Refractory Iliofemoral Venous Thrombosis in the Setting of May-Thurner Syndrome as the Presenting Symptom of Behcet's Disease
Chien Yi M. Png, Sameer Lakha, MD, Windsor Ting, MD.
Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Objective(s):We report a patient presenting with acute DVT whose initial treatment outcome was adversely affected by the concurrent presence of May Thurner syndrome and the long term outcome adversely influenced by undiagnosed Behcet's Disease.
Methods:A 19-year-old male presented to an outside hospital with three days of back pain and left leg swelling without any precipitating factor. Doppler ultrasound showed acute DVT and he was started on low-molecular weight heparin. Five days later, he was transferred to our institution due to a lack of symptomatic improvement. Venogram demonstrated acute thrombosis from the proximal left common iliac vein to the common femoral vein. Imaging also demonstrated pelvic collaterals, suggesting an additional chronic stenosis. Intravascular ultrasound confirmed a left common iliac vein stenosis consistent with May-Thurner syndrome. Catheter-based pharmaco-mechanical thrombolysis and thrombectomy were performed but unsuccessful in reduction of the thrombus load. After 24 hours of tPA infusion, repeat venography showed persistent thrombosis in the left common iliac vein to the proximal common femoral vein. Pharmaco-mechanical thrombolysis and thrombectomy were repeated, following which a 18mm x 90mm Wallstent (Boston Scientific) was deployed across the stenosis at the proximal common iliac vein. An additional 48 hours of tPA infusion was administered. Subsequent venography showed significant patent flow through the left iliac veins without collaterals. The patient was discharged on rivaroxaban.
Results:Five months later, the patient returned to the ED with left calf pain. In the interim, he had been diagnosed with Behcet's Disease based on the presence of oral ulcers and genital skin lesions, and treated with prednisone, colchicine and azathioprine. Intraoperative IVUS and venogram revealed thrombotic occlusion of the previously placed stent. ( ) Overnight tPA infusion into the stent and subsequent pharmaco-mechanical thrombectomy restored flow through the left iliac veins. Preoperative laboratory workup revealed subtherapeutic azathioprine dosing, and after appropriate adjustment, his iliac veins have remained patent and he has been asymptomatic for over 12 months.
Conclusions:Satisfactory inflow and outflow are essential for success in catheter thrombolysis. A precipitating etiology should be considered whenever a patient presents with acute DVT.
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