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J Vasc Surg Cases Innov Tech
J Vasc Surg Cases Innov Tech
Journal of Vascular Surgery Cases, Innovations and Techniques
2468-4287
Elsevier

S2468-4287(24)00177-1
10.1016/j.jvscit.2024.101593
101593
Case report
Polyethylene debris following metal-on-metal total hip arthroplasty as a rare cause of symptomatic iliac vein compression and iliofemoral deep venous thrombosis
Hanif Hamza MD a
Clark Ross M. MD, MBA, RPVI b
Gehlert Rick MD c
Danczyk Rachel MD b
Chavez LeAnn MD, MBA, FACS, RPVI b
Ali Rana Muhammad MD, FACS, FSVS mrana@salud.unm.edu
b∗
a Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
b Division of Vascular Surgery, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
c Division of UNM Department of Orthopaedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, NM
∗ Correspondence: Muhammad Ali Rana, MD, FACS, FSVS, Chief, Division of Vascular Surgery, Interim Chief, Division of Cardiothoracic Surgery, Director of Endovascular Surgery, Associate Professor, University of New Mexico, Department of Surgery, 1 University of New Mexico, MSC 10 5610, Albuquerque, NM 87109 mrana@salud.unm.edu
05 8 2024
12 2024
05 8 2024
10 6 10159318 5 2024
17 7 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Extrinsic venous compression of the pelvic vasculature is associated with deep venous thrombosis of the iliac veins. Inflammatory pseudotumors are a known rare complication of metal-on-metal and metal-on-polyethylene hip resurfacing, We report the case of a 73-year-old woman with such a pseudotumor compressing the left iliac vein with associated deep venous thrombosis extending distally into the lower leg. In this case, we demonstrate safe and effective use of endovascular techniques, including percutaneous mechanical thrombectomy and iliac vein stenting, followed by revision total hip arthroplasty and excision of the pseudotumor.

Keywords

Deep venous thrombosis
Inflammatory pseudotumor
Percutaneous mechanical thrombectomy
Iliac vein stenting
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pmcExtrinsic venous compression of the pelvic vasculature increases the risk of deep venous thrombosis (DVT) of the iliac veins.1 Iliac vein compression syndrome, pelvic tumors, and other such pathologies are some of the implicated etiologies historically associated with DVT. Pseudotumors are a well-known complication of total hip arthroplasties (THAs). These are non-neoplastic masses that form from a biological response to wear debris of several materials, most commonly polyethylene particles.2 We report a case of a 73-year-old woman with symptomatic DVT of the left iliac vein owing to external compression from a pseudotumor, for which a combination of endovascular and open techniques were used for treatment. The patient provided consent to share the clinical details of her case.

Case report

A 73-year-old woman presented to the emergency department for evaluation of worsening left leg swelling over a 1-month period. She had history of bilateral THAs for developmental hip dysplasia >40 years ago. On physical examination, the left lower extremity was significantly edematous with whitish discoloration concerning for phlegmasia alba dolens. Subsequent imaging, including a computed tomography scan of the abdomen and pelvis with venous phase contrast demonstrated a large, rounded, multiloculated masses bilaterally with a larger mass on the left centered around the hip, with high-grade compression of the left external iliac vein (Fig 1). Distally, significant soft tissue swelling was present with occlusive thrombosis of the left distal external iliac vein. A venous duplex scan of the lower extremity revealed an acute appearing, occlusive DVT visualized within the external iliac, common femoral, femoral, popliteal, posterior tibial, peroneal, and gastrocnemius veins.Fig 1 (A) Preoperative computed tomography venogram demonstrating inflammatory pseudotumor completely occluding the left external iliac vein. (B) Severe soft tissue edema in the left lower extremity.

The vascular surgery team, after extensive discussion with the orthopedic team, prioritized percutaneous mechanical thrombectomy (PMT) to the relieve the venous obstruction and treat the threatened leg, followed by resection for the compressing lesion. With the patient in a prone position, the left popliteal vein was accessed under ultrasound guidance. A Glidewire was passed through the popliteal, femoral, and iliac veins into the inferior vena cava. Iliofemoral venograms confirmed thrombosis of the left femoral vein, extending up to the proximal external iliac and distal part of the left common iliac vein (Fig 2). An Inari ClotTriever (Inari Medical, Irvine, CA) venous thrombectomy device sheath was then advanced across the thrombus into the vena cava with the wire tip in the right innominate vein. The collection bag was advanced into the vena cava and then retracted. With multiple passes, a significant amount of thrombus was retrieved from the external iliac and femoral venous portions. A post-thrombectomy venogram demonstrated fixed high-grade compression of the distal external iliac vein. An 18 x 60-millimeter Wallstent was selected based on the diameter of the contralateral external iliac vein on a preoperative computed tomography venogram after oversizing by 50%. This stent was deployed within the external iliac vein, spanning from the common iliac bifurcation to the superior border of the inguinal ligament. A 14-mm angioplasty balloon was then used to dilate the stenotic segment. Completion venogram demonstrated excellent patency restored within the left external iliac, femoral, and popliteal veins (Fig 3).Fig 2 (A and B) Intraoperative digital subtracted images of the venogram demonstrating high-grade stenosis of left external iliac vein with deep venous thrombosis (DVT) extending into the lower extremity.

Fig 3 (A) Post-thrombectomy venogram demonstrating complete retrieval thrombi, with persistent high-grade stenosis at the left external iliac vein. (B) Completion venogram demonstrating complete resolution of stenosis with an iliac vein Wallstent.

The patient was discharged home the following day and was prescribed therapeutic enoxaparin subcutaneous injections. Two weeks later, she was taken to the operating room electively by the orthopedic team for mass excision and revision THA. Severe polyethylene wear debris was noted around the hip joint during this procedure, with debris cysts compressing the left common iliac vein. This cystic wear was excised to remove the external pressure on the pelvic vasculature. Her postoperative recovery was unremarkable. The patient was prescribed rivaroxaban on discharge for 6 months. Upon her follow-up at 12 months after the initial procedure, the left lower extremity edema had resolved completely. A repeat duplex study was obtained which showed complete resolution of DVT with a patent iliac vein stent.

Discussion

Extrinsic venous compression of the iliocaval vessels leading to iliac vein DVT has previously been described with multiple etiologies. Inflammatory pseudotumors are a known complication of hip resurfacing. This type of metal-on-metal and metal-on-polyethylene THAs were popularized in the 1990s. These pseudotumors are rare, with a reported incidence of 1% in 5 years. The onset of symptoms is usually multiple years after the initial THA. External compression of the surrounding structures from this development can lead to multiple complications, including nerve palsies, persistent pain, ureteral obstruction, and DVT.3

Pseudotumors with associated iliac vein DVT have been reported previously in very few case reports. These were treated with mass excision and revision THA, with or without placement of a temporary inferior vena cava filter. In one case, catheter-directed thrombolysis (CDT) was also used.4, 5, 6, 7 In our patient, mechanical thrombectomy was performed before surgical excision, decreasing the risk of clot dislodgement. This case report is the first to demonstrate a safe and effective combination of endovascular venous thrombectomy with subsequent open surgical intervention for the treatment of a pseudotumor causing DVT owing to mass effect.

Endovascular management of acute DVT has gained popularity in the past decade. These techniques include CDT, PMT, and endovenous stenting. Multiple recent meta-analyses and systematic reviews have demonstrated the safety and efficacy of PMT for lower extremity DVT.8 In a 2018 meta-analysis that included 1323 patients who underwent PMT and CDT for acute DVT, Wang et al9 demonstrated a partial (>50%) and complete lysis rate of 93.4% and 67.0%, respectively. The long-term outcomes were also satisfactory, with a rethrombosis rate of 10.6%, and post-thrombotic syndrome in 15.1%.9 When comparing CDT with PMT, another meta-analysis showed PMT to decrease post-thrombotic syndrome and have fewer bleeding complications.10

Endovascular techniques are being used in other etiologies as well, causing external venous compression. In a retrospective study consisting of 46 patients with acute DVT caused by iliac vein compression syndrome, a technical success rate of 100% was achieved with iliac vein stenting and CDT. Mid-term follow-up revealed >90% primary patency rates at the 24-month follow-up.11 The long-term patency rates of iliac vein stenting are high in general.12 Our patient had external venous compression from the pseudotumor itself; however, her symptoms were similar to those in iliac vein compression syndrome. In patients with a prior history of pelvic surgeries, including hip arthroplasties presenting with DVT, axial imaging should be obtained to evaluate for externally compressing lesions.

Conclusions

We have presented a patient with extensive DVT of iliac vein extending distally into the lower leg veins. With a combination of endovascular techniques including PMT and iliac vein stenting, followed by delayed revision THA, our patient had near-complete resolution of symptoms with a good short-term outcome. Further studies to analyze long-term outcomes in these patients are needed to standardize treatment.

Disclosures

None.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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