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 Activities of 82 years old daily Life: ok Our Case Male CAD /CVA / PAD (-) HTN (+) CKD (-)

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 of DVT which results from extensive thrombotic occlusion 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 oliguria 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 or 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 Terumo wire successfully enter into IVC DVT into IVC

Left venous EVT: Stage 1 Left leg venography showed thrombosis Right venography from right CFV over left venous system

Left venous EVT: Stage 1 Perform PTA for left common iliac vein Mild improve of left venous blood flow to external iliac vein

Left venous EVT: Stage 1 Crossover V18 wiring from right side Successfully wiring into into left SFV under CXI support 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 over 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, After CDT treatment for 2 days, still lots thrombus (++) still lots thrombus (++)

Left venous EVT: Stage 2 Further PTA for left common iliac to Improved left venous blood flow external iliac vein

Left venous EVT: Stage 2 Wall stent (16 x 90mm ) implantation for Improved blood flow into IVC noted left common iliac to external iliac vein & post dilatation for in-stent area

Left venous EVT: Stage 2 Larger balloon (16 x 40 mm) for in-stent However, impaired blood flow noted post dilatation after larger balloon post dilatation

Left venous EVT: Stage 2 Due to suspect in-stent thrombus- PTA from SFV to common iliac vein (via related impaired blood flow  Using crossover wire) snare to let wire crossover into left side

Left venous EVT: Stage 2 Still impaired Blood flow Insert fountain catheter for 2 nd CDT after further PTA

Left venous EVT: Stage 3 Post 2 nd CDT blood flow: CFV & SFV thrombosis also more Adequate blood flow noted improved

Left venous EVT: Stage 3 Wiring into popliteal vein Distal SFV still with lots thrombus (antegrade approch)

Left venous EVT: Stage 3 Venography from popliteal vein Venography from PTV

Left venous EVT: Stage 3 Then We insert fountain catheter again for 3 rd CDT treatment Blood flow from BTK to popliteal vein However, popliteal vein to SFV still with seems acceptable lots thrombus (+)

Left venous EVT: Stage 4 After 3 rd CDT  Great blood flow from popliteal vein Great blood flow below the knee to SFV

Left venous EVT: Stage 4 Great blood flow above SFV Great blood flow above SFV

後續的藥物治療 • NOAC (Xarelto) for anticoagulation • Post iliac stenting : add on Plavix use x 3 months

Further Operation by Plasty Surgeon Scalp Advancement Flap and STSG

Left leg before EVT & post EVT Post EVT (still mild edema status) Post EVT (complete recovery) Before EVT (post fasciotomy)

Left leg before & post hybrid treatment with Surgery + EVT After Before treatment treatment

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

Many Newspapers in Taiwan also reported our 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 outcomes • 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 43