A CASE REPORT ON THE CRISS-CROSS TECHNIQUE FOR LOWER LIMB VENOUS THROMBOSIS
Keywords:Criss-cross technique, deep venous thrombosis, catheter directed thrombolysis
Introduction: The criss cross technique combines antegrade and retrograde vascular access to the popliteal vein in order to achieve venous recanalization in patients with acute iliofemoral deep venous thrombosis (DVT) with concomitant popliteal and calf vein thrombosis.
Case report: We report a 57-year-old female, with a background of radical hysterectomy and pelvic lymphadenectomy in 2013 due to uterine tumour, resulting in right lower limb chronic lymphedema. Admitted in the emergency service due to severe right lower limb oedema, beginning 7 days before. Upon observation the patient presented severe leg and thigh oedema, leg cyanosis, swollen and painful calf, warm extremities and palpable peripheral pulses. Venous ultrasound exposed thrombosis of the lower limb veins. Contrast CT confirmed the ultrasound findings, excluded proximal extension of the thrombus to the right common iliac vein or the vena cava, excluded pulmonary thromboembolism and exposed surgical staples in close relation with the right external iliac vein causing a >50% luminal reduction. The patient underwent thrombectomy and catheter directed thrombolysis. Venous access was obtained with ultrasound-guided popliteal vein puncture. After anterograde and retrograde sheaths placed in the popliteal vein, thrombectomy using catheter aspiration was performed in the calf veins and up to the common femoral vein. Thrombolytic infusion with alteplase and peripheral unfractionated heparin infusion was initiated and maintained for 72 hours with a control phlebography performed every 24 hours. We achieved satisfactory recanalization and performed an angioplasty with a 14x40mm balloon followed by a 14x80mm stent deployment on the external iliac vein. There were no major haemorrhagic complications. The invasive treatment was complemented with postural drainage and compressive stockings, leading to an immediate and progressive clinical improvement. Two days later the patient was discharged and prescribed a low molecular weight heparin. A month later, on a scheduled appointment, progressive clinical improvement was reported and life-long rivaroxaban prescribed.
Conclusion: The criss-cross technique allows for inflow and outflow thrombus removal, restoring venous patency and maintenance of valve function which may play a critical part on the outcome after iliofemoral DVT.
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