A 64-year-old male presented with right-sided weakness and CT head confirmed a haemorrhagic stroke in the left basal ganglia. On admission, he was recruited into the CLOTS trial, a multicenter randomised control trial assessing the use of intermittent pneumatic compression (IPC) in immobile stroke patients. A baseline ultrasound (US) Doppler scan of his lower extremities on day 2 post-stroke showed no thrombus and IPC was commenced.\nA follow-up US Doppler scan was conducted on day 10 post-stroke, as per trial protocol. Although the patient was asymptomatic, the US showed non-occlusive thrombi within the right common femoral and superficial femoral veins, with occlusive thrombi in the right popliteal and calf veins. There was no evidence of thrombus in the left leg. Anticoagulation and thrombolysis were contraindicated due to the recent haemorrhagic stroke, so a decision was made to insert a Günther Tulip® Vena Cava filter (Cook Medical, IA). The procedure was performed the following day, via an uncomplicated right femoral approach.\nA repeat US Doppler on day 30 post-stroke showed extension of the thrombus into the iliac veins bilaterally, and into the IVC. Long-term pharmacological anticoagulation was initiated, but the IVC filter was left in situ due to the extent of the thrombosis.\nOver the following year, the patient was lost to follow up. He re-presented 18 months later with features of PTS - including extensive swelling and oedema of his right leg extending up to his groin, pigmentation changes, venous eczema and active ulceration affecting his right lower calf and lateral thigh (). His left calf demonstrated pigmentation changes, but no swelling. He scored 20/30 points using the Revised Venous Clinical Severity Score. Examination further revealed prominent dilated tortuous superficial abdominal veins. The swelling of his right leg caused him excruciating pain, which compounded his residual mobility issues post-stroke, and rendered him wheelchair bound.
A 45-year-old male patient, formerly hypertensive, who had been involved in an automobile accident 17 years previously, was diagnosed with hemothorax and underwent thoracotomy and tracheostomy. He remained in the intensive care unit for 105 days, during which period he was given nephrotoxic antibiotics, and developed chronic renal failure. He had a brachiocephalic AVF in the left arm, which developed increased flow after 10 years, with ulcers on the fourth and fifth fingers and dorsum of the left hand (\n), causing pain that limited manual activities.\nVascular Doppler ultrasonography of the AVF showed a patent anastomosis. Arterial flow was normal from the brachial artery to the radial and ulnar arteries () and flow direction, systolic and diastolic velocity, resistance indices and other echographic features were all incompatible with venous access steal syndrome.\nThe diagnosis made according to clinical signs and supplementary echographic details was therefore venous hypertension due to occlusion of the vein in the arm providing return (the cephalic) and overdevelopment of the descending collateral (). The AVF flow diverted through the collateral branch was 446 mL/min, reaching 2,763 mL/min at the level of the wrist ().\nHaving detected the complication in course, the patient underwent an examination with mapping to detect the best site to construct a new AVF, which was a superficialized right brachiobasilic fistula. The patient continued receiving dialysis via the AVF in the left upper limb until the new AVF had matured, and it was not necessary to insert a catheter.\nAfter maturation of the AVF, the tributary in the left limb was ligated and sectioned at the most proximal point possible (in the elbow). Edema had improved and the finger ulcers started to heal within 1 week of the operation. The patient returned to the clinic in the second week, with the ulcers already healed. At follow-up, 2 months after discharge, function in the left hand had already been recovered (). The right brachiobasilic fistula had good thrill and flow during hemodialysis, and only a darker coloration of the right limb remained.