Transjugular ultrasound-assisted catheter direct fibrinolysis (EKOS) for relapsed IVC filter thrombosis and phlegmasia cerulea dolens.

Phlegmasia cerulea dolens (PCD) is a devastating presentation of deep venous thrombosis (DVT), that may cause venous gangrene, amputation, and death. A 69-year old male presented with PCD in the lower limbs. Ultrasound (US) and CT-angiogram revealed lower extremities DVT cranially extended to iliac veins and inferior vena cava (IVC) involving an infrarenal IVC filter. In his history, there was 10 years earlier his first occurrence of filter-related PCD, which did require surgical thrombectomy. Currently, we gained access to IVC-filter thrombus from left internal jugular vein and easily placed an EKOS catheter in right femoral vein. Then we started the US-assisted fibrinolysis (EKOS) with low-dose r-TPA. Immediate overnight clinical improvement occurred and a postprocedure venography at 48 hours confirmed complete recanalization. We report the present case upon PCD to remark 2 unique features. First, we used successfully EKOS by transjugular route for PCD. EKOS combines the effectiveness of low dose r-TPA catheter direct thrombolysis (CDT) with the ultrasound's technology. The descending transjugular approach, previously unreported in this clinical setting, can reduce operative time, invasiveness and risk of filter's displacement in comparison with other thrombectomy devices used via popliteal or femoral approach. Second, we verified for the first time to the best of our knowledge the relapse of PCD in a very long time span (a decade) in the same patient underscoring the significance of vena cava filter as a powerful and persistent risk factor for IVC-thrombosis.