When Technology Exceeds its Application: The First Reported Reconstruction of the Iliocaval Confluence Using an Aortic Endograft.

Taylor S Harmon,Victoria V Villescas,Preston Hood,Travis E Meyer,Jerry Matteo

doi:10.7759/cureus.4640

Abstract

Severe venous dysfunction in the setting of subacute iliocaval occlusion is a high cause of morbidity and mortality in patients. Fortunately, the development of the appropriate interventional management has allowed for better patient prognosis, despite device limitations. Severe cases of venous insufficiency, anatomically challenging vasculature, and device failure remain imperative when discussing the caveats for interventional success. The current gold standard of treatment for iliocaval disease has proven to be venoplasty in conjunction with stent placement within thrombotic occlusive areas. Though intuitive for modern day interventionists, this standard is not always forthright, especially when the most prevailing interventions fail to adequately treat certain venous pathologies. In this case, interventional operators must be willing to adapt their technical proficiency and knowledge of readily available devices to successfully treat the progressive nature of venous insufficiency. The following report demonstrates an example of how an interventional operator acclimated their interventional approach to successfully treat a severe and technically challenging case of subacute iliocaval occlusion, using an aortic endograft. In this first documented deployment of an aortic endograft in an iliocaval confluence, the results show resolution of the patient’s subacute iliocaval occlusive disease, as well as complete iliocaval patency and the absence of post-procedural complications.

Highlights

Chronic and acute-on-chronic iliocaval disease has been historically difficult to manage, based on the limited treatment options that have been available
In 1984, Plate et al first recognized the poor prognosis for patients who developed post-thrombotic disease as a result of anticoagulation management [1,2]; 59% of those documented patients who were managed with anticoagulation developed severe thrombosis in their lower venous systems, due to thrombotic lesions in the follow-up period [2]
Multiple published studies have reported favorable prognoses for patients who receive venoplasty and stent placement, in an attempt to achieve iliocaval patency. These studies report a technical success rate of thrombotic iliocaval reconstruction that ranges from 83%-95% [11]

Summary

Introduction

Chronic and acute-on-chronic iliocaval disease has been historically difficult to manage, based on the limited treatment options that have been available. A one-week post-operative axial T1 in/out of phase magnetic resonance image of the lower abdomen (8A) demonstrates patency of the right and left iliac veins (yellow arrows) and normal signal flow through the distal abdominal aorta (red arrow). A one-week post-operative axial T2 magnetic resonance image of the lower abdomen demonstrates low signal void in the bilateral iliac veins with patency through the stent graft (yellow arrows), and low signal flow void within the distal abdominal aorta (red arrow), consistent with patency. A one-month post-operative non-contrast enhance coronal computed tomography of the abdomen and pelvis (10A) demonstrates patency within the iliocaval confluence (yellow arrow) and right and left iliac veins (red arrows). A one-month post-operative non-contrast enhance axial computed tomography of the abdomen and pelvis (10B) demonstrates patency of the right and left iliac veins (yellow arrows) with no evidence of thrombus. The plan is to follow-up with patient in six months

Discussion

Conclusions

Disclosures