A 40-year-old obese woman with history of hypertension and uterine fibroids presented with acute onset of left lower extremity swelling and pain that began a day earlier. The pain mostly involved the left thigh and calf area. There was no tingling, numbness, or weakness of lower extremities. The patient denied recent surgery or trauma to the leg. She denied shortness of breath, palpitations, and chest pain. She did report progressive abdominal swelling over the past year. She had a history of menorrhagia for which she was taking norethindrone/ethinyl estradiol(Drug information on estradiol). She reported no family history of cancer, hypercoagulable state, or cardiovascular disease. She denied any history of cigarette smoking.
On physical examination, she appeared comfortable. Her height was 170 cm; weight, 117 Kg; and BMI, 40.5. Vital signs were blood pressure, 136/75 mm Hg; temperature, 36°C (99.7°F); pulse rate, 84/min; respiratory rate, 18/min; and SPO2, 95% on room air.
Her lungs were clear and findings from the cardiovascular examination were normal. There was firmness noted in the abdomen although her morbid obesity made it difficult to appreciate any defined mass. There was significant swelling of the left leg compared to the right with marked erythema and tenderness around the medial thigh and calf area. There were no signs of trauma. There were palpable bilateral femoral, posterior tibial, and dorsalis pedis pulses. Findings of the neurologic assessment were within normal limits.
A Doppler ultrasound study of the left lower extremity showed extensive acute deep venous thrombosis (DVT) extending from the iliac through popliteal vein with clotting in the greater saphenous vein. Findings from a complete blood cell count and a comprehensive metabolic panel were within normal reference limits. Prothrombin and factor V genotype analysis showed no mutation, and findings from the balance of the coagulation and biochemical studies were also normal.
Because of her young age and presentation of acute onset DVT with extensive clot burden, transcatheter thrombolysis was performed with successful removal of extensive clots in the popliteal, superficial femoral, femoral, and external iliac veins. Anticoagulation therapy was initiated with unfractionated heparin(Drug information on heparin).
Residual thrombus (Figure 1) was noted in the origin of the left common iliac vein shortly after the procedure and required extensive catheter-directed infusion of tissue plasminogen activator. The following day additional mechanical thrombolysis was performed and the patient underwent post-procedure evaluation with intravascular ultrasound. A persistent round filling defect was noted at the inferior vena cava bifurcation with near complete occlusion of the right common iliac vein. There was progressive recurrence of thrombus in the left iliac venous system (Figure 2) and involvement of the right lower extremity, where a new clot was noted.
Figure 2
