MJV

The patient is a 49-year-old female without known co-morbidities who sought consult due to entire left leg pain aggravated by walking and relieved by rest that started three days prior to admission and became persistent.Past medical history: Previous deep venous thrombosis of the left leg treated with an unrecalled blood thinner.On examination, the left leg was overtly larger than the right with tenderness of the thigh and calf area. Peripheral arterial pulses were full.

Venous Compression Test of the lower extremities showed:Extensive acute deep vein thrombosis totally occluding the left common iliac, proximal external iliac, distal external iliac, common femoral, femoral, deep femoral, popliteal and gastrocnemius veins.
Venous Phase of Abdominal Aorta CT scan showed:Compression of the left common iliac vein by the right common iliac artery consistent with May-Thurner syndrome with secondary acute thrombophlebitis in the left common iliac vein and tributaries

The left common iliac vein to left external iliac vein showed venous stasis with high thrombus burden and approximately 70-80% at the mid segment of the left common iliac vein.

First, an IVC Filter was positioned and deployed at the infra-renal inferior vena cava and implanted at the L2-L3 level through a right femoral vein access.

Several attempts to advance an introducer wire and guiding catheter were done with difficulty due to the thrombus-filled left common iliac vein. Hence, ultrasound-guided access to the left femoral vein was made. The V18 guidewire was then inserted and advanced up to the left common iliac vein. An IMA 6F guiding catheter was then inserted over the wire and advanced into the right common femoral vein. The V18 wire was then ensared using a makeshift snare that was made from another V18 wire and the JR4 catheter which was used as the shaft. Both the IMA catheter and V18 wire were pulled into the right vascular sheath and wire countertraction was done, forming a body floss which was used as a rail for the Rotarex catheter. Mechanical thrombectomy of the left common iliac to the left external iliac vein was then done using a Straub Medical/BD Rotarex 6F mechanical atherectomy catheter. The left common iliac to external iliac vein was then visualized which showed a thrombus-filled vessel severe and severe stenosis (70-80%) at the mid left common iliac vein. Then, a Medtronic Protege self-expanding stent was then deployed at the left common iliac vein followed by another self-expanding stent at the mid left common iliac vein overlapping the distal edge of the first stent. Repeat thrombectomy was then done inside the deployed stents.

The case report shows that mechanical thrombectomy using Rotarex System may be an effective therapeutic maneuver for managing extensive thrombosis in May-Thurner Syndrome and inserting an IVC filter for this purpose is intuitive to decrease the chances of complications from escaped emboli. Furthermore, a 'body floss' from two V18 guidewires can be created and seems to be effective to be used as rails for the Rotarex System especially when encountering a left common iliac vein thrombus that is difficult to penetrate. Lastly, self-expanding stents provide greater radial strength and may be ideal for May-Thurner Syndrome Common Iliac Vein compression.