Chronic IVC occlusion causing venous claudication and ulcers requires treatment

The patient is a gentleman from out of state who had called about problems he was having with walking and with leg ulcers that wouldn’t heal. He is in his seventies and has a pacemaker for an arrhythmia for which he was on Xarelto. He also had type II diabetes. He had bilateral lower extremity deep venous thromboses 6 years prior requiring IVC filter placement. The filter occluded, and it resulted in sudden sharp and debilitating pain in both legs with walking short distances -some days only 50 paces.He described it as an unbearable pain in calves and thighs that felt like his legs were going to burst. He also had ulcers on his legs that would heal with ministration but soon recur. This was all despite being quite active, with regular workouts, and being fit. He was compliant with compression. He sent a CT scan done last year (below).

Annotated R iliocaval Centerline Preop CT.jpg
Right iliocaval centerline projection

It showed an Optease retrievable vena cava filter that was occluded and the iliac systems bilaterally (right above and left below) were chronically occluded with patent vena cava above and femoral confluences bilaterally below.

Annotated L iliocaval Centerline Preop CT.jpg
Left iliocaval system showing chronic occlusion on centerline projection

He had no hypercoagulability nor ongoing recent DVT’s. I thought there was a good chance that we would be able to recanalize the occluded iliocaval segment and he flew in for a consultation, and he was pencilled into the schedule ahead of his visit.

Examination revealed a fit and trim man in his 70’s in no apparent distress. He had bilateral leg edema that was moderate with small superficial and tender ulcers of the right posterior distal calf. Pulses were normal. He was taken to our hybrid suite and venography from femoral vein access in the proximal thigh in the supine position revealed his right and left iliac venous systems to be occluded (below figures).

right initial venogram
Right injection from femoral sheath showing occluded iliac vein with collaterals
left initial venogram.png
Left injection

Wire access into the iliac systems was performed with Glidewire and Glidecatheter periodic venography to confirm that I had not exited the vein. Unlike the arterial system, extravasation from being extravenous does not have the consequence of bleeding, hematoma development, and pseudoaneurysm formation because of the low pressure, but it can be a long procedure and uncomfortable as well so these are done under general anesthesia.

intervention fig 1.png
Advancing wire and sheath into iliac vein, crossing filter resulted in extravasation of contrast

Once position confirmed to be in the iliac vein, the vein was dilated to allow for greater ease of movement. In the case of the uncrossable filter, I switched to access from above via a right internal jugular vein access.

intervention fig 2.png
Dilating vein (left) for greater mobility, and crossing from above (R. IJV access)

Once the wire crossed into the iliac vein from above, it was captured and brought out. While ballooning by itself is inadequate for revascularization, it greatly eases wire capture and on the right, it was done simply by driving the wire from above into the sheath. Wire capture wins access across the iliocaval and IVC filter occlusion from below.

intervention fig 3.png
Wire passage across IVC filter into right and left systems

Once wire access is done, ballooning across the filter is done from both sides. A large sheath is them delivered across the IVC filter. Finally, a Palmaz stent mounted on a large balloon is delivered and deployed. I chose to do this from the right access, and retracted the wire on the left -something done with some trepidation because of the great difficulty gaining this access, but with with prior balloon dilatation, reaccess is made easier. Also, plan B would be reaccess from above.

intervention fig 4.png
After balloon dilatation of occlusion typically to 8mm from both sides, a sheath placed and Palmaz stent deployed across filter on a large 24mm balloon

When this is accomplished, the left sided wire is reaccessed across this stent. This is the venous side analogue to gate access in EVAR (below).

intervention fig 5.png
Reaccess of the left iliac venous wire across Palmaz stent

Once this is done, the iliac veins are dilated to 14mm from the IVC to the common femoral arteries. large 18mm Wall stents are deployed in a kissing fashion from the caval stent into both iliac systems and dilated to 18mm.

intervention fig 6.png
Predilatation of iliac venous systems with ever larger balloons, deployement of bilateral 18mm Wall Stents

After deployment, the Wall Stents are ballooned to 18mm. These stents were extended into the common femoral artery with 14mm nitinol stents.

intervention fig 7.png
Ballooning 18 mm Wall Stents with 18mm Atlas balloons, then extending to CFA with nitinol stents of 14mm

Completion venography suggested successful iliocaval recanalization and revascularization but these procedures are not done without a final intravascular ultrasound (IVUS).

Looks done, but needed final intervention after IVUS.

Intravascular ultrasound revealed incomplete expansion of the right common femoral stent. This was treated with another stent and ballooning with the result on the right.

Stent compression on IVUS treated with second stent

Venography alone is insufficient in determining patency. As illustrated, IVUS ensures a durable outcome.

The leg ulcer was treated with an Unna’s boot. A word about the venerable Unna’s boot –it works. The dressing dries and compresses while the Zinc Oxide prevents bacterial growth. It is interesting that the dressing is so infrequently used nowadays but not so when you consider that it isn’t reimbursed. And patients generally hate it.

This revascularization has an excellent chance at working as the patient has no hypercoagulability and had a patent common femoral confluence bilaterally. As I had mentioned in a prior post, the idea in venous revascularization is connecting confluences that serve as inflow and outflow.


This will require followup, consisting of duplex, and it is advantageous that he is anticoagulated for his arrhythmia. It is becoming more apparent that those languishing with chronic venous insufficiency and its complications need the IVC and iliac veins interrogated with a duplex. When an obstruction is found, they should be treated with these techniques as a first line therapy.


IVC Filter Migration Causing Acute Abdominal Pain

CT IVC migration_1

The patient had a carotid dissection over five years prior to presentation and had a stroke and DVT. To protect her from pulmonary embolism, an IVC filter was placed, she was anticoagulated for a while. She rehabilitated and was doing well when several months prior to consultation she developed severe upper abdominal pain that occurred intermittently without triggers. She underwent a workup which included laboratory testing and endoscopy which were negative, and a CT scan showing the IVC filter had tilted and the legs had eroded through the vena cava to abut the duodenum and abdominal aorta. No other pathology could be found and after discussion operative resection was planned.

3DVR planning

As mentioned in an earlier post, 3DVR image processing has become indispensable in planning not only aortic interventions but open surgery as well. An oblique incision was created, basically a high transplant incision, and we stayed in the retroperitoneum. The leg of the filter abutting the duodenum did not penetrate it and there was no leakage of bile. The end of the leg, of which there are two types on this filter, was in the vena cava, but the side had eroded out of the cava. Control of the IVC is always treacherous because of the fragile lumbar tributaries underneath the cava. Once heparinized and clamped, a longitudinal venotomy released the filter. The head was embedded in the cava wall and would not have been easily accessible with a snare.

removing filter

The tine that was headed towards the aorta had to be removed from the filter to manipulate it out. No bleeding was noted from the aorta.

exvivo filter

This is my fifth operative removal of an IVC filter that had eroded into adjacent organs. Recently I removed a filter which had eroded into the aorta -this required a pledgetted suture. In my first case, about 7 years ago, a filter placed in a teen, the victim of polytrauma due to an MVA, caused fevers and an upper GI hemorrhage which was diagnosed on upper endoscopy -somewhere I have a great picture of an IVC filter leg in the duodenum.

Which brings me to my last point. The guidelines for placing these filters has evolved and it is clear now that they are not as benign as once thought. They are not only associated with migration but also iliocaval thrombosis. Stenting across them can push the legs out into organs. Their migration into the retroperitoneum can cause an atypical abdominal pain syndrome -in this patient, the pain was immediately gone. If placed, plan should be made for removal if feasible, anticoagulation maintained if possible, and filter choice limited to those that have long track records.

The treatment of venous thromboembolism remains primarily pharmacologic. When the indication for the filter expires, the filter should be removed unless the risks of removal exceed the risks of leaving it in.