Case presentation Activities of 82 years old daily Life: ok Our - - PowerPoint PPT Presentation

Hybrid treatment with EVT and Surgery for

acute compartment syndrome induced by severe DVT

Nai-Yu Chi / Po-Chao Hsu

Presentor: Nai-Yu Chi From:

Kaoshiung Medical University Hospital, Division of Cardiology

Case presentation

HTN (+)

CKD (-)

CAD /CVA / PAD (-)

Activities of daily Life: ok Male 82 years old

Our Case

Case presentation

• Chief Complaint:

Soreness of left thigh and leg calf for 2 days, then left foot pain, swelling with cyanotic change noted subsequently

Case presentation

• Due to rapid progression of left foot

symptom/sign, the patient was brought to our emergency department for first aid.

• Associated S/S of left foot:

– Left foot pain (+), swelling (+) – numbness (+), paralysis (+) – Cyanosis (+): bilateral leg with significant different color

Case presentation

At our ER:

• Initially acute PAOD was suspected, however,

bilateral leg CT revealed:

– 1) Venous thrombosis involving the inferior vena cava, left common, external & internal iliac veins, common, superficial, deep femoral veins, popliteal vein, and deep veins in the left lower leg. – 2) Soft tissue swelling over left thigh and lower leg. – 3) Atherosclerosis in the abdominal aorta, bilateral common iliac arteries and distal run-off.

May-Thurner Syndrome

http://circ.ahajournals.org/content/133/6/e383

Phlegmasia cerulea dolens

• Phlegmasia cerulea dolens

(literally: painful blue edema)

• An uncommon severe form
• f DVT which results from

extensive thrombotic

• cclusion of the major and

the collateral veins of an extremity.

• Characterized by sudden

severe pain, swelling, cyanosis and edema of the affected limb.

Case presentation

• LAB data at ER:

– WBC: 20770 / ul, CRP: 53 mg/L – D-Dimer: 83.6 mg/L FEU – Cr: 1.72 mg/dL – Lactate: 4.1 m mol/L

• CVS & plasty doctor were consulted

for further treatment strategy.

Emergent fasciotomy was suggested by plasty Dr due to acute compartment syndrome

• Fasciotomy was performed over left leg
• Wound covered with aquacel wet dressing

Case presentation

• Patient was then admitted to SICU for further care.
• After admitted to SICU, profound shock was noted

and vasopressors (levophed and adrenaline) were used for shock status

• Acute kidney injury was also noted

subsequently after profound shock (+) episode  CVVH was performed for acute renal failure with

• liguria and unstable hemodynamic

(Cr: 1.72  2.66  2.78…….  1.01)

• Because thrombectomy was not favored by

CVS Dr, our CV division was consulted for further endovascular treatment (EVT) for left leg severe DVT

Prone position

• r

Supine position

Because left leg acute compartment syndrome post fasciotomy  We decided to use supine position approach for EVT of DVT

Bilateral common femoral vein approach

• Left common femoral vein echo-guide

approach due to DVT

Left venous EVT: Stage 1

Using terumo wire to cross the left leg DVT into IVC Terumo wire successfully enter into IVC

Left venous EVT: Stage 1

Left leg venography showed thrombosis

• ver left venous system

Right venography from right CFV

Left venous EVT: Stage 1

Perform PTA for left common iliac vein to external iliac vein Mild improve of left venous blood flow

Left venous EVT: Stage 1

Crossover V18 wiring from right side into left SFV under CXI support Successfully wiring into left popliteal vein

Left venous EVT: Stage 1

Venography from left distal SFV PTA for left SFV to common iliac vein

Left venous EVT: Stage 1

Improve left venous blood flow However, still significant thrombosis

• ver left venous system

Left venous EVT: Stage 1

Insert fountain catheter from left SFV to common iliac vein for CDT treatment

Left venous EVT: Stage 2

After CDT treatment for 2 days, still lots thrombus (++) After CDT treatment for 2 days, still lots thrombus (++)

Left venous EVT: Stage 2

Further PTA for left common iliac to external iliac vein Improved left venous blood flow

Left venous EVT: Stage 2

Wall stent (16 x 90mm ) implantation for left common iliac to external iliac vein & post dilatation for in-stent area Improved blood flow into IVC noted

Left venous EVT: Stage 2

Larger balloon (16 x 40 mm) for in-stent post dilatation However, impaired blood flow noted after larger balloon post dilatation

Left venous EVT: Stage 2

Due to suspect in-stent thrombus- related impaired blood flow  Using snare to let wire crossover into left side PTA from SFV to common iliac vein (via crossover wire)

Left venous EVT: Stage 2

Still impaired Blood flow after further PTA Insert fountain catheter for 2nd CDT

Left venous EVT: Stage 3

Post 2nd CDT blood flow: Adequate blood flow noted CFV & SFV thrombosis also more improved

Left venous EVT: Stage 3

Wiring into popliteal vein (antegrade approch) Distal SFV still with lots thrombus

Left venous EVT: Stage 3

Venography from popliteal vein Venography from PTV

Left venous EVT: Stage 3

Blood flow from BTK to popliteal vein seems acceptable However, popliteal vein to SFV still with lots thrombus (+)

Then We insert fountain catheter again for 3rd CDT treatment

Left venous EVT: Stage 4

After 3rd CDT  Great blood flow below the knee Great blood flow from popliteal vein to SFV

Left venous EVT: Stage 4

Great blood flow above SFV Great blood flow above SFV

• NOAC (Xarelto) for anticoagulation
• Post iliac stenting: add on Plavix use x 3

months

後續的藥物治療

Further Operation by Plasty Surgeon Scalp Advancement Flap and STSG

Left leg before EVT & post EVT

Before EVT (post fasciotomy) Post EVT (still mild edema status) Post EVT (complete recovery)

Left leg before & post hybrid treatment with Surgery + EVT

Before treatment After treatment

Team Work Result was published in NEJM (Image in Clinic medicine)

Many Newspapers in Taiwan also reported

• ur case which was published in NEJM

New era of endovascular therapy Angiojet / Aspirex / EKOS

Take home massage (1)

• Most DVTs are confined to the thigh or the lower

leg and are not the candidates for EVT  However, acute iliofemoral DVTs have a more severe spectrum of presentations and post thrombotic syndrome (PTS) is more common

• Phlegmasia Cerulea Dolens (PCD) is an

uncommon severe form of DVT which results from extensive thrombotic occlusion of the major and the collateral veins of an extremity

• PCD can cause venous gangrene and has

extremely high risk of amputation and mortality if not early treated

Take home massage (2)

• Early EVT to remove iliofemoral thrombus and

stent implantation may help improve long-term

• utcomes
• There was rare case reporting about PCD

complicated with acute compartment syndrome treated by surgical decompression and EVT

• Our case reminds physicians that combination of

surgical decompression and EVT might be a good treatment strategy for these high risk patients

• Further advance flap may have further benefit for

wound closure and cosmetic effect

Thanks for your attention

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