A 48-year-old woman with underlying diseases of primary antiphospholipid syndrome, presented with abdominal pain and left leg swelling for weeks. Physical exam showed diffuse abdominal tenderness without muscle guarding or rebounding pain, bilateral lower extremities pitting edema (3+), especially left leg.

Abdomen CT (with/without contrast) revealed IVC to bilateral iliac vein thrombosis. No abdominal/pelvic tumor was noted.

Via left popliteal venous access, venography showed abundant thrombus formation, from left popliteal vein up to IVC.

After venography, EKOS catheter was inserted via left popliteal vein, positioned from left femoral vein to IVC. No IVC filter large enough to fit proximal IVC was available, so IVC filter was not implanted. Urokinase (bolus 120000U, maintenance 60000U/hr) was given via infusion catheter. Heparinization via peripheral IV line was also administered. In the following days, patient reported markedly improvement of abdominal pain and appetite. Follow-up venography showed partial resolution of thrombus over IVC to left femoral vein.Balloon angioplasty (8mm, 10mm) was done, then infusion catheter (Fountain,4Fr, 40cm) was placed over IVC to left femoral vein for 4 more days. Final venography showed patent IVC and femoral vein flow. Symptoms resolved completely,no pulmonary embolism or major bleeding was reported.

•      EKOS provides a effective,promising treatment for IVC thrombosis•      Without IVC filter protection,risk of pulmonary embolism during CDT should be considered and discussedthoroughly•      Before EKOS implantation,recanalization of deep vein thrombus using balloon angioplasty may be an optionto enhance and accelerate the contact of thrombolytic agent and thrombus