May Thurner Syndrome - Endovascular Treatment Utilizing Adjunctive Techniques for Cardiopulmonary Protection and Profunda Femoris Vein Thrombectomy During Percutaneous Mechanical Thrombectomy for a Complete DVT Treatment

With the development of minimally invasive treatment options including the Inari Clotriever, Penumbra, and Angiojet systems, we are seeing a shift in the treatment paradigm for deep venous thrombosis. Through this case, we present our department’s approach to lower extremity deep venous thrombectomy using adjuncts including the Protrieve sheath for cardiopulmonary protection as well as profunda femoris vein thrombectomy for a more complete endovascular treatment of the venous system.

Methods:

36 y.o. female Jehovah’s witness with history of abdominoplasty 1 week prior who presented with significant left lower extremity edema and associated numbness in her forefoot.  A left lower extremity venous duplex and CT Venogram was performed demonstrating iliofemoral deep venous thrombosis with central extension into the IVC.  She was started on anticoagulation with IV heparin and intravenous fluids for volume expansion. May Thurner syndrome was diagnosed, and the patient was offered left lower extremity deep venous embolectomy with plan for intravascular ultrasound, and possibility of balloon angioplasty and stenting to relieve the external compression seen on axial imaging.

Results:

The patient was positioned supine. We accessed the left popliteal vein. Left lower extremity venogram confirmed the extent of the DVT seen on CT venogram.  For cardiopulmonary protection, we accessed the right internal jugular vein and placed an Inari-Protrieve device in the infrarenal IVC. We obtained through-and-through access using an EnSnare and 400cm-Glidewire via the right IJ and left popliteal veins. An Inari-Clotriever sheath was placed in the left popliteal vein. Percutaneous thrombectomy was performed using the Inari-Clotriever device.  We then catheterized the left profunda femoris vein from our right IJ access and performed over-the-wire thrombectomy using an 8-mm balloon. A repeat LLE venogram was performed demonstrating patency of the left iliofemoral veins with filling defects noted in the Protrieve basket.  Thrombus was aspirated from the Protrieve sheath and filtered blood was returned using the FlowSaver system.  Intravascular ultrasound demonstrated severe external compression of the left common iliac vein by the right common iliac artery. A 18x80mm Venovo stent was deployed with central extent 2-3 mm into the IVC. Post-deployment angioplasty was performed.  Completion venograms demonstrated brisk flow through the profunda femoris and iliofemoral veins. Sheaths were removed and access sites were closed. A compression wrap was applied, and she noted significant improvement afterwards. On post-op day 2, she was transitioned to Eliquis and discharged (Figure 1).

Conclusions: Our institutional experience with these adjuncts for a complete lower extremity DVT thrombectomy have allowed for safe extraction of large volumes of thrombus with immediate relieve in venous congestion, while having the safety of cardiopulmonary protection using the Protrieve sheath.