1. Complex Case Presentations. Complications and Management.
Rabih A. Chaer MD
Assistant Professor of Surgery
Division of Vascular Surgery
University of Pittsburgh Medical Center

2. Rabih A. Chaer, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

3. CASE 1. HISTORY 55 yo man Presented with calf trauma s/p assault
Developed compartment syndrome, required fasciotomy
Venous duplex negative for DVT
Immobile, open calf wounds

4. HISTORY PMH: DVT, PE, stroke, Factor V Leiden deficiency.
Previously placed IVC filter for PE one year prior
DVT pharmacologic prophylaxis held for oozing from surgical site

5. COURSE
Severe bilateral lower extremity swelling noted postop on day 14
Sensory and motor loss with paralyzed lower extremities
Heparin anticoagulation initiated
Repeat duplex: extensive bilateral LE DVT from tibial veins to bilateral iliac veins
Clinical diagnosis of phlegmasia

6. PHELGMASIA

7. PARALYSIS? Not a classical presentation of phlegmasia or DVT
Literature review

8. TREATMENT Bilateral popliteal venous access
Extensive thrombosis into the filter on initial venogram

9. Pharmacomechanical Thrombolysis
Trellis device

10. PMT/drip

11. OUTCOME
Phlegmasia resolved immediately after the first session with marked resolution of paralysis
DVT and symptom free at one year follow up
Acute cauda equina syndrome secondary to iliocaval thrombosis successfully treated with thrombolysis and pharmacomechanical thrombectomy.
Go MR, Baril DT, Leers SA, Chaer RA. J Endovasc Ther Apr;16(2):233-7.

12. CASE 2. HISTORY 62 yo woman Spine surgery for herniated disc
No history of DVT
Not on anticoagulation
Prophylactic IVC filer
DVT prophylaxis/heparin sc post op day 2

13. COURSE Severe bilateral lower extremity swelling on day 5 post op
Duplex: extensive iliofemoral DVT
Started on systemic heparin anticoagulation
Progressive deterioration of renal function, normal at baseline
Non contrast CT scan

14. TREATMENT

15. PMT

16. Popliteal approach/PMT

17. CDT/12 HOURS

18. OUTCOMES Dialysis for 4 weeks via TDC INR 5 on post procedure 5
Surgical site hematoma requiring evacuation
Currently dialysis free, normal renal function
Follow up duplex: no DVT
Perianal numbness, ambulatory

19. CASE 3. HISTORY 61yoF w/ unprovoked femoral DVT 1 month previously
IVC filter placed at OSH for relative contraindication to anticoagulation (diverticular bleeding)
Recurrent thrombosis, now in iliofemoral distribution 1 week s/p IVC filter
Unsuccessful thrombolysis at OSH: recurrence within one week
?HITT, placed on lepirudin
Transferred for further management

20. WORKUP Hypercoagulable screen Family h/o venous thrombosis
Lepirudin continued until increasing Plts
Physical exam: significant LLE pain and edema, no phlegmasia, dopplerable signals distally, no ulcerations

21. Day 1– Lysis Prone positioning Sedation and local
Thrombosed popliteal accessed under U/S guidance

22. Day 1– Lysis

23. Day 1– Lysis EKOS infusion catheter 40cm
4mg tPA, 2mg via popliteal sheath
tPA 0.5mg/hr

24. 18h – Lysis check
8x6mm balloon venoplasty

25. 18h – Lysis check
PMT w/ AngioJet tPA 8mg
8mins of thrombectomy mode

26. CDT: UniFuse infusion catheter 50cm
tPA 0.5mg/hr

27. 16h later - Lysis Check

29. PTA/stent
18x60mm wallstent for focal iliac vein stenosis

30. Case 4. HISTORY
22 yo man presenting with chest pain and shortness of breath
Noted fullness under the right axilla
CT chest showed evidence of PE
Otherwise healthy

32. EXAM Swollen RUE. Improving No O2 requirement Heparin anticoagulation
Duplex: extensive DVT
Working diagnosis: TOS

33. VENOGRAM

35. PMT/Trellis

36. Axillary/brachial aneurysm

37. 18 months follow up
Asymptomatic
Declines surgery
On coumadin