RT CASE OF THE SWOLLEN LEG Cimi Achiam

RT: CASE OF THE SWOLLEN LEG Cimi Achiam MD, DTMH, FRCPC

FIRST VISIT: SEPT 14, 2011 12: 25: � 50 yr male cc: L leg swelling 6 days of L leg swelling Transient SOBOE w/ mildly pleuritic chest pain yesterday, but completely resolved on presentation � PMHx: L DVT Jan 2011 Precipitated by flight to Hawaii Tx w/ 6/12 of Warfarin D/C in mid June � No meds currently � Family Hx: nil

VISIT 1 O/E: T 37. 2 HR 70 BP 145/78 RR 20 Sat 96% RA � Chest: GAEBL, clear � CVS: S 1 S 2 N, no murmur � Abdo: Soft NT, not distended � Neuro: Normal � L Leg: proximal swelling

VIST 1 INVESTIGATIONS 6 Pack: - D dimer: 646 Troponin: -

VISIT 1: IMAGING CTPA: � no PE, mildly prominent R hilar node of uncertain clinical significance CT Abdo/Pelvis: � � � No large pelvic mass causing obstruction of veins No acute intra-abdominal abnormality Questionable narrowing of the left common iliac vein at the level of the overlying right common illiac artery ? May-Thurner syndrome. Recommend Interventional Radiology consult. If there is still significant clinical concern, an MRV could be attempted or a CTV could be reattempted with a longer delay between contrast and imaging Doppler US: � � � - DVT, deep venous system widely patent No residual thrombus identified Normal waveforms, phasicity, augmentation, and compression were obtained

VISIT 1 Given high clinical concern for DVT, case was discussed with radiologist and plan was made for MR venogram next day Pt was tx in the mean time with Enoxaparin 1. 5 mg/kg SC

VISIT 2: SEPT 16, 2011 13: 42: Return for MRI results � Patient’s leg re-examined: Pt looks well, no pedal swelling, good circulation to L foot � MR Venogram of Pelvis & Thighs: Negative MR venogram with no evidence of DVT in the pelvis and LE to just above the knees Pt instructed to return on an as needed basis

VISIT 3: SEPT 20, 2011 Patient represented with progressive swelling of his L leg, non- painful, no paraesthesias. No CP or SOB currently or since last evaluation O/E: � Abdomen: Soft NT, no masses or inguinal lymphadenopathy � LE: non-pitting edema from foot to mid thigh, no erythema, normal pedal pulses and motor exam

VISIT 3 Given multiple investigations on previous visits case was discussed with radiology Repeat Doppler U/S planned Doppler U/S report: Occlusive thrombus seen within the left external iliac vein Non-occlusive thrombus within one branch of both of the duplicated superficial femoral, and popliteal veins ? May Thurner’s syndrome

VISIT 3 On suggestion of radiology, interventional radiology consulted re: possibility of thrombolysis/stenting Vascular surgery consult Was informed would have to consult vascular surgery and that they would consult IR if required Pt was admitted anticoagulated with IV heparin protocol Sept 21/11: � Pt underwent thrombolysis & stenting of his left iliac vein � Pt advised to restart IV heparin and continue coumadin x 6 mo minimum

PATHOPHYSIOLOGY OF MAY THURNER SYNDROME

VIRCHOW’S TRIAD

ANATOMY

MAY THURNER SYNDROME Most commonly seen in women between 20 -50 yrs Episodes of DVT may be recurrent and/or poorly responsive to treatment with anticoagulation alone � May require: Catheter-directed thrombolysis Venous angioplasty and/or intravascular stenting Visualization of a clot this high in the pelvis may be difficult to detect using ultrasound of LE � If DVT is strongly suspected, further testing should be performed

DIAGNOSIS OF SUSPECTED DVT OFLE Only a minority of patients (17 and 32 % in two large series) actually have the disease Accurate diagnosis is essential � Potential risk of fatal PE in untreated proximal LE DVTs � Potential risk of fatal bleeding due to anticoagulating a patient who does not have a DVT Birdwell BG, et al. Ann Intern Med 1998; 128: 1 -5 Huisman MV, et al. N Engl J Med 1986; 314: 823

DIAGNOSIS OF SUSPECTED LE DVT Pre-test probability: � Modified Well’s Score Imaging: � “Doppler” Compression U/S Abnormal compressibility of the vein Abnormal Doppler color flow The presence of an echogenic band Abnormal change in diameter during valsalva maneuver Non-compressibility is 95% Sens & Spec for a proximal DVT

DIAGNOSIS OF SUSPECTED LE DVTS

DIAGNOSTIC IMAGING MODALITIES: BEYOND U/S Contrast Venography Non-invasive Tests: � Impedance Sensitivity 91%; Specificity 96 % � MRI Plethysmography Venography Sens 100%; Spec 96% � CT Venography

AT RCH: HIGH SUSPICION & -DOPPLER U/S Options: Order D-dimer: if positive bring patient back for repeat U/S in 5 -7 days Order more imaging: CT Venogram � May be best option to rule out causes of pelvis compression ie mass and to assess iliac vessels MR Venogram Repeat U/S in 1 week without D-dimer

MANAGEMENT OF DVTS: BEYOND ANTICOAGULATION Thrombolytics Surgical thrombectomy Percutaneous mechanical thrombectomy Potential indications: � Hemodynamically unstable PE � Massive iliofemoral thrombosis � May Thurner syndrome

THROMBOLYTICS May result in more rapid and complete lysis of LE DVT & less post-thrombotic syndrome However, seldom used because: � Clinical relevance of achieving earlier relief of venous obstruction is uncertain � Increased risk of major bleeding � Low risk of death and early recurrence if anticoagulants are started promptly at an appropriate dose � Increased risk of catastrophic bleeding may not be worth preventing post-thrombotic syndrome

THROMBOLYTICS Indications: � Massive proximal LE or iliofemoral thrombosis PLUS Severe symptomatic swelling or Limb-threatening ischemia (phlegmasia cerulea dolens)

TAKE HOME POINTS In patients with recurrent left sided DVT consider May Thurner syndrome In patients with a high probability of DVT a single negative U/S study may be insufficient � Repeat the U/S in 5 -7 days or � Consider adding a D-dimer at the time of the initial workup or � Consider other imaging modalities ie CT venogram