In recent publications, the analysis of the evolution of deep vein thrombosis of abdominal vessels was performed, where two well-defined stages were evidenced. The first until 2000, where 75% of the procedures were performed by open surgery and 25% were endovascular. After that date, 4.1% went through open surgery and the remaining 95.9% was endovascular. The current situation is, endovascular interventions without thrombolysis (53%) or with thrombolysis (33.2%), open surgery (6.8%) and medical treatment (7%) (anticoagulation and elastocompression) [18,19].
In patients with absolute contraindication of anticoagulation, the initial criterion was the inferior vena cava filter implant, a complex situation when the thrombosis compromised the adrenal cava segment. Therefore, the ligation or clipping of the inferior vena cava with high renal thrombosis and general involvement was chosen .
Removable and non-removable filters can be used but all have high thrombogenic power. The implant of removable filters is currently recommended, with the possibility of repositioning before 21 days, as an optimal situation .
In the following clinical case, thrombosis of inferior vena cava secondary to inferior vena cava filter can be evidenced (Figure 7).
Figure 7: Thrombosis of inferior vena cava secondary to inferior vena cava filter. Courtesy of Dr. Guillermo Eisele.
Case report No. 3: Woman, 28 years old, with a history of deep vein thrombosis in the right lower limb, after recent abdominal surgery, with a high risk of bleeding. Color Doppler-US and angiotomography with signs of May-Thurner Syndrome and total thrombosis of the common and external iliac venous axis. Optease vena cava filter is implanted for jugular route. In the 1st week of evolution, clinical progression is evident, with bilateral edema. Inferior vena cava thrombosis is evident at the filter level. Anticoagulant treatment was performed. After 30 days a filter extraction with a loop, thromboaspiration with Penumbra catheter, balloon angioplasty and implant of 2 stents dedicated to vein type Zilver Vena (Cook) is performed. Total restitution of the ilio-cavo axis. Anticoagulant treatment with dicumarinics for 1 year is established.
Among the early complications of the filter implant can be mentioned [21,22]:
- Hematoma or thrombosis in the puncture area, incorrect position of the filter, renal veins, iliac, etc.
- Incomplete opening or not opening. More frequent when the approach is jugular
- Cava drilling
- Migration of proximal filter or right heart
On the other hand among the late complications we can mention:
- Recurrent lung thromboembolism (PET). It is similar with all filters in the current market ranging from 2-5%
- Vena Cava thrombosis. Incidence between 2-22%. Maintain anticoagulation to avoid these thrombosis. 33% exceed the filter proximally
- Flow or cephalic migration. 4-17% of all filters migrate one or two centimeters up or down, without major clinical significance
- Filter breakage
- Postphlebitic syndrome secondary to filter implantation in non-anticoagulated patients
With respect to the different techniques of conventional surgery for the treatment of venous thrombosis, it is possible to mention the femoro-cavo, uni or bilateral iliao-cavo, femoro-femoral or Palma bypass, endarterectomy with patch, venous iliac interposition, etc. Saphenous veins, prostheses, have been used as ducts, where the preparation of distal arteriovenous fistula increases their permeability. Patients should remain prolonged anticoagulated and antiplatelet. Early complications include bridge thrombosis, due to poor inflow or outflow, inadequate conduit, lack of adequate anticoagulation, prosthetic infections, inguinal lymphomas, deep distal venous thrombosis and pulmonary embolism as isolated cases [23,24].
Case report No. 4: Young patient with retroperitoneal tumor, with histology of metastatic testis teratocarcinoma, with infiltration of the right common iliac artery and inferior vena cava. Block tumor resection was performed with vascular reconstruction by iliac-iliac arterial replacement and infrarenal inferior vena cava replacement. Preparation of arteriovenous fistula distal to the replacement of the inferior vena cava, with the aim of increasing the caval venous flow and reducing the risk of venous thrombosis. Primary permeability of 12 years, up to the present  (Figure 8).
Figure 8: A, B) Metastatic tumor with compromise of inferior vena cava, and right iliac artery. C, D) Prosthetic replacement surgery of the infrarenal inferior vena cava with distal arteriovenous fistula with inverted saphenous vein. E, F) Color Doppler-US and AngioTc where permeability of the bypasses is evidenced.
Partial resections and repair with primary closure or patches (autologous or prosthetic), in patients with tumor involvement of the inferior vena cava are very effective and simple to perform.
Case report No. 5: Male, 34 years old with a history of testicular metastatic tumor at the level of the right renal hilum, involvement of the lateral wall of the cava and the right renal artery. Second tumor recurrence. Tumor resection with retroperitoneal lymph node emptying, with safety margins, lateral resection of the inferior vena cava with venous raffia, resection of the renal artery compromised with aortic-renal bypass with inverted saphenous vein (Figure 9).
Figure 9: A) Patient with tumor recurrence. B, C) Angiotomography with evidence of tumor with invasion of the inferior vena cava and right renal artery. D, E) Partial lateral resection of inferior vena cava and compromised right renal artery. Aortic-renal bypass with inverted saphenous vein.
But tumors that involve more than half of the circumference of the vessel wall or with massive intraluminal thrombus require complete resection of the inferior vena cava, to achieve safety margins [25-27].
It is necessary to define previously, the level of cava compromised, for example the adrenal cava is more complex but has greater permeability. The replacement of infrarenal vena cava is simpler but is associated with an increased risk of thrombosis, so that the arteriovenous fistula increases the flow and pressure, decreasing its incidence. Another factor to take into account is whether the vena cava is totally occluded with a satisfactory degree of collaterality through the paralumbar, parietal, azygos, hemizygos, etc., in which case it would have no indication of bypass, only resective surgery. Phlebography plays a very important role in certifying these derivative pathways since it is more difficult to determine compensation with the other diagnostic methods. Other factors to consider are the cancer outcome to be obtained with tumor resection and the general condition of the patient [28,29].
Currently, the management behavior is that of endovascular resolution, in cases of acute thrombosis the combined use of thrombolytics, pharmacomechanical thrombolism and / or thromboaspiration, in the majority of cases associated with balloon angioplasty and stent implantation.
While in chronic thrombosis, angioplasty with a balloon and stent implant is chosen directly. Initially arterial stents were used, such as those of Wallstent Boston, because of their large diameter and length. High rates of primary and secondary permeability have been obtained with this type of stent [30,31].
With the appearance of stents dedicated to veins the results are very satisfactory, with high primary and secondary permeability [32-34]. Anticoagulant treatment decreases the incidence of PTE risk, but has little dissolutive effect of thrombosis, which depends primarily on thrombolysis [35,36].
The combined use of thrombolytics and heparin decreases the incidence of Post-Thrombotic Syndrome (SPT) due to early thrombus lysis and valvular preservation. Systemic fibrinolytic treatment is 4 to 10 times more effective than anticoagulation alone, but its non-localized systemic use may increase bleeding morbidity .
Intra-thrombotic selective thrombolism has greater benefits because it allows the impregnation of the fibrinolytic agent and the rapid removal of the thrombus. It has a greater local efficacy with low concentration of systemic drug and lower hemorrhagic complications [38-41].
Among the options for the interventional treatment of deep vein thrombosis we can mention:
- Catheter-directed thrombolysis
Plasminogen Activator (rt-PA)
- Endovascular mechanical thrombectomy
Rheolithic thrombectomy (AngioJet)
Ultrasonic accelerated thrombolysis (EKOS EndoWave)
Rotational thrombectomy (Aspirex catheter, Penumbra)
- Isolated segmental pharmaco-mechanical thrombolysis
Double-balloon catheter (Trellis)
- Endovascular Stent
- Conventional thrombectomy
We can divide the thrombosis according to their time of evolution in acute, subacute and chronic. The approach and behaviors vary, having more favorable results in acute and subacute situations.
Interventional behavior of acute venous thrombosis
According to our protocol they have the possibility of treatment:
- Acute venous thrombosis should be treated within the period considered as optimal, 21 days. The earlier the therapy is performed, the greater the results obtained
- Thrombosis of 2, 3, or 4 levels that compromise the viability of the upper or lower limb and greater risk of developing post-thrombotic syndrome:
- iliac-femoral-popliteal thrombosis
- bilateral cavo-iliac thrombosis
- Flegmasia cerulean dolens or albans independently of the compromised territories
- Patients in good general condition with acceptable life expectancy
Are excluded out of the protocol patients with:
- Thrombosis that exceeds 21 days of thrombosis, since the aspiration thrombolytic therapy has less efficacy. These patients enter into the program of reassessment and eventual programmed endovascular intervention, generally they go to angioplasty and stent implantation
- Patients with isolated infrainguinal, femoral, popliteal, tibial thrombosis that do not compromise the viability of the limb or risk of imminent embolism
- Patients in poor general condition, with renal, heart failure, or multi-organ failure and with low life expectancy
Case report No. 6: A 32-year-old woman had a bladder injury that required raffia during scheduled caesarean section surgery. Reduced mobility, without elastocompression or prophylaxis for DVT. It evolves on the 5th day of hospitalization with significant edema of the lower left limb. By color Doppler-US, partial thrombosis of the inferior vena cava, total thrombosis of the common iliac vein, external iliac, common femoral vein, partial thrombosis of the femoral, popliteal and bilateral twin veins were suspected. AngioTc showed inferior vena cava indemnity, signs of May Thurner with confirmation of thrombosis on the entire left axis. Signs of phlegmasia cerulea dolens, with significant edema, functional impotence, bluish coloration of the limb, absence of pedial and posterior tibial arterial pulses. Anticoagulation is initiated with sodium heparin. Interventional therapy was decided, without a vena cava filter implant, pharmaco-mechanical thrombolism with AngioJet system (Boston Scientific) with rtPA. Two stents dedicated to vein, Zilver Vena (Cook), of 16 x 140 mm and 14 x 90 mm in the iliac and proximal femoral veins were implanted. The patient is discharged at 24h after the procedure with anticoagulation and antiplatelet protocol and the total resolution of the clinical profile (Figures 10 and 11).
Figure 10: A) Clinical profile of flegmasia cerulea dolens. B) AngioTC with evidence of common iliac, external and common femoral vein thrombosis. Low collaterality C, D) Ascending phlebography, evidence of total occlusion of iliac veins and common femoral veins. E) Pelvic selective phlebography, partial thrombosis of the femoral and popliteal vein.
Figure 11: A) AngioJet System (Boston Scientific). B) Zelante Boston Scientific catheter. C, D and E) Pharmaco-mechanical thrombolysis rtPA. F, G) Balloon angioplasty and iliac-femoral stent implant. Total recovery of the venous axis.
In our experience in the Interventional phlebology section of the Favaloro Foundation, we treat cases of deep venous thrombosis in acute, subacute and chronic phase, mostly from a period of 1 to 35 years of evolution. The recanalization of chronic situations where exists fibrosis, stenosis, and very resistant intravascular septae is a challenge. In favorable cases, it is possible to distinguish a filiform passage from iliac, femoral and inferior vena cava, while in others it is impossible to identify such axes, only abundant collaterality.
Technical details for treatment of acute, subacute and chronic thrombosis
- Clinical evaluation, intensive care hospitalization or intermediate therapy
- Monitoring of vital signs, diuresis
- Blood test with evaluation of renal function and coagulogram, thrombin
- -Place of realization. Hybrid hemodynamics room, with an angiograph capable of generating and reconstructing images in 365°
- General anesthesia. Strict monitoring of vital signs
- Bladder catheter to prevent bladder interposition with images and diuresis control
- Triple US-assisted approach with bilateral femoral or popliteal cannulation and right internal jugular vein. The closest to the occlusion site to facilitate angioplasty, with enough space so that the introducer sheath is not interposed
- Approach of the left distal or popliteal femoral vein in the dorsal position according to the site of thrombosis, distal to it and right femoral vein. In situations, the ventral position is chosen to facilitate it.
- Systemic heparinization, ev. Sodium heparin, according to the patient's weight, which is adjusted according to the duration of the procedure
- Placement of 7F introducers
- In other situations we perform ascending phlebography with an US-assisted puncture of superficial veins of the leg or foot, such as the internal saphenous vein, external, or accessory posterior saphenous vein of the leg to perform a mapping of the lesions, with placement of radial introducer of 4F or abocath No. 18 with 3-way key connector. A loop is placed on the leg in the middle third of the leg to facilitate referral to the deep venous system
- The phlebography is done with and without Valsalva maneuvers, and includes the evaluation of superior vena cava, inferior cava, renal, iliac, internal iliac, femoral and popliteal veins. The injection can be manual with 10-20 ml syringe or with injection pump. The use of an injection pump is recommended to facilitate the study, with a flow rate of 6-8ml / s, volume of 10-20ml, Duration 3sec. and pressure 900psi. This allows the entire limb to be evaluated and even iliac vessels with the use of subtraction
- Progress or negotiation through occlusion through femoral vein, iliac vessels, inferior cava, and according to the site of occlusion, with a 0.035 260cm hydrophilic guide with a J-tip and straight. (Type Terumo, Zip wire (Boston Scientific), or Roadrunner (Cook)) and a multipurpose catheter of 5F of 120cm Boston Scientific, or vertebral Terumo of 5F
- In the case of acute thrombosis, a 260mm Amplatz short 0.035 guide is progressed to the pharmaco-mechanical thrombolis process, until healthy inferior vena cava. Intra-thrombus is progressed from distal to proximal with Zelante DVT TM thrombectomy catheter. AngioJet system (Boston Scientific) with rtPA is used in doses of 15 mg / 150 ml of physiological solution, with the Power Pulse TM system. This allows the thrombolytic to be applied directly to the clot allowing pharmacomechanical therapy due to its saturation and softening effect. The thrombus fragmented by the solution jets is absorbed by the catheter by a vacuum effect, Bernoulli effect
- In most cases it is possible to objectify occlusions as a result of joint rupture with guide and vertebral hydrophilic catheters Terumo, multipurpose diagnosis 6F Boston, or right coronary. Preferably by the committed member, or simultaneously from the contralateral side or retrogradely
- We opted for maneuvers performed with 2 operators, one near the introducer that pushes the catheter and the other distal that pushes the guide, which facilitates the procedure
- Continuous testing with contrast with 10ml syringe, to certify the progression of angioplasty, evidence of collaterality, signs of iliac or cavus axes. Venous perforation is frequent, self-delimiting without clinical implication, but requiring continuous evaluation of the general condition and progression of the hematoma
- Once we have overcome the occlusion with a guide and catheter, tested with phlebography evidencing flow in vena cava, we change the first one with a 260 cm Amplatz 0.035 tip short tip
- We change the introducer of the member committed by one of 11 or 12F, and the initial catheter for an 8F guide catheter on Amplaz 0.035 guide of 260cm. We perform ascending phlebography with pump to certify intravascular permanence
- We perform angioplasty with balloons of progressive diameter, 4, 6, 8, 10, 12 mm and of greater length that are available, everything depends on the vessel to be treated
- Testing with phlebography of the progression of balloon angioplasty
- Placement of self-expanding stents dedicated to veins in their preference at the proximal level, with diameters according to the vessel
- We recommend using vein stents:
- 18-20 mm inferior vena cava
- 16-18 mm iliacveins
- 14-16 mm femoral veins
- Among the stents dedicated to veins in our environment and that we have used we can mention Zilver Vena (Cook), Sinus Vena (Optimed), Sinus Oblicus (Optimed), ViciStent Veniti (Boston Scientific) and Venovo (Bard)
- In some circumstances we use arterial stents such as the Wallstent (Boston Scientific) at the distal level, in the external iliac vein and femoral due to budgetary and medical coverage issues
- The stents are ballooned with high pressure 16, 18 or 20 mm Atlas De Bard type balloons, according to the stent diameter
- Simultaneous ascending phlebography in lower limbs in different positions, rotation in 365º to visualize the restitution of the venous axis and need for implantation of another stent or complementary balloon angioplasty
- We do not have IVUS for evaluation, due to budgetary limitations, so the evaluation is optimized in multiple incidents and 3 D reconstruction, angio-3D
- Do not reverse anticoagulation. Extraction of introducers with adequate hemostasis by prolonged selective compression
- Start anticoagulation on the first day with LMWH and Clopidogrel, 75 mg / day. And then go to last generation oral anticoagulants and antiplatelet according to protocol
Post-stenting venous recommendations
- Early wandering and elastocompression
- 18 to 24h of hospitalization in general room
- Use of analgesics such as tramadol, codeine. Low back and pelvic pain is common, which can last in more extreme cases to one month
Anti-coagulation and anti-aggregation schemes with:
- Rivaroxaban 15 mg every 12 h + Clopidogrel 75 mg / day for 3 weeks
- Then Rivaroxaban 20 mg / day + Clopidogrel 75 mg / day
- Another scheme with Apixaban 5mg every 12h + Clopidogrel 75 mg / day
- Duration of anticoagulation in patients with Post-Thrombotic Syndrome (PTS): anticoagulation for 6 months + antiplatelet therapy (Clopidogrel or ASA)
- Patient with non-thrombotic iliac lesions (NIVL) ACO at therapeutic range x 3 months + antiplatelet.
- In case of multiple stent implants or with regular inflow or outflow, we recommend keeping the anti-aggregation prolonged
- Follow-up with venous color echodoppler at the 1st week, and first 3 months. Veno-CT at 3 months
In case of bilateral iliac occlusion or vena cava, it is necessary to apply different techniques for restitution of the compromised axes. Different stenting techniques are described. Gloviczki P, Rajú and other authors detailed the techniques [11,42,43]:
- Stent Overlap. Kissing Balloon Technique
- Double Barrel Technique or in pants with Kissing Balloon and Kissing Stent
- Inverted “Y” Fenestration or Piercing
- d-Apposition Technique
Among the tips for venous stenting we can take into account :
- Opt for stents dedicated to veins with diameter and length according to the vessel and these should be positioned about 3cm in healthy vein at the proximal and distal level
- Oversize the vessel 20% to avoid stent migration, and take into account that some stents have a certain degree of retraction during implantation
- Do not leave space between stents, a situation that would favour stenosis or occlusion, and overlap them
- A characteristic sign of an optimal result is the disappearance of collaterality, and absence of contrast stasis
- It is necessary to have an adequate inflow and outflow; otherwise it is the main cause of procedural failure. Including stent implantation at the infrainguinal level to ensure adequate inflow, and in case of femoral vein occlusion, the positioning of the deep femoral vein is chosen
- Use anticoagulation and antiplatelet according to protocol. Many cases of early occlusion are due to non-compliance with these guidelines
We present clinical cases with a diagnosis of inferior vena cava agenesis, where the return of venous return was achieved, using as lumbar veins, azygos and hemiazygos.
Case report No. 7: Male, 26 years old. From childhood presence of varicose veins in lower limbs, abdomen and thorax. Diagnosis of inferior vena cava agenesis. In adolescence he presented venous claudication, varicocele, and pelvic and lumbar pain. At 25 years of age, he presented an acute picture of edema of the lower limbs, functional impotence and dyspnea. Diagnosis of deep venous thrombosis of bilateral femoral veins was made. There was no evidence of iliac veins or inferior vena cava. Abundant collaterality. Treatment with acenocoumarol, phlebotonic medications and medium compression elastic stockings. Angiotomography and phlebography were performed where there is an absence of inferior vena cava at the infra and adrenal level, absence of iliac vessels, drainage of renal veins in retroaortic horseshoe, right by azygos vein and left by hemiazygos system, and abundant collateral circulation by wall abdominal and pelvic (Figures 12 and 13).
Figure 12: Clinical case with diagnosis of inferior vena cava aplasia. A, B) Evidence of parietal collateral circulation. C-G) Angiotomography with evidence of infrarenal and adrenal inferior vena cava aplasia. No evidence of primitive and external iliac veins. Bilateral retroaortic renal drainage by azygos and hemiazygos vein.
Figure 13: Pelvic selective phlebography. A) Abdominal parietal collateral circulation. B, C) Absence of primitive iliac veins, outline of external iliac veins. D) Reconstruction where it is possible to visualize drainage through bilateral lumbar veins, azygos and hemiazygos system. E) Azigos vein. F) Renal veins that drain in the hemiazygos and azygos system.
Endovascular treatment was chosen. Combined approach, bilateral femoral in middle third of thigh, and internal jugular vein. It is possible to pass hydrophilic guides through lumbar veins and azygos vein. Angioplasty is performed with progressive diameter balloons, and implant of 1 Sinus Vena 16 x 150mm stent in azygos vein or lumbar collateral; in bilateral lumbar veins with location similar to iliac veins, it was implanted on the left side, 1 Sinus Vena stent 16 x 150mm and 1 Wallstent stent 14 x 95mm and on the right side 3 Wallstent 16 x 95mm stent. In a procedure that lasted 3 hours. He is discharged at 24h with anticoagulation with Rivaroxaban and antiplatelet with Clopidogrel 75mg. During the 1-year follow-up period, the disappearance of venous claudication, pain, collateral circulation significantly and pelvic congestion was evident (Figures 14 and 15).
Figure 14: A) Amplatz guides positioned in lumbar veins, azygos vein. B, C) Angioplasty with balloon and stent kissing technique, overlap technique. D) Evidence of significant disappearance of collaterality. E) Restitution of the axis, from femoral to proximal azygos system. F) CT angiography with 3D reconstruction, where stent permeability is evidenced. G, H) Significant clinical improvement evidenced by decreased abdominal and pelvic collaterality, disappearance of varicocele.
Figure 15: A) Previous. Scheme and phlebography with evidence of inferior vena cava and iliac veins aplasia. B) Rear. Venous stenting with Stent Overlap and Kissing Balloon technique. Drawings made by Dándolo M.
Case report No. 8: Male, 34 years of age, who suddenly presented lumbar region pain 2 years ago, associated with lower limb edema. A venous color Doppler-US is performed where bilateral deep femoral venous thrombosis is observed. Receive anticoagulant treatment with Acenocoumarol. It evolves with post-thrombotic syndrome, lower limb edema, venous claudication, severe congestion syndrome and hemorrhoids. Abdominal and pelvic venous color Doppler-US and computed angiotomography are performed, showing aplasia of the inferior vena cava, iliac veins, azygos and hemizygous drainage. Retroaortic connected renal veins with azygos vein drainage on the right side and left hemizygos vein (Figure 16).
Figure 16: Computed angiography of the abdomen. A, B) Development of abdominal collateral circulation C) 3D reconstruction, evidence of absence of infrarenal inferior vena cava and iliac vessels. D) Development of hemiazygos and azygos vein. E-H) Drainage of the left retroaortic renal vein by hemiazygos system and right renal vein in azygos, collaterality.
Triple approach was performed, through the right internal jugular vein, and bilateralby femoral veins in the middle third of the thigh. Aplasia of iliac vessels and inferior vena cavawas evident. To restore the venous return axis, ascending lumbar veins and azygos system were used. It was impossible to connect the left axis to the right side at the abdominal level, only at the distal femoral level, through the left ascending lumbar vein and presacral vein making an endovascular palm system. Angioplasty was performed with progressive diameter balloons. In the azygos and right lumbar veins, 1 Sinus Vena (Optimed) stent of 18 mm x 150 cm was implanted proximally, and on the left side 1 Sinus Vena stent of 14 mm x 150 cm. At the distal level, 2 Wallstent were implanted on the right side and 1 on the left side of 14 mm x 90 cm, in an intervention lasting 2 hours. The patient remains hospitalized 18h and is given anticoagulation with Rivaroxaban 15 mg every 12h and Clopidogrel 75 mg / day (Figures 17 and 18).
Figure 17: A-D) Ascending and descending phlebography. Evidence of bilateral iliac vein and inferior vena cava aplasia with drainage by hemiazygos and azygos system. Retroaortic renal veins, right with drainage to azygos vein and left to hemiazygos vein. E-H) Angioplasty with hydrophilic guides and catheters, progressive diameter balloons, and stent implantation dedicated to vein, Sinus Vena and Wallstent distal femoral bilateral.
Figure 18: Scheme and phlebography of results before and after venous stenting. Drawings made by Dándolo, M.
Case report No. 9: Male, 30 years. History of deep vein thrombosis in lower limbs. Anticoagulant treatment for 5 years. It evolves with insufficient internal saphenous vein and perforating veins on the inner side of the left leg. Surgery was performed with internal safenectomy and Cigorraga operation of perforating veins. At 2 years later it evolves with new deep infrainguinal left venous thrombosis. Thrombophilia is identified and receives anticoagulant treatment with dicumarinics. It evolves with ocher dermatitis and epifascial varicose veins, which requires new surgery with poor evolution with increased trophic disorders, edema and the appearance of venous claudication. Phlebography was performed with evidence of double inferior cava, where the left side drains into the left renal vein, with duplication with subtotal thrombosis. No evidence of left iliac vein. Angioplasty was performed with an 18 mm x 150 cm Sinus Vena (Optimed) stent implant in the left vena cava to the renal vein. Disappearance of collaterality and significant clinical improvement (Figures 19 and 20).
Figure 19: A) Post-thrombotic syndrome secondary to duplication or double inferior vena cava thrombosis. B, C) Flebography with evidence of duplication of vena cava with thrombosis sequelae. D, E) Results of balloon angioplasty. F) Sinus Vena stent implant with restitution of the left axis through left vena cava.
Figure 20: A) Previous. Evidence of total occlusion of the left iliac vein and partial left inferior vena cava. B) Balloon angioplasty, and stent implantation in left vena cava to renal vein. Restitution of the axis and disappearance of collaterality.