Diagnosis and management of right external iliac vein “sandwich”: A rare cause of iliofemoral deep venous thrombosis Elizabeth Tai, MD, PhD, Arash Jaberi,

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Diagnosis and management of right external iliac vein “sandwich”: A rare cause of iliofemoral deep venous thrombosis Elizabeth Tai, MD, PhD, Arash Jaberi, MD, MEd, George D. Oreopoulos, MD, MSc, Thomas L. Forbes, MD, Kong Teng Tan, MD, Sebastian Mafeld, MBBS Journal of Vascular Surgery Cases and Innovative Techniques Volume 5, Issue 3, Pages 314-318 (September 2019) DOI: 10.1016/j.jvscit.2019.02.006 Copyright © 2019 The Authors Terms and Conditions

Fig 1 Duplex venous ultrasound images on presentation to the emergency department. A, Occlusive thrombus is noted in the right common femoral vein with intraluminal echoes and noncompressibility of the right common femoral vein. B, Intraluminal echoes with no venous waveform or filling of the right common femoral vein on spectral Doppler compatible with occlusive thrombus. C, Anechoic, noncompressible right popliteal vein compatible with acute thrombus. D, Occlusive thrombus in the right external iliac vein. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 314-318DOI: (10.1016/j.jvscit.2019.02.006) Copyright © 2019 The Authors Terms and Conditions

Fig 2 Contrast-enhanced computed tomography (CT) of the abdomen and pelvis. The arrows demarcate the position of the right external iliac artery (black arrow), right internal iliac artery (gray curved arrow), and right external iliac vein (block arrow). A, Axial portal venous phase image of the pelvis demonstrating compression of the right external iliac vein between the right internal and external iliac arteries. B, Coronal portal venous phase image demonstrating compression of the right external iliac vein between the right internal and external iliac arteries. C, Coronal maximum intensity projection image demonstrating compression of the right external iliac vein between the bifurcation of the right internal and external iliac arteries. D, Reconstructed image demonstrating compression of the right external iliac vein between the bifurcation of the right internal and external iliac arteries. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 314-318DOI: (10.1016/j.jvscit.2019.02.006) Copyright © 2019 The Authors Terms and Conditions

Fig 3 Venography images demonstrating diagnosis and management of the deep venous thrombosis (DVT) and vascular compression. A, There is a meniscus sign and expansion of the vein in the right proximal femoral vein/distal external iliac vein in keeping with thrombus. B, After 1 day of catheter-directed thrombolysis (CDT), thrombus remains in the right proximal femoral vein/distal external iliac vein. Note that in the proximal external iliac vein, there is a stenosis compatible with the area of vascular stenosis identified on computed tomography (CT; arrow). C, Insertion of a 16-mm × 6-cm self-expanding Zilver Vena venous stent in the region of the venous stenosis. D, After 2 days of catheter-directed thrombosis in addition to mechanical thrombectomy using the AngioJet Solent Omni catheter, there is a significant reduction in the volume of clot in the right proximal femoral vein/distal external iliac vein with small burden of residual clot. There is also improved flow in the deep venous system to the central veins. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 314-318DOI: (10.1016/j.jvscit.2019.02.006) Copyright © 2019 The Authors Terms and Conditions

Fig 4 Computed tomography (CT) pulmonary angiography for chest pain and heaviness performed 2 months after thrombolysis of deep venous thrombosis (DVT). A, Web (arrow) in the right lower lobe pulmonary artery compatible with chronic pulmonary embolism. B, Web (arrow) in the right lower lobe pulmonary artery as well as in the left lower lobe at the origin of the anteromedial and lateral basal segmental arteries (arrow) in keeping with chronic pulmonary embolism. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 314-318DOI: (10.1016/j.jvscit.2019.02.006) Copyright © 2019 The Authors Terms and Conditions