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 64-year-old male patient had been treated by HD in the last 5 years via right brachiocephalic fistula (BCF). He presented with gradually increasing painful swelling of the right upper limb, a sign of VH. He was evaluated with CT angiography and documented to have right internal jugular vein (IJV) stenosis with extensive collaterals in upper limb [].\nUnder all aseptic precautions, right IJV access was secured with 7 Fr sheaths. 5 Fr KMP catheter was used to negotiate across the IJV stenosis over a guide wire. A 10 mm × 40 mm balloon dilator was deployed across the stenosis and dilatation done. 14 mm × 40 mm self-expandable stent was passed across the stenosis. Poststent check angiogram revealed few collaterals still persisting around the stenotic site []. The AVF was cannulated via radial artery and fistulogram done revealing multiple stenosis along the whole length of the cephalic vein which were dilated sequentially from central to the peripheral. The venogram revealed persistent stenosis in IJV proximal to the level of the stent already in situ. Another 14 mm × 40 mm self-expandable stent was deployed proximal to the first one and final check angiogram revealed good direct flow in central vein []. AE of the peripheral collaterals near the anastomotic site was also done to give a further advantage.