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Phlegmasia Cerulea Dolens: A Complication of Filter Use in the Vena Cava and Successful Treatment With Ultrasound-Assisted, Catheter-Directed Thrombolysis (Video 5)
Case
A 78-year-old male presented to our facility with a previous history of right lower-extremity deep venous thrombosis and pulmonary embolism 10 years prior. At that time, the patient had a negative workup for a hypercoagulable condition and was treated with coumadin for 6 months. In 2010, the patient had another episode in his right lower extremity while travelling. At that time, to prevent pulmonary embolism, the patient had a VenaTech LP permanent vena cava filter placement (B. Braun Interventional Systems, Inc.) and was again started on anticoagulation (Figure 1).
This patient presented to our facility with an acute onset of lower abdominal pain and severe pain, swelling, cyanosis, and edema of bilateral lower extremities consistent with phlegmasia cerulea dolens. The patient had returned from a 10-hour flight from Alaska 1 day earlier and had not been on anticoagulation for several months. The initial venous ultrasound showed extensive deep venous thrombosis in bilateral lower extremities.
The patient was taken to the cardiac catheterization laboratory. Two accesses were obtained in the bilateral posterior tibial veins using 5 French (Fr) Terumo Radial Glidesheath Slender Introducer Sheaths. The initial venogram showed extensive deep venous thrombosis in bilateral lower extremities (Figure 2; Videos 1-2). The Glidewire crossed easily into the IVC from the left posterior tibial vein; however, due to extensive scarring of the right below-the-knee veins from the previous occurrences of deep venous thrombosis, it was difficult to cross from the right posterior tibial vein. A third access was obtained in the right common femoral vein. The venogram showed complete occlusion of the IVC filter, with the clot extending into the renal veins (Figure 3; Videos 3-4).
Two EKOS catheters (EndoWave Infusion Catheter System, EKOS Corporation) were deployed through the left posterior tibial vein and the right common femoral vein, respectively (Figure 4; Video 5).
