Endovascular Treatment of Extensive Acute Thrombosis Involving the Iliocaval and Renal Veins Associated with Chronic Caval Occlusion: A Case Report

Abstract

Deep venous thrombosis (DVT) may present with a wide spectrum of clinical manifestations, ranging from asymptomatic cases to signs and symptoms associated with pulmonary embolism, depending on the location and extent of the thrombus. Extensive acute DVT accompanied by chronic caval occlusion may not be adequately treated with anticoagulation or catheter-directed thrombolysis alone. We present a case of extensive acute iliocaval and renal vein thrombosis associated with chronic inferior vena cava occlusion that was successfully treated using endovascular techniques, including rheolytic thrombectomy and stent insertion.

INTRODUCTION

Inferior vena cava (IVC) thrombosis is a rare but potentially life-threatening condition, accounting for approximately 2%–4% of all deep venous thromboses, and is often under-recognized due to its variable clinical presentation and relatively low incidence (1). IVC thrombosis can manifest across a wide spectrum of signs and symptoms, ranging from asymptomatic cases to lower back pain, painful swelling of the lower limbs, dilation of cutaneous abdominal wall venous collaterals, and even cardiovascular collapse, depending on the location and extent of involvement (2). The presence of an underlying chronic steno-occlusive lesion in the IVC predisposes patients to extensive acute thrombosis involving major venous tributaries. Failure to address both chronic lesion and superimposed thrombus increases the risk of recurrence, postthrombotic syndrome, and pulmonary embolism (3).

Endovascular therapy has emerged as the preferred approach for managing extensive IVC thrombosis with concomitant chronic lesions, as it enables both removal of the acute thrombus and treatment of the underlying chronic steno-occlusive lesion (4,5). The authors present a case of extensive acute iliocaval and renal vein thrombosis associated with chronic IVC occlusion, successfully treated using endovascular methods, including rheolytic thrombectomy and stent placement.

CASE REPORT

A 29-year-old male patient was admitted to the vascular surgery department via the emergency medicine department, presenting with progressively worsening back pain for one month, accompanied by lower abdominal pain and painful edema of the left lower extremity that had developed one day prior. The patient had a 12 pack-year history of smoking. Apart from a diagnosis of spinal stenosis at another hospital six years earlier—reportedly managed with a presumed caudal block—he had no other known medical diseases. Contrast-enhanced CT venography revealed occlusion and calcification of the renal-suprarenal IVC, suggestive of chronic venous changes. An extensive acute-stage thrombus was observed in the left renal vein, infrarenal IVC, and left iliofemoral vein, extending to the hepatic confluence (Fig. 1A). Multiple collateral veins, including the lumbar vein, were well-developed. The right main renal vein had collapsed and was indistinguishable on CT. Additionally, multiple collateral veins were seen around both kidneys. Despite these findings, both kidneys appeared normal in location, shape, and size. To investigate the underlying cause of chronic IVC changes, a rheumatology consultation was obtained during hospitalization, followed by outpatient follow-up. However, no laboratory, imaging, or clinical findings suggested vasculitis or connective tissue disorder. The patient denied any history of trauma.

Fig. 1. Imaging findings and endovascular treatment in a patient with extensive cavoiliac and left renal vein thrombosis caused by a chronic steno-occlusive lesion.

A. Coronal image of preprocedural contrast-enhanced abdominopelvic CT demonstrates a chronic stenoocclusive lesion (arrow) involving the suprarenal-renal segment of the IVC. Extensive thrombosis is present in the cavoiliac vein (*) and left renal vein (arrowhead).

B. Left femoral venography reveals complete obstruction of flow into the IVC with prominent collaterals. A retrievable filter is inserted in the suprarenal IVC (arrow).

C. Venography during rheolytic thrombectomy of the IVC shows a marked reduction in thrombus burden. However, the chronic steno-occlusive lesion (arrows), as seen on preprocedural CT, persists as an eccentric contrast filling defect.

D. Venography during rheolytic thrombectomy following selective catheterization of the left renal vein shows substantial thrombus clearance in the left renal vein.

E. A self-expandable bare metal stent (*) is deployed to cover the majority of the chronic lesion while avoiding coverage of the left renal vein. Completion venography reveals significantly improved venous flow and resolution of collateral circulation compared to the preprocedural venography.

F. At 2-year follow-up CT, the lumens of the left renal vein (*) and the IVC are demonstrated to be patent. Although mild intraluminal hyperplasia is noted within the stent, luminal patency is maintained. A residual chronic lesion is observed in the renal segment of the IVC (arrow); however, it does not appear to cause any significant compromise of venous flow.

IVC = inferior vena cava

The patient subsequently underwent thrombolysis, angioplasty, and stent insertion. Prior to these procedures, a retrievable filter (Denali, BD, Tempe, AZ, USA) was placed in the suprarenal retrohepatic IVC via the right internal jugular vein to prevent periprocedure-related pulmonary thromboembolism. Manual aspiration of red thrombi in the infrarenal IVC and left iliofemoral vein was attempted via the left common femoral vein using a 7-Fr guiding catheter (Mach 1, Boston Scientific, Marlborough, MA, USA); however, substantial thrombotic burden remained, and no significant improvement in flow was observed (Fig. 1B). Due to the significant residual thrombus burden in the inflow veins, including the infrarenal IVC, left renal vein, and left iliofemoral vein, stenting the renal/suprarenal IVC in this state posed a high risk of massive pulmonary thromboembolism. Therefore, a rheolytic thrombectomy device (AngioJet Zelante, Boston Scientific) was used to minimize the residual thrombus burden. After positioning the catheter at the target site, 5 mg of recombinant tissue plasminogen activator (rt-PA) (Actilyse Injection, Boehringer Ingelheim, Ingelheim, Germany) was injected into the thrombotic infrarenal IVC (Fig. 1C), left renal vein (Fig. 1D), and left femoral vein using the power-pulse mode. After a 20-minutes dwell time for adequate drug penetration, thrombectomy was performed by slowly withdrawing the catheter while keeping the pump unit activated. Post-thrombectomy venography showed removal of the thrombi in the left femoral vein and improved inflow. Subsequently, the retrievable filter previously placed in the suprarenal retrohepatic IVC was removed in preparation for stent insertion to treat the chronic occlusive lesion of the renal-suprarenal IVC (Fig. 1E). Preprocedural CT imaging indicated a suprarenal IVC diameter of 16–17 mm. To reduce the risk of migration associated with smaller-diameter stents and ensure sufficient venous flow after successful recanalization, a stent with a 20-mm self-expandable bare-metal stent (Hercules, 20 mm-6 cm, S&G Biotech, Seongnam, Republic of Korea) was deployed in the suprarenal IVC. Completion venography demonstrated significant blood flow improvement and resolution of collateral venous circulation (Fig. 1E).

Following the procedure, the patient experienced symptomatic improvement, and no procedure-related complications were observed. The patient was then discharged with significant improvement in both back pain and lower extremity swelling, and no recurrence was observed during the subsequent two-year period of outpatient follow-up while receiving daily oral anticoagulant therapy with rivaroxaban (Xarelto 10 mg, Bayer, Leverkusen, Germany). On two-year follow-up CT scan, the stent lumen was confirmed to be patent with maintained patency of the iliac vein, IVC, and left renal vein (Fig. 1F).

This study was approved by the Institutional Review Board (IRB No. GDIRB2025-117).

DISCUSSION

Iliocaval thrombosis may result from a variety of etiologies, with treatment strategies ranging from conservative anticoagulation to surgical thrombectomy (6). Most previously published reports on IVC thrombosis and chronic venous change management have described lesions associated with delayed retrieval of temporary filters placed in the infrarenal IVC (6). However, in the present case, a chronic steno-occlusive lesion of uncertain etiology was identified in the suprarenal-renal segment of the IVC. This lesion was presumed to have contributed to the development of cavoiliac and left renal venous thrombosis. Considering that acute thrombosis likely developed secondary to this underlying chronic lesion, failure to manage the chronic lesion could have led to the recurrence of acute thrombotic events. Endovascular treatment is generally recommended for extensive acute symptomatic venous thrombosis involving the iliofemoral veins, especially in patients with a favorable life expectancy and low risk of bleeding (7). It should also be considered in cases of end-organ-compromising venous thrombosis, including renal vein thrombosis, as demonstrated in the present case (8). Furthermore, endovascular treatment allows for simultaneous management of acute thrombosis and underlying chronic lesions, which are suspected to contribute to its development through recanalization and stent insertion (5). Although stent insertion is often required to resolve the structural abnormalities associated with chronic steno-occlusive lesions (3), the presence of an acute thrombus, such as in the present case, poses a significant procedural risk. Specifically, stent insertion without initial management of the acute thrombus could have potentially led to catastrophic pulmonary thromboembolism. Therefore, prior to stent insertion, a significant number of acute thrombi were removed via aspiration thrombectomy and rheolytic thrombectomy. In particular, for the acute thrombus that had extended into the retrohepatic IVC, a retrievable filter was temporarily placed in the retrohepatic IVC and aspiration thrombectomy was performed to remove a significant amount of thrombus. The chronic lesions were subsequently treated.

Rheolytic thrombectomy provides several advantages over catheter-directed thrombolysis, including a reduced rt-PA dose requirement, an increased rate of thrombolysis, and a lower risk of bleeding complications. Rheolytic thrombectomy has been shown to significantly reduce rt-PA dosage by approximately two-thirds while maintaining equivalent thrombus clearance and hemodynamic efficacy compared with full-dose catheter-directed thrombolysis (9). These benefits are expected to be favorable in clinical scenarios involving a massive thrombus burden, as demonstrated in the present case. However, use of the AngioJet rheolytic thrombectomy device has been associated with the risk of gross hematuria and acute kidney injury, which are thought to result from intravascular hemolysis caused by high-pressure saline jets (10). To mitigate these risks, it is recommended to limit the duration of the procedure, ensure that catheter tip occlusion does not occur, and closely monitoring renal function following the procedure.

In summary, this case highlights the clinical utility of combining rheolytic thrombectomy and endovascular stenting to safely and effectively manage extensive acute thrombosis associated with chronic suprarenal-renal IVC occlusion, while minimizing the risk of procedure-related complications.