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.