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).