Use of Advanced Endovascular Techniques for Management of an Iatrogenic Iliac-Vein Injury

Introduction

Major venous injury is a known complication of extensive retroperitoneal surgery. Management of such injuries requires suture repair in some instances. Venous trauma is part of Virchow's triad of factors predisposing patients to deep-vein thrombosis (DVT). A relatively common but significant sequela of DVT is post-thrombotic syndrome (PTS), which complicates ∼20%–50% of symptomatic DVTs. ¹ PTS manifests clinically as a painful, swollen, heavy leg with venous claudication, and leads to significant impairment in quality of life. ² When thrombosis is extensive or the repair has created significant luminal stenosis, there may be a greater likelihood of PTS and, possibly, recurrent thrombosis and pulmonary embolism. This article presents a case of iliac-vein injury complicated by extensive acute postoperative thrombosis that was managed aggressively by thrombectomy, dilation, and stent placement.

Case

A 59-year-old obese female was undergoing surgical staging for a high-grade endometrial carcinoma. During right pelvic lymph-node dissection, a 1-cm laceration occurred along the lateral part of the right external iliac-vein injury ∼2 cm above the inguinal ligament. The laceration was repaired with a 5–0 prolene running suture. Secondary to difficulty with exposure, it was necessary to repair the laceration parallel to the lumen of the vein, creating some apparent luminal compromise. On postoperative day (POD) #2, the patient was noted to have lower-extremity swelling. Evaluation with Doppler imaging revealed occlusive thrombi in the right external iliac; common femoral; greater saphenous; proximal; mid and distal femoral; and peroneal veins and nonocclusive thrombi in the right popliteal and posterior tibial veins. An interventional radiologist was then consulted, and the patient underwent placement of an IVC filter followed by a pharmacomechanical thrombectomy in which tissue plasminogen activator was delivered directly to the site of occlusion followed by a mechanical thrombectomy using the Possis AngioJet system (MEDRAD, Warrendale, PA) until no residual thrombi were noted. Balloon angioplasty was then used to dilate the area of iliac-vein narrowing. Subsequently, extravasation was noted. A self-expanding Viabahn-covered stent (Gore, Flagstaff, AZ) was then placed across the area of extravasation with no residual thrombosis, stenosis, or extravasation noted. The patient did initially require transfusion of 2 units of packed red blood cells postprocedure but responded appropriately and remained hemodynamically stable afterwards. She was discharged from the hospital on POD #7 and placed on therapeutic Lovenox and was switched over to Coumadin as an outpatient.

Results

At her 6-month follow-up, this patient was doing well with no clinical evidence of post-thrombotic syndrome or recurrent thrombosis.

Discussion

Venous thromboembolism and its potential sequelae, including PTS and pulmonary embolism, remain significant medical problems with a high degree of morbidity and mortality. Standard management is systemic anticoagulation therapy.

However, up to 50% of patients treated with anticoagulation alone will have evidence of PTS2 as anticoagulation works via prevention of clot propagation as opposed to removing clots. Furthermore, more centralized DVT confers a much higher risk of developing PTS and pulmonary embolisms. ³

The shortcomings of oral anticoagulation have led to the development of other treatment modalities that focus on clot lysis and removal. These techniques include catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT), and pharmacomechanical thrombolysis. CDT is well-established for treating of symptomatic DVT3, and, according to current guidelines from the American College of Chest Physicians (ACCP) is considered to be a first-line treatment for significant DVT in selected patients. ⁴ According to these recommendations, patients who are considered likely to benefit most from this therapy include individuals with extensive thrombosis with high risk of pulmonary embolism, proximal DVT (iliofemoral or femoral vein), an underlying predisposing anatomic anomaly, life expectancy >1 year, good physiologic reserve, recent onset of symptoms <14 days, and no contraindications to thrombolysis. These same guidelines include two major contraindications to CDT—(1) patients who have undergone recent surgery and (2) those with malignancies—two subgroups of patients that may actually benefit most from treatment. ²

According to current guidelines, thrombolysis is contraindicated in the case reported here. However, the patient was treated with pharmomechanical thrombolysis and had a good clinical outcome. Although this patient did have some bleeding requiring blood transfusions, she did well overall and had no additional complications from the procedure. She remained symptom free-with no evidence of PTS at her 6-month follow-up visit.

The other interesting aspect of this case was the use of angioplasty and endovascular stents on a recently sutured major venotomy. Although use of angioplasty and stent placement are well-described for treating stenosis and DVTs, especially in the presence of abnormal anatomy as the underlying cause, the current authors were unable to find cases in which these techiques were used to treat a stenotic lumen after a recent venous repair. The obvious concern was the potential to tear open the recently repaired defect and cause additional hemorrhage. However, in this woman's case, angioplasty followed by covered stent placement was performed successfully without any major complications.

Conclusions

Recent surgery and malignancy are considered contraindications to CDT under current guidelines. However, the safe use of limited CDT with adjunctive mechanical thrombectomy in this case after recent surgery—a woman with a gynecologic malignancy—suggests consideration of this option in selected similar cases.