A 66-year-old female presented to the emergency department with three days of acute LLE swelling, pain, cyanosis, inability to bear weight, dyspnea, and hypoxemia (Figure ). She denied recent travel, hormone replacement, or a history of DVT/pulmonary embolism (PE). Her medical history was notable for systemic lupus erythematosus, CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome, Sjogren’s syndrome, and local invasive anal squamous cell carcinoma. Doppler ultrasound revealed LLE thrombus extending from the greater saphenous vein to the popliteal vein. She was admitted to the intensive care unit (ICU) and started on an unfractionated heparin drip.\nThe vascular surgery team was consulted for surgical intervention. After further review of her case, the vascular surgery team elected for an endovascular approach with CDT of LLE. Initial venogram demonstrated extensive clotting of the tibial, popliteal, and femoral venous systems extending into the iliac system (Figures , ). From a tibial approach, a guidewire was advanced up to the common iliac, but a chronic occlusion of the left common iliac vein was found, which could not be crossed. A venous collateral circulation system in communication with the right iliac venous system was identified. In order to decrease the overall clot burden, two 50-cm EKOS endovascular catheters were placed in the left external iliac vein and collateral system. Repeat venogram at 24 hours post-CDT showed significant improvement of the overall clot burden with almost complete resolution of the clot in the LLE; however, the chronic occlusion remained (Figure ). A 20 x 80 mm Boston Scientific Wallstent™ (endoprosthesis stent) was advanced across the total chronic total occlusion and deployed. Post-operative venogram demonstrated significant improvement in flow in the system, with all flow going through the iliac system, and no flow further through the previously seen collaterals. Intravascular ultrasound was advanced through the area, which showed severe compression of the stent. A 12x 40 mm Atlas® dilatation catheter (Bard Peripheral Vascular Inc., Tempe, AZ, USA) was used for angioplasty. Repeat intravascular ultrasound showed persistent compression of the area. A 8 x 40 mm Boston Scientific Mustang™ dilatation catheter (high-pressure balloon) was used to re-attempt angioplasty; however, compression was still noted (Figure ). Regardless, outflow improved throughout the left common iliac system, and no further interventions were performed. The patient returned to the ICU and transitioned to direct oral anticoagulation without any further complications. She was subsequently transferred to a medicine ward for further care.
A 64-year-old man with a history of obesity (BMI 38 Kg/m^2), arterial hypertension, atrial fibrillation, type 2 diabetes, chronic kidney disease, obstructive sleep apnea, and chronic venous insufficiency presented to the Emergency Department complaining of dyspnea, fever, and chest pain which started 7 days before. The patient was hypoxemic in room air (SpO2 80% and PaO2 43 mmHg). Inferior limbs appeared normal. A molecular swab formalized diagnosis of SARS-CoV2-related pneumonia. Respiratory distress progressed despite non-invasive-ventilation and hemodynamic instability requiring vasoactive support ensued. The patient was intubated and transferred to the ICU. The patient received invasive protective ventilation and hemodynamic support with noradrenaline. Gas exchange progressively worsened to a PaO2/FiO2 ratio of 70 mmHg. He developed a shock, and his lower limbs started to appear mottled. Lung and cardiac ultrasound were compatible with severe interstitial pneumonia and with no signs of pressure overload of the right heart. His coagulation profile was highly altered, as both aPTT and INR were elevated (respectively 2.28 seconds and 6.42), platelets were 164,000/mm3, and D-dimer was 117,521 UI/ml. Coagulation parameters continually worsened (), and treatment with one unit of fresh frozen plasma and vitamin K was required. Inferior limbs’ color progressively worsened, becoming frankly cyanotic, while pulses were still normal. Doppler ultrasound showed bilateral thrombosis of tibial and small saphenous veins. A continuous infusion of iloprost was started, as PCD was suspected (). Continuous infusion of unfractionated heparin was instituted, at a dose of 500-1000 IU per hour, according to aPTT, as well as continuous veno-venous hemodiafiltration as the patient developed acute kidney injury. The patient’s general conditions worsened (), and despite maximal treatment, he passed away after eight days of ICU care.