Endovascular reconstruction of an interrupted inferior vena cava
A 65-year old female was referred to our institution with an infected painful chronic right lower limb venous ulcer. The ulcer had been present for 8 months, with periods of infective exacerbations, where no complete healing was achieved despite appropriate limb compression and wound therapies. The right lower limb revealed typical chronic venous changes with near circumferential ulceration just proximal to the ankle. She had a past history of left-sided deep venous thrombosis and recurrent pulmonary embolism post partum in her late twenties, for which she received an IVC plication clip as an open surgical procedure. She went on to develop bilateral lower limb venous insufficiency and had presented 3 years prior with left leg venous ulceration. At this time venography demonstrated a left common iliac vein (CIV) occlusion, presumed to be due to May Thurner's syndrome, but the plicated IVC was not noticed. At that time she was successfully managed with a Cook Zilver stent (Cook, Bloomingdale, IN, USA) to revascularise the occluded iliac vein along with the adjuncts of split skin grafting to the ulcer and long term bilateral compression therapy.\nA CT venogram (A) demonstrated in stent stenosis of the Zilver stent and a narrowing of the proximal right CIV. The plication clip appeared to be reducing the IVC lumen to 2–3 mm in diameter. Digital Subtraction Venography (B and C) confirmed a severe stenosis of the right CIV ostium with a large filling defect in the proximal portion of the CIV stent. Lateral projections revealed a pin hole stenosis of the IVC, approximately 4 cm proximal to the iliocaval confluence, presumably due to the encircling clip.\nThe patient was taken to theatre where bilateral antegrade 7 FG (Cordis Corp, Johnson and Johnson, Bridgewater, NJ, USA) common femoral venous sheaths were placed. The stenoses were crossed with a Van Schie 2 (Cook Medical, Bloomington, IN, USA) catheter and an .035 Terumo angled stiff glidewire (Terumo Medical, Somerset, NJ, USA), which was then exchanged for a stiff type Amplatz wire (Cook Medical, Bloomington, IN, USA). The caval stenosis was predilated using two kissing 10 mm × 40 mm Fox PTA balloons (Abbott Vascular, Illinois, USA). The right Amplatz wire was pulled back into the iliac vein and the left sheath exchanged for a short 12 FG sheath (Cordis Corp, Johnson and Johnson, Bridgewater, NJ, USA). A Palmaz balloon expandable stent (Cordis Corp, Johnson and Johnson, Bridgewater, NJ, USA) was placed on a 20 mm balloon into the stenosed IVC and inflated, ensuring enough distal clearance from the iliocaval confluence. The right amplatz wire was then placed through the Palmaz stent and bilateral 14 mm × 140 mm Vena Zilver stents (Cook Medical, Bloomington, IN, USA) were ‘kissed’ into the Palmaz stent. These were post dilated with 14 mm × 40 mm Fox PTA balloon (Abbott Vascular, Illinois, USA). Final venography did not demonstrate any residual stenosis of the iliocaval confluence, nor of the cava itself ().\nThe patient made an uneventful post-operative recovery, with significant improvement in her lower limb pain. She was later taken back to theatre to place a split skin graft over the venous ulceration. Oral anticoagulation was continued and she was discharged home after a 4-week stay in hospital with all wounds healed. Follow up duplex ultrasound at 4 weeks post discharge demonstrated patency of the stents with no evidence of restenosis.