Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity Santiago Herrera,

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Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity Santiago Herrera, MD, Anthony J. Comerota, MD, FACS, FACC, Subhash Thakur, MD, Shiraz Sunderji, MD, Robert DiSalle, MD, Sahira N. Kazanjian, MD, Zakaria Assi, MD Journal of Vascular Surgery Volume 59, Issue 2, Pages 456-464 (February 2014) DOI: 10.1016/j.jvs.2013.07.108 Copyright © 2014 Terms and Conditions

Fig 1 A 24-year-old patient, 32 weeks pregnant, presented with a 2-week history of left iliofemoral deep venous thrombosis (DVT) causing severe pain and swelling of her left leg, unresponsive to low-molecular-weight heparin (LMWH) and leg elevation. Venography revealed iliofemoral DVT from the proximal femoral vein and common femoral vein to the vena cava. A, Ascending venogram shows the thrombosed proximal femoral and common femoral veins and (B and C) a patent vena cava with compression by a gravid uterus. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions

Fig 2 The patient underwent isolated, segmental, pharmacomechanical thrombolysis (PMT) with the Trellis catheter (Covidien, Mansfield, Mass), which removed a large bulk of the thrombus and restored patency to the iliac and common femoral veins. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions

Fig 3 Residual thrombus in the femoral vein was treated overnight with the ultrasound-accelerated EkoSonic thrombolytic system (EKOS Corp, Bothell, Wash) infusing 1-mg recombinant tissue plasminogen activator (rt-PA) per hour. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions

Fig 4 Repeat venography demonstrated a patent iliac system but (A) segmental continued segmental obstruction of the proximal femoral vein. Venoplasty resulted in recoil. A recommendation was made for operative venous thrombectomy. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions

Fig 5 Operative exposure revealed a markedly inflamed and thickened vein wall measuring 4 mm in thickness (A). B, Following removal of the adherent thrombus, a bovine pericardial patch was used to close the venotomy and the patient was maintained on heparin via a catheter in her popliteal vein and returned to the intensive care unit. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions

Fig 6 Repeat venography on postoperative day 2 showed reocclusion of her femoral and common femoral veins. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions

Fig 7 The femoral and common femoral segments underwent rheolytic thrombectomy and were dilated to 10 mm with a residual high-grade stenosis refractory to balloon dilation. Two overlapping stent grafts (10 × 60; 10 × 40) were placed that did not cross the inguinal ligament. Stent grafts were chosen because of the marked inflammatory changes in the femoral veins, anticipating that the inflammation would more rapidly subside if blood was not in contact with the vein wall. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions

Fig 8 The following morning, the patient underwent her fourth and final venogram, confirming patency. The patient subsequently did well without post-thrombotic signs or symptoms. She had a second child 2 years later and was treated with low-molecular-weight heparin (LMWH) throughout pregnancy. She is now a long-distance runner competing in marathons. She continues to demonstrate patent veins with normal valve function. Journal of Vascular Surgery 2014 59, 456-464DOI: (10.1016/j.jvs.2013.07.108) Copyright © 2014 Terms and Conditions