A 65-year-old gentleman was referred with left lower extremity phlegmasia cerulea dolens (PCD) 1 day following an exploratory laparotomy. Postoperatively he developed painful diffuse swelling of his left lower extremity with bluish discoloration (Figure 58-1). On arrival, he underwent a venous duplex that demonstrated thrombosis of his tibial, popliteal, femoral, common femoral, and external iliac veins. Computed tomographic angiography (CTA) scan with contrast of the head, chest, abdomen, and pelvis was performed. The patient had bilateral, asymptomatic pulmonary emboli (Figure 58-2), and mediastinal, retroperitoneal, and pelvic lymphadenopathy (Figure 58-3), which subsequently proved to be lymphoma. The patient was brought to the interventional radiology suite and an ascending phlebogram was performed. The phlebogram confirmed extensive venous thrombosis from the calf veins through the iliac veins (Figure 58-4). With the patient in the supine position and under ultrasound guidance, access to the posterior tibial vein was obtained through which an EKOS Lysus (EKOS Corp, Bothell, WA) catheter was positioned. The patient was then placed in the prone position. Under ultrasound guidance, the popliteal vein was entered and a sheath advanced through which a Trellis (Covidien, Mansfield, MA) catheter was used (Figure 58-5).

Isolated segmental pharmacomechanical thrombolysis was performed with the Trellis catheter (Covidien, Medrad, MA) using 2 to 3 mg of recombinant plasminogen activator (rt-PA) in 10 cc of saline between the two balloons. The catheter was activated to macerate the thrombus for 15 to 20 minutes. After several runs, the Trellis catheter was removed, the sheath was advanced, and liquefied thrombus was aspirated (Figure 58-6). The femoral and iliac veins showed early and marked thrombus resolution (Figure 58-7). Infrapopliteal, popliteal vein, and residual iliofemoral thrombus was treated overnight with catheter-directed thrombolysis using the EKOS Lysus catheter, infusing rt-PA at 1 mg per hour. The following morning, an ascending phlebogram was performed, indicating both intrinsic stenosis and external compression of the external iliac vein. This was dilated and stented. The completion phlebogram (Figure 58-8) demonstrated patent veins providing unobstructed venous drainage into the vena cava.

Sixteen months post-treatment, he was asymptomatic (Figure 58-9). A complete noninvasive venous evaluation demonstrated that all veins were patent with normal venous valve function.