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Case Reports
. 2020 Nov 16:19:e20200075.
doi: 10.1590/1677-5449.200075.

Free-floating thrombus in lower limb deep veins and May-Thurner syndrome: case report

Helio Bergantini  1 , Selma Regina de Oliveira Raymundo  1   2 , Daniel Gustavo Miquelin  1 , Gleison Juliano da Silva Russeff  1 , Desirée Francini Del Frari Silva  1 , Gabriela Leopoldino da Silva  1 , Amabile Oficiati de Carnevale Galeti  1 , Matheus Pietraroia Dos Santos  1
Affiliations
Case Reports

Free-floating thrombus in lower limb deep veins and May-Thurner syndrome: case report

Helio Bergantini et al. J Vasc Bras. .

Abstract
in English, Portuguese

Free-floating thrombus in the deep venous system has a high potential to cause pulmonary embolization. It can also be found in patients with superficial venous thrombosis (SVT) that extends to a deep vein. There are still no defined criteria for treatments described in the literature, which range from anticoagulation and fibrinolytic treatments with vena cava filter implants, through open or endovascular thrombectomies, to more invasive procedures such as surgical interruption with ligation of the venous system. We present the case of a patient with extensive deep venous thrombosis affecting the iliofemoral-popliteal territory with a floating thrombus extending from the left common iliac vein to the inferior vena cava. Treatment was performed with fibrinolytic therapy delivered with a multiperforated catheter, supplemented with anticoagulation with heparin and daily control angiography. At the end of the treatment, a significant stenosis was identified in the left common iliac vein, and angioplasty was performed with stenting.

Resumo: O trombo flutuante no sistema venoso profundo manifesta elevado potencial de embolização pulmonar. Pode também ser encontrado em pacientes com trombose venosa superficial (TVS) com extensão para uma veia profunda. Os tratamentos descritos na literatura, ainda sem critérios definidos, variam desde anticoagulação e tratamentos fibrinolíticos com implantes de filtros de veia cava, trombectomias abertas ou com dispositivos endovasculares até condutas mais invasivas como a interrupção cirúrgica com ligadura do sistema venoso. Apresentamos o caso de uma paciente com trombose venosa profunda extensa, acometendo o território ilíaco-fêmoro-poplíteo com um trombo flutuante estendendo-se da veia ilíaca comum esquerda até a veia cava inferior. O tratamento foi realizado com terapia fibrinolítica com um cateter multiperfurado, associado a anticoagulação com heparina e a controles angiográficos diários. Ao final do tratamento, foi identificada uma estenose significativa na veia ilíaca comum esquerda, sendo realizada angioplastia com implante de stent.

Keywords: anticoagulants, fibrinolysis; pulmonary embolism; venous thrombosis.

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Conflict of interest statement

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Figures

Figure 1
Figure 1. Duplex ultrasound (DUS) showing: (A) left common iliac vein (LCIV) with large caliber and no blood flow, with hypoechoic intraluminal material indicating acute deep venous thrombosis (DVT) and compression by the right common iliac artery (RCIA); and (B) left superficial femoral vein (LSFV) with normal caliber, flow present, and absence of thrombi.
Figure 2
Figure 2. Phlebography showing: (A) progression of thrombosis to the femoral and popliteal veins; (B) extensive thrombosis of the left iliac veins and inferior vena cava (IVC); and (C) presence of free-floating thrombus in the IVC (arrow).
Figure 3
Figure 3. Control phlebography 72 hours after fibrinolysis showing: (A) recanalization of the inferior vena cava (IVC) and left common iliac vein (LCIV); (B) recanalization of the superficial femoral vein; and (C) extrinsic compression of the LCIV, characteristic of May-Thurner Syndrome (arrow).
Figure 4
Figure 4. Control angiography after angioplasty and implantation of a Wallstent (Boston Scientific Corporation) in the left common iliac vein (LCIV) with satisfactory results (arrow).
Figure 5
Figure 5. Control ultrasound in mode B showing the patent stent in the left common iliac vein (LCIV) and an absence of extrinsic compression: (A) 3 months after the procedure and (B) 18 months afterwards.
Figura 1
Figura 1. Ultrassom Doppler (USD) mostrando: (A) veia ilíaca comum esquerda (VICE) com calibre aumentado e fluxo ausente, com material hipoecoico intraluminal indicando trombose venosa profunda (TVP) aguda e compressão pela artéria ilíaca comum direita (AICD); e (B) veia femoral superficial esquerda (VFSE) com calibre normal, fluxo presente e ausência de trombos.
Figura 2
Figura 2. Flebografia mostrando: (A) progressão da trombose para as veias femorais e poplítea; (B) trombose extensa das veias ilíacas esquerda e da veia cava inferior (VCI); e (C) presença de trombo flutuante em VCI (seta).
Figura 3
Figura 3. Flebografia de controle após 72 horas de fibrinólise evidenciou: (A) recanalização da veia cava inferior (VCI) e veia ilíaca comum esquerda (VICE); (B) recanalização da veia femoral superficial; e (C) presença de compressão extrínseca de VICE, característica da síndrome de May-Thurner (seta).
Figura 4
Figura 4. Controle angiográfico após angioplastia e implante de Wallstent (Boston Scientific Corporation) em veia ilíaca comum esquerda (VICE) com resultado satisfatório (seta).
Figura 5
Figura 5. Controle ultrassonográfico em modo B evidenciando stent pérvio na veia ilíaca comum esquerda (VICE) e ausência de compressão extrínseca: (A) 3 meses após procedimento e (B) 18 meses após.
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