DVT Case Study 4

Right Common Femoral with Pseudoaneurysm

Background

A 55 year-old male presented with right leg groin swelling and pain three days after a cardiac catheterization procedure. The patient had a medical history of idiopathic pulmonary fibrosis and pending lung transplantation. Venous duplex revealed a right common femoral vein pseudoaneurysm and an acute external ilio-femoral DVT (Fig. 1). The patient was referred to Vascular Surgery for endovascular treatment and subsequent patient management. The right common femoral vein pseudoaneurysm was treated with ultrasound-guided thrombin injection. The patient was then scheduled for isolated pharmacomechanical thrombolysis of the external iliac DVT. 

Procedure

A temporary vena cava filter was placed with the patient in the supine position. Then the patient was placed prone on the operating room table. IV sedation was initiated and continued throughout the procedure. The right popliteal vein was accessed using ultrasound guidance and an 8 Fr introducer sheath was inserted. Venography revealed thrombus in the right common femoral vein (Fig. 2). Isolated thrombolysis using the Trellis-8, a pharmacomechanical infusion catheter, was initiated. After two Trellis runs infusing a total of 12mg of t-PA and thrombus aspiration, the Trellis catheter was removed. Venography revealed complete thrombus removal with a residual 90% common femoral vein (CFV) stenosis.

Balloon angioplasty of the CFV was then performed with excellent results (Fig. 3).  The patient was transported to the recovery room in stable condition. Duplex ultrasound performed the following morning revealed a patent CFV with no residual pseudoaneurysm or thrombus (Fig. 4). The patient was discharged from the hospital on anticoagulation therapy.

Conclusion

The patient was seen in a follow-up visit one week after treatment. Duplex ultrasound revealed a patent CFV without thrombus, but a recurrent CFV pseudoaneurysm. The treatment plan included discontinuing the anticoagulation, as the patient had an indwelling IVC filter. Re-treatment of the pseudoaneurysm with thrombin injection was scheduled in the upcoming week.

Discussion

Isolated pharmacomechanical thrombolysis using the Trellis-8 catheter, along with adjunctive angioplasty restored venous patency in this patient’s right CFV in a single-setting treatment. Symptomatic relief was immediate and the vessel remained thrombus free in follow-up visits.

Courtesy of Arnold Babar, MD, Tahoe Hospital, Tahoe City, Ca.

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