Endovascular Management of Venous Ulcer in a Patient With Occluded Duplicated Inferior Vena Cava and Review of Inferior Vena Cava Development

Case Report

A 45-year-old male underwent a right femorocaval bypass at another center. He had a history of venous ulceration for the preceding 6 years following a posttraumatic chronic iliofemoral DVT. This ulcer was healed following surgery for the initial 2 months but worsened in size, local pain, and leg swelling thereafter. He was referred to our institute with a recurrent venous ulcer in his right leg. A CT venogram demonstrated duplication of the infrarenal IVC with chronic thrombosis of right trunk of the IVC, common iliac, external iliac, and common femoral veins. An occluded graft was also seen extending from right common femoral vein to occluded right-sided infrarenal IVC (Figure 1A). Prothrombotic workup was negative for any hypercoagulable state.

OPEN IN VIEWER

Figure 1.

A, CT venogram showing duplicated IVC with occluded right IVC. B, Venogram with patient in prone position shows trabeculations in femoral vein, popliteal vein, and in occluded right iliac vein and (C) in patent communicating vein and left-sided IVC. CT indicates computed tomographic; IVC, inferior vena cava.

In view of his active ulcerative disease and occlusion of the graft, we decided to one more attempt an endovascular recanalization.

Under ultrasound guidance, the short saphenous vein was punctured with the patient in prone position. Venogram demonstrated chronic trabeculations in the femoral and popliteal veins with complete occlusion of right iliac veins (Figure 1B). A 0.038-hydrophilic wire was negotiated into the right common iliac vein. Venogram from this position showed a good caliber, straight, nontortuous vein joining the left common iliac vein, which was draining into a patent left IVC trunk (Figure 1C). The wire was negotiated through this communicating vein into the patent left iliac vein. Right common iliac vein, external iliac vein, and femoral vein were serially predilated with 8-, 10-, and 12-mm balloons.

A 12 × 100-mm nitinol self-expandable bare stent-Eluminexx (Bard Peripheral Vascular Inc, Tempe, Arizona) was placed across the communicating vein extending through the right common iliac and external iliac veins. Further 2 Eluminexx stents of length 10 × 100 mm (Bard Peripheral Vascular Inc) were deployed from external iliac to femoral vein and 9 × 40 and 8 × 100 mm Absolute Pro (Abbott Vascular Devices, Illinois) self-expandable bare stents were deployed in femoral vein to proximal popliteal vein. Balloon molding was done with 12, 10, and 8 mm balloons (Figure 2).

OPEN IN VIEWER

Figure 2.

Postvenoplasty and stenting venogram.

Considering previous occlusion of bypass graft and metal stents extending to thigh, postoperatively lifelong anticoagulation was commenced with a target international normalized ratio of 2 to 3 and below-knee Class II compression stockings. Complete ulcer healing was achieved within 4 weeks. Venous duplex at 3, 6, 9, and 12 months showed patent stents with no evidence of stenosis. No recurrence of ulcer in 18 months of follow-up.

Embryological Development of IVC

Brief embryological development of IVC has been shown in Figure 3(A-D). Paired anterior cardinal veins (1) drain cranial vein, and posterior cardinal veins (8) drain caudal part of embryo. Bilateral anterior cardinal vein develop a communicating vein, future left innominate vein (14). Both anterior cardinal veins join to form common cardinal veins (3), which empty into sinus venosus (2). Paired vitelline and umbilical veins also empty directly into sinus venosus. With development of septum transverses, future liver (7), vitelline vein (5), and umbilical veins (4) break into numerous channels and cranially rejoin to form right and left hepatocardiac channel. Left hepatocardiac channel (16) regresses, and right hepatocardiac channel (15) forms future hepatic portion of IVC. ^7–9

OPEN IN VIEWER

Figure 3.

Embryology of IVC. IVC indicates inferior vena cava.

Right umbilical vein regress, and left umbilical vein forms ductus venosus which persists as ligamentum venosum (17). Paired vitelline veins (18) anastomose on dorsum and ventral aspects of duodenum (6) to develop future portal venous system.

At the same time, pair of subcardinal veins (10) develop in relation to mesonephros (12), and supra cardinal veins (9) develop in relation to posterior body wall. Paired subcardinal veins join at renal level to form a communicating vein, future left renal vein (11).

Caudally bilateral posterior cardinal veins also develop a communicating vein, future left common iliac vein (13). With development, some of right side and most of left embryological venous channels disappear (21), dotted lines in Figure 3B, and remaining portions join to form infrahepatic IVC (20). Infrahepatic IVC joins with right hepatocardiac channel to complete IVC development (19).

During development, parts of left-sided sub, supra, and posterior cardinal veins may not regress and form a duplicated infrarenal IVC. Interposterior cardinal vein may also persist as a communicating vein between right and left iliac veins (Figure 3D).

In our case, this communicating vein (13) was patent and was utilized for stenting to decompress occluded right lower limb venous system. To our knowledge, this is the first case in the English literature of iliac vein stenting for chronic venous insufficiency with duplicated IVC. This patients’ experience highlights a few important features. First, the need to be aware of anatomical variations in the IVC and to utilize alternative pathways such as the patent communicating vein (intersupracardinal vein) between right and left iliac veins which we used. Second, a failure at a prior attempt at recanalization or bypass does not completely preclude an endovascular solution as recanalization of chronic occlusions is an ongoing process and new pathways may become available. Third, this case highlights the vital importance of maintaining good venous inflow to decompress the leg. We achieved this by extending the venous stents well into the leg to open up occlusive disease in that region.