (15-20 mm Hg) compression stockings. After 8 weeks of therapy, she was evaluated with repeat ultrasound study, which showed persistent occlusive DVT. Clinically, she was CEAP (clinical, etiology, anatomy, pathophysiology) class 4 (Figure 1), and continued to experience bilateral lower-extremity discomfort with edema. Based on her persistent symptoms, which were refractory to conservative measures, she was brought to the endovascular lab for venogram. 

Bilateral common femoral vein access was obtained with insertion of 6 Fr sheaths. Selective right external iliac venogram demonstrated 100% occlusive disease of the distal right external iliac vein with an extensive pelvic collateral network (Figure 2). Selective left external iliac venogram showed 100% occlusive disease involving the distal left common iliac vein extending into the IVC and involving the previously placed IVC filter (Figure 3). Collaterals were noted to communicate above the level of the IVC filter. A stiff-angled glidewire with a 0.35˝ support catheter was initially used from the left common femoral vein to partially cross the occluded left common iliac vein segment; however, it failed to progress further. A Wingman catheter was then used to successfully cross the left common iliac vein into the IVC and IVC filter (Figure 4). The glidewire was then advanced above the IVC filter into the IVC, with intraluminal position confirmed by contrast injection. The Wingman catheter with glidewire was then used to successfully cross the occluded right external/common iliac vein and IVC into the IVC filter. The glidewire was again advanced above the IVC filter. Simultaneous kissing-balloon inflations were then performed in the IVC using two 6 x 150 mm balloons. Further balloon dilations were performed in each iliac vein. Intravascular ultrasound was used for accurate measurement of the IVC and iliac veins. Two 14 x 80 mm Protégé self-expanding stents (Medtronic) were simultaneously deployed in a “double-barrel” fashion in the IVC (through the IVC filter) extending into the common iliac veins. The left limb was further extended using 14 x 80 mm and 14 x 40 mm Protégé stents in the left common iliac vein. The right limb was extended with a 14 x 60 mm Protégé stent and a 12 x 60 mm Epic stent (Boston Scientific) into the right external iliac vein. All stents were postdilated with 8 mm balloons. Final venogram demonstrated patent iliac veins and inferior vena cava with brisk flow (Figure 5). The patient was discharged home the following day on aspirin, clopidogrel, and warfarin.

Discussion

Therapeutic options for chronic venous obstructive disease include conservative measures such as leg elevation, elastic compressive devices, compression pumps, analgesics, and chronic anticoagulation. However, when these options fail to resolve symptoms, invasive therapies are often pursued. Depending on the timing of clot formation and the composition of thrombus (soft versus fibrotic), general therapies revolve around thrombolysis with clot extraction and balloon/stent angioplasty. Catheter-directed thrombolysis (CDT) with an infusion catheter or Ekos catheter (BTG International) and pharmacomechanical catheter-directed thrombolysis (PCDT) utilize the infusion of a thrombolytic agent, typically alteplase, to dissipate thrombus. Further removal of thrombus during PCDT may be accomplished with rheolytic thrombectomy using the AngioJet device (Boston Scientific).⁸ Stent angioplasty is often required in the presence of chronic, fibrotic, veno-occlusive disease with good long-term results. Iliocaval stenting has proven safe, with a cumulative patency rate ranging from 90% to 100% and 74% to 89% for non-thrombotic and post-thrombotic disease, respectively, at 3 to 5 years.⁹ Stent angioplasty across a thrombotically occluded IVC filter has also proven safe, without an increase in morbidity and mortality.¹⁰ These invasive measures help prevent the recurrence of thrombus, improve PTS, heal venous ulcers, and improve quality of life.¹¹ 

In the clinical case presented, successful stent angioplasty of the IVC, bilateral common iliac veins, and right external iliac vein was significantly aided by the use of the Wingman crossing catheter. The Wingman catheter is an over-the-wire extendable-tip crossing catheter with a stainless-steel blade (Figure 6).¹² Designed to cross peripheral arterial CTOs, the blade on the Wingman crossing catheter can be advanced, retracted, or rotated to penetrate the proximal cap of vessel occlusions. Once an intraluminal channel is created, the blade is retracted and the catheter follows the wire as a support catheter.⁶

Conclusion

Iliocaval stent angioplasty is a safe and effective method of managing chronic obstructive disease to relieve symptoms and improve PTS. Innovative tools such as the Wingman catheter may aid in successfully crossing CTOs. IVC filter thrombosis remains an underdiagnosed condition; therefore, a high clinical suspicion for the disease process is warranted in patients with a history of IVC filter placement.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted January 16, 2017, provisional acceptance given March 1, 2017, final version accepted March 4, 2017.

Address for correspondence: Vincent Varghese, DO, Deborah Heart and Lung Center, Division of Endovascular Medicine, Browns Mills, NJ 08015. Email: Varghese178@yahoo.com

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