Combined Mechanical and Pharmacological Thrombolysis for Iliofemoral DVT presenting as Phlegmasia Cerulea Dolens

Contact Email:  mark_davies@urmc.rochester.edu

A 60 yr. old female presented with an acutely swollen, painful, blue-colored leg to the emergency. She stated it felt weaker than the other leg. There was no history of injury deep venous thrombosis or malignancy. On examination the leg was swollen cyanotic and has diminished power and decreased arterial pulses.

Duplex imaging and a CT scan in the emergency room demonstrated extensive deep venous thrombosis extending from the popliteal vein to the left iliac vein (Figure 1). A diagnosis of Phlegmasia Cerulea Dolens was made.

The patient underwent a venogram from the ipsilateral popliteal approach, which confirmed an extensive iliofemoral DVT. A combined mechanical and chemical thrombolysis intervention was planned. A rheolytic catheter (AngioJet, Possis Medical Inc, Minneapolis, MN) was passed through the clot in a power pulse spray mode (its outflow valve turned off and a 5mg/100ml tPA solution infusate) in orer to locally lyse and mascerate the clot. Thereafter the system was returned to its normal set up and 750mls of solution was used to angiojet the ilio-femoral DVT over five passages of the rheolytic catheter (Figure 2).

A 6mm and then a 10mm angioplasty balloon were used to angioplasty the common iliac vein. 80% of clot burden was removed and TIMI-2 flow was restored (Figure 2). The patient's leg was markedly improved after debulking of the clot. An infusion catheter was positioned in the iliac venous system and 1mg/hr of tPA was infused for 18 hrs.

On return to the angiography suite, repeat venography showed TIMI-2/3 flow and 90% clot lysis. A significant stenosis was identified in the common iliac vein consistent with the May-Thurner syndrome (Figure 3). A 14mmx40mm Wallstent was placed and post ballooned in position with restoration of TIMI-3 flow and the absence of collateral vein opacification (Figure 3).

The final technical result was excellent (Figure 3). The patient made an uneventful recovery. She was placed on oral anticoagulation for 3 months. Hypercoagulation and malignancy screens were negative. At six and twelve months, the patient was asymptomatic and duplex imaging confirmed a patent iliac vein stent and a patent venous system. Endovascular therapy utilizing combined mechanical and chemical thrombolysis is a successful approach for phlegmasia cerulea dolens.

	Fig. 1 The initial CT scan images with duplex ultrasound images as inserts of the patient on presentation. Panels A and B shows the CT scan cross-section of the left common iliac vein (A) and the Doppler tracing from the venous duplex scan reveals no flow (B). Panels C and D shows the CT scan cross-section of the left common femoral vein (A) and Left popliteal vein (B) with their associated Doppler tracing from the venous duplex scan
	Fig. 2 The left iliac vein views from the initial venogram after the vein has been power pulsed sprayed with tPA using a rheolytic catheter which demonstrates significant improvement in clot burden compared to Fig 1A. Panel B shows an 3 Fr tPA infusion catheter (MITI) positioned within the residual clot burden in the left common iliac vein
	Fig. 3 Venogram images of the left iliac vein after 18 hrs of tPA infusion (A). A stenosis remains after successful lysis of the clot burden with evidence of collateral formation (A, arrow). A wall stent is placed and the completion venogram shows a widely patent left common iliac vein and no collaterals evident (B, arrow). Panel C shows the wall stent in position on plain X-Ray and Panel D a color flow duplex of the left common iliac vein 6 months after the procedure.