Clinical Images

Angioplasty of CTO of Entire Length of Inferior Vena Cava and Bilateral Iliac Veins

Rajeev Bhardwaj, MD, DM;  Anupam Jogta, MD;  Malay Sarkar, MD

Rajeev Bhardwaj, MD, DM;  Anupam Jogta, MD;  Malay Sarkar, MD

J INVASIVE CARDIOL 2019;31(6):E155-E156.

Key words: angioplasty, balloon, inferior vena cava

A 48-year-old male presented with swelling in the left lower limb that had progressed slowly over a period of 8 years. Treatment obtained from a local hospital provided no relief. After 1 year, swelling in the right lower limb also appeared. He was diagnosed with chronic kidney disease and put on medical treatment, with no improvement. For the past year, he was unable to walk more than few steps because of marked lower limb swelling.

Nephrology exam showed normal blood parameters except for renal function tests. Computed tomography of the kidneys revealed prominent veins over the abdomen and Doppler exam revealed bilateral deep vein thrombosis extending the entire length of the inferior vena cava (IVC) (Figure 1). He was put on anticoagulants and referred to us.

We performed right femoral vein puncture with contrast through the sheath. There was evidence of thrombus in the iliacs and the IVC was not visualized (Figure 2).Through right femoral sheath, we started manipulating a Terumo wire through the iliac veins. A Judkin’s right catheter was used to support the wire. The superior vena cava (SVC) was reached after slow wire manipulation for ~2 hours. Tandem dilations with 7 mm balloons were started from the external iliac to the uppermost part of the IVC. We then tried to exchange the 10 Fr sheath, but it would not cross the femoral vein; thus, we dilated the puncture site with a 7 mm balloon and introduced a 10 Fr sheath. Tandem dilations with 10 mm and then 14 mm balloons were performed throughout the vessel. Next, we dilated the IVC with an 18 mm balloon. Some portions were very difficult to dilate, and the patient had severe pain. After deflating and reinflating the balloon, we could dilate the entire IVC segment and right common and external iliac veins and achieved good flow. We then approached via left side and were able to cross the wire up to the SVC in ~1 hour. We dilated the iliacs with 7 mm, 10 mm, and then 14 mm balloons and achieved good flow on the left side. Stent implantation was foregone due to financial considerations.

The patient tolerated the procedure well and swelling in the limbs disappeared in 2 days. Prominent abdominal veins disappeared. He was put on antiplatelet therapy and oral anticoagulants, with overlap of low-molecular-weight heparin and discharged after 5 days. Renal function normalized on follow-up after 1 month and he continues to do well 4 years later.

From the Department of Cardiology, Radiology and Pulmonary Medicine, Indira Gandhi Medical College, Shimla, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted February 11, 2019.

Address for correspondence: Dr Rajeev Bhardwaj, House no 24, Block 3, US Club, Shimla 171001, India. Email: