Introduction
Here we introduce a lady, undergoing right heart catheterization for her
perioperative evaluations through the left femoral vein, and at the
beginning of the procedure, the wire crossed from the left external
iliac vein into the collateral veins and some upward branches.
Afterward, the operator redirected the wire into the common iliac vein
and inferior vena cava and performed the right heart catheterization.
Thereafter the patient developed severe ongoing gross hematuria. Careful
reevaluation of the procedure revealed a nearly occluded left common
iliac vein with many collaterals indicating the unknown diagnosis of
May-Thurner syndrome in a patient with no known history of deep vein
thrombosis.
Right heart catheterization (RHC) is a procedure that is commonly
performed for a variety of indications, including pulmonary artery
hypertension assessment and management, evaluation of valvular heart
diseases, and providing a diagnostic tool for the determination of
intracardiac pressures and hemodynamics, which can guide the treatment
strategies for cardiologists handling heart failure patients (1). RHC is
usually done under fluoroscopy guidance and the venous access can be via
the internal jugular vein, subclavian vein, antecubital vein, or femoral
vein (2). After vascular sheath insertion, a diagnostic angiographic
catheter (often an MPA1 catheter) is introduced over a 0.035-inch J
guidewire through the common iliac vein, inferior vena cava, and then to
the right atrium, right ventricle, and pulmonary artery respectively. In
a study by Hoeper et al, among 7218 RHCs, the overall number of serious
complications related to the procedure was 76 cases (1.1%, 95% CI=
0.8% to 1.3%), which the most frequent event being access-site
complications (hematoma and pneumothorax), arrhythmias and vasovagal
reactions, and three patients (0.052%) died (3).
Renal perforation during heart catheterization is an extremely rare
complication. Peters et al. reported a 55 years old male, who suspected
dilated cardiomyopathy and was scheduled for a left heart
catheterization via right femoral artery access. After the procedure,
the patient developed hematuria with back pain and the multidetector CT
scan revealed a retroperitoneal hematoma and renal perforation (4).
However, to the best of our knowledge, this adverse event has not been
reported during right heart catheterization to date.
Iliac venoplasty is an effective treatment for individuals with
symptomatic stenosis of common iliac veins (CIV). This condition could
be developed as a consequence of compression of the left common iliac
vein (CIV) between the right common iliac artery (crossing anterior to
the vein) and vertebral body, which is recognized as the May-Thurner
syndrome. Due to the chronic obstruction, many collateral veins
including engorged cross-pelvic and other complex vascular networks
could be found in venography, which is the gold-standard diagnostic
method for establishing the diagnosis (5).