Complex Case Presentations. Complications and Management. Rabih A. Chaer MD Assistant Professor of Surgery Division of Vascular Surgery University of Pittsburgh Medical Center

Rabih A. Chaer, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

CASE 1. HISTORY 55 yo man Presented with calf trauma s/p assault Developed compartment syndrome, required fasciotomy Venous duplex negative for DVT Immobile, open calf wounds

HISTORY PMH: DVT, PE, stroke, Factor V Leiden deficiency. Previously placed IVC filter for PE one year prior DVT pharmacologic prophylaxis held for oozing from surgical site

COURSE Severe bilateral lower extremity swelling noted postop on day 14 Sensory and motor loss with paralyzed lower extremities Heparin anticoagulation initiated Repeat duplex: extensive bilateral LE DVT from tibial veins to bilateral iliac veins Clinical diagnosis of phlegmasia

PHELGMASIA

PARALYSIS? Not a classical presentation of phlegmasia or DVT Literature review

TREATMENT Bilateral popliteal venous access Extensive thrombosis into the filter on initial venogram

Pharmacomechanical Thrombolysis Trellis device

PMT/drip

OUTCOME Phlegmasia resolved immediately after the first session with marked resolution of paralysis DVT and symptom free at one year follow up Acute cauda equina syndrome secondary to iliocaval thrombosis successfully treated with thrombolysis and pharmacomechanical thrombectomy. Go MR, Baril DT, Leers SA, Chaer RA. J Endovasc Ther. 2009 Apr;16(2):233-7.

CASE 2. HISTORY 62 yo woman Spine surgery for herniated disc No history of DVT Not on anticoagulation Prophylactic IVC filer DVT prophylaxis/heparin sc post op day 2

COURSE Severe bilateral lower extremity swelling on day 5 post op Duplex: extensive iliofemoral DVT Started on systemic heparin anticoagulation Progressive deterioration of renal function, normal at baseline Non contrast CT scan

TREATMENT

PMT

Popliteal approach/PMT

CDT/12 HOURS

OUTCOMES Dialysis for 4 weeks via TDC INR 5 on post procedure 5 Surgical site hematoma requiring evacuation Currently dialysis free, normal renal function Follow up duplex: no DVT Perianal numbness, ambulatory

CASE 3. HISTORY 61yoF w/ unprovoked femoral DVT 1 month previously IVC filter placed at OSH for relative contraindication to anticoagulation (diverticular bleeding) Recurrent thrombosis, now in iliofemoral distribution 1 week s/p IVC filter Unsuccessful thrombolysis at OSH: recurrence within one week ?HITT, placed on lepirudin Transferred for further management

WORKUP Hypercoagulable screen Family h/o venous thrombosis Lepirudin continued until increasing Plts Physical exam: significant LLE pain and edema, no phlegmasia, dopplerable signals distally, no ulcerations

Day 1– Lysis Prone positioning Sedation and local Thrombosed popliteal accessed under U/S guidance

Day 1– Lysis

Day 1– Lysis EKOS infusion catheter 40cm 4mg tPA, 2mg via popliteal sheath tPA 0.5mg/hr

18h – Lysis check 8x6mm balloon venoplasty

18h – Lysis check PMT w/ AngioJet tPA 8mg 8mins of thrombectomy mode

CDT: UniFuse infusion catheter 50cm tPA 0.5mg/hr

16h later - Lysis Check

PTA/stent 18x60mm wallstent for focal iliac vein stenosis

Case 4. HISTORY 22 yo man presenting with chest pain and shortness of breath Noted fullness under the right axilla CT chest showed evidence of PE Otherwise healthy

EXAM Swollen RUE. Improving No O2 requirement Heparin anticoagulation Duplex: extensive DVT Working diagnosis: TOS

VENOGRAM

PMT/Trellis

Axillary/brachial aneurysm

18 months follow up Asymptomatic Declines surgery On coumadin