A 75-year-old male presented at our emergency department with painful swelling of his left leg for 12 hours without prior trauma history (). He also complained of numbness and weakness of the left lower leg and foot. His medical history was notable for hypertension and hyperlipidemia. On physical examination, the entire leg showed purplish discolorization and left femoral and dorsalis pedis artery pulses were detectable by hand-held Doppler. Duplex ultrasound (DUS) revealed left ilio-femoro-popliteal DVT (). Intravenous heparin was immediately administered and an emergent venous thrombectomy was performed under local anesthesia (), which provided pain relief. The next day, the left leg color was normalized () and motor and sensory defects were fully recovered. Anticoagulation therapy was prescribed for 6 months and follow-up computed tomography (CT) at 6 months revealed no residual thrombus ().
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.