Case Presentation
A seventy years old lady with a history of breast cancer and mastectomy (seven years ago), who was diagnosed with severe aortic valve stenosis, became a candidate for aortic valve replacement (AVR) surgery and was scheduled for perioperative assessments including a right heart catheterization. The procedure started with a left common femoral vein (CFV) access because the right CFV had a central venous line (CV line) in place. After advancing the 0.035-inch J wire and some wire manipulation, resistance to the crossing was felt by the operator, so an injection was done using a right Judkins catheter (Figure 1). The operator continued wire manipulation to cross left CIV and IVC. The right heart catheterization was done successfully however the patient had gross hematuria after the procedure. Careful re-evaluation of images showed the contrast entrance into the left renal major calyces, through collateral vessels of the left common iliac vein severe stenosis of the left common iliac vein (LCIV), which was consistence with the May-Thurner syndrome (MTS), The patient’s hemodynamics was stable, with a blood pressure of 135/85 mmHg, a heart rate of 78 beats/minute, and arterial oxygen saturation of 96%. Regarding the diagnosis of MTS, and continuation of severe gross hematuria, the heart team decided to perform balloon venoplasty of the left common iliac vein with peripheral intervention balloons including the Cronus 6*40 mm (Rontis Medical) and the AltoSa XL 16*50 mm (AndraTec) (Figure 2 and Figure 3). Results after the procedure showed an appropriate opening of LCIV, with no remaining stenosis, and the mentioned collateral which led to blood extravasation disappeared (Figure 4). The venoplasty procedure was successful with good final results, but the stenting of LCIV wasn’t performed since the patient had ongoing gross hematuria and we couldn’t administer full anticoagulation. Regarding the results, the patient then closely followed up, and fortunately, after three hours, the hematuria stopped. The patient was hemodynamically stable, free of pain, and serial hemoglobin measurement didn’t show any drop. Abdominopelvic CT scan without contrast demonstrated significant contrast accumulation in the left renal pelvis and calyces compared to normal contrast excretion on the right side. Also, there were not any signs of extravasation of contrast, or perirenal collection suggestive of ongoing bleeding (Figure 5). Three days later, the patient was discharged from the hospital in good general condition.