Challenging case of iliofemoral venous occlusion due to previous intravenous drug abuse crossed by sharp recanalization technique with subsequent endovascular stenting

Challenging case of iliofemoral venous occlusion due to previous intravenous drug abuse crossed by sharp recanalization technique with subsequent endovascular stenting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenging case of iliofemoral venous occlusion due to previous intravenous drug abuse crossed by sharp recanalization technique with subsequent endovascular stenting Paul Segui, Valérie Monnin-Bares, Hamid Zarqane, Juliette Vanovershelde, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7541593/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Recanalization of chronic venous occlusions is sometimes technically challenging. We present a rare case of venous occlusion, due to previous intravenous femoral drug use, with a fibrotic peri venous tissue in the groin, hard to cross. This patient presented severe venous claudication with active ulcer. After failure of conventional attempts, we opted for a more aggressive strategy using a modified Chiba needle assisted sharp recanalization technique. We achieved initial technical success in recanalization, but thrombosis eventually recurred due to residual compression on the created extravascular tract. Iliofemoral obstruction Post-thrombotic syndrome Sharp recanalization Endovascular therapy Venous stenting. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Endovascular treatment is currently the first-line approach in post-thrombotic syndrome management ( 1 – 4 ). However, recanalization of chronic venous occlusions is sometimes technically challenging. Sharp recanalization can help when obstructive lesions cannot be crossed with conventional techniques ( 5 ). We report the case of a hard fibrotic occlusion due to previous intravenous drug use, successfully crossed with a modified Chiba needle assisted sharp recanalization technique. Case Report A 51-year-old man presented with post-thrombotic syndrome of the left lower limb with an active venous ulcer and severe venous claudication with CIVIQ score of 77 and Villalta score of 22 ( 6 , 7 ). He had a history of deep vein thrombosis in 2010 in the context of intravenous drug use, with femoral vein injection complicated by local infection in groin area. Direct CT venography revealed post-thrombotic obstruction extending from the common femoral vein to the common iliac vein (Fig. 1 A). First endovascular procedure was scheduled under local anesthesia and sedation. Right internal jugular and left femoral vein were accessed by ultrasound-guided puncture. Retrograde recanalization was achieved to the level of the acetabulum but failed beyond it, despite using the back end of the guidewire and guiding sheath. Antegrade attempts were also unsuccessful and painful, with an extremely hard fibrous occlusion about 1 to 2 cm high in projection of the femoral head, which cannot be crossed (Fig. 2 ). CT venography review identified a perivenous fibrous thickening likely linked to prior intravenous drug use in the groin, corresponding to the area not crossed during first recanalization (Fig. 1 B). A multidisciplinary discussion led to a second attempt under general anesthesia 6 months later. We performed again a double jugular and left femoral venous access. Inspired by the Cupidon’s strike technique described in arterial recanalization( 8 ), we placed two 10 mm Amplatz Goose Neck snares (EV3) via each access above and below the fibrotic block (after prior balloon angioplasty to widen the lumen of the upper venous stump to allow proper opening of the loop) (Fig. 3 ). Under ultrasound guidance, we punctured the left femoral vein upstream from the lower snare with a 20G Chiba needle (88 mm). The needle was first inserted through the lower loop snare. Under fluoroscopic guidance using different angles, the needle was advanced endovenously as close as possible, crossing the occlusion. A 0.018-inch guidewire was inserted through the needle and upper snare was tightened over its tip. The tightened snare and the guidewire were moved en-bloc cephalad up to the jugular sheath placed through-and-through from the skin entry. The newly created tract was pre-dilated using 4- and 5-mm balloons. Then, a 4F CXI support catheter (Cook) was introduced from the jugular approach up to the lower snare. A 0.014-inch guidewire was inserted in the catheter and its soft tip was snared up to the femoral sheath with the 4F catheter. The 0.014-inch guidewire was then exchanged for a 0.035-inch stiff Amplatz wire and we performed a balloon angioplasty with 9 mm and 12 mm high-pressure balloons (Conquest, Bard), with final breakthrough achieved at 30 atm. After an additional 12 mm balloon angioplasty on iliac vein, we performed an ilio-femoral stenting with two overlapping 14x100 mm and 14x150 mm nitinol self-expanding stents (Optimed Sinusflex), dilated with 12- and 14-mm high pressure balloons. Completion venography demonstrated the restoration of rapid flow with washing and disappearance of collaterals. Patient initially showed clinical improvement in both scores (Villalta from 22 to 10; CIVIQ from 72 to 29). Doppler at day one demonstrated patency of stenting but the control at two weeks showed an occlusion confirmed by CT venography, also demonstrating an extravascular tract behind the fibrotic granuloma. A new intervention was planed two days later (Fig. 4 ). No material could be aspirated during the thrombectomy attempt. Venography showed irregularity of the intrastent lumen like a fatty protrusion through the stent mesh on extravascular segment. We decided to place a self-expandable covered stent (Viabahn, Gore) into the nitinol stent with an excellent angiographic result and stent patency on Doppler monitoring at day one. However, thrombosis recurred two weeks later due to insufficient radial force of the covered stent with an aspect of plication of the Viabahn compressed by the fibrotic granuloma on CT venography. Further stenting with a nitinol device was considered, but the patient already showed partial improvement and was poorly cooperative. Medical staff therefore rejected additional procedure. Discussion Sharp recanalization of occluded veins has been previously described, mainly for central venous recanalization ( 8 , 9 ). Most of post-thrombotic femoro-iliac occlusions can be crossed with conventional techniques with possible help of sheaths or triaxial catheters system. In this case, the uncrossable occlusion was due to a rock-solid fibrotic tissue of the groin due to previous drug injections in femoral vein. Indeed, chemical effect of injected drugs can lead to endothelial damage, thrombosis and destruction of surrounding soft tissues( 10 ). Chiba needle assisted sharp recanalization is usually performed through a 4F sheath placed in the upstream vein. Due to the short and superficial nature of this occlusion and because of the venous curvature, we opted for a direct percutaneous puncture between two loop snares, placed via each access, enabling accurate orientation of the needle trajectory and successful passage through the rigid fibrotic occlusion. The use of a transseptal needle could have been discussed, with possible adjustable curvature, but a limitation of this device is the increased difficulty in penetrating heavily fibrotic occlusions. ( 5 ). We should have used a covered stent from the first procedure because of the partially extravascular tract but we chose nitinol self-expanding dedicated venous stent with open-cell design for its radial strength. The best solution would probably have been to use a covered stent from the outset, strengthened by a nitinol stent inside. Procedural CBCT images would have allowed us to better understand the recanalization path and thus guide the choice of stents. Conclusion Sharp recanalization of challenging occlusions may require creative approaches. Despite the disappointing mid-term patency outcomes associated with this procedure, this original approach initially made it possible to successfully cross an extremely hard occlusion related to drug crystals without complication. Declarations Ethics approval and consent to participate : NA Consent for publication : Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials : My manuscript has no associated data Competing interests : No Competing interests are at stake and there is “No Conflict of Interest” with other people or organizations that could inappropriately influence or bias the content of the paper Funding : NA Authors' contributions : All authors have seen and approved the manuscript and have contributed significantly for the paper. Acknowledgements : None References Qiu P, Zha B, Xu A, Wang W, Zhan Y, Zhu X et al (2019) Systematic Review and Meta-Analysis of Iliofemoral Stenting for Post-thrombotic Syndrome. Eur J Vasc Endovasc Surg Off J Eur Soc Vasc Surg mars 57(3):407–416 David A, Thony F, Del Giudice C, Goyault G, Loffroy R, Guillen K et al (2022) Short- and Mid-Term Outcomes of Endovascular Stenting for the Treatment of Post-Thrombotic Syndrome due to Iliofemoral and Caval Occlusive Disease: A Multi-Centric Study from the French Society of Diagnostic and Interventional Cardiovascular Imaging (SFICV). Cardiovasc Intervent Radiol févr 45(2):162–171 Guillen K, Falvo N, Nakai M, Chevallier O, Aho-Glélé S, Galland C et al (2020) Endovascular stenting for chronic femoro-iliac venous obstructive disease: Clinical efficacy and short-term outcomes. Diagn Interv Imaging janv 101(1):15–23 Mahnken AH, Thomson K, De Haan M, O’Sullivan GJ CIRSE Standards of Practice Guidelines on Iliocaval Stenting. Cardiovasc Intervent Radiol [Internet]. 15 mars 2014 [cité 23 févr 2024]; Disponible sur: http://link.springer.com/ 10.1007/s00270-014-0875-4 Rizk T, Gayed A, Stringfellow S, Younan Y, Yamada R, Guimaraes M (2024) Review of Sharp Recanalization Techniques in Central Venous Occlusions. Cardiovasc Intervent Radiol déc 47(12):1626–1641 Lattimer CR, Kalodiki E, Azzam M, Geroulakos G (2014) Validation of the Villalta scale in assessing post-thrombotic syndrome using clinical, duplex, and hemodynamic comparators. J Vasc Surg Venous Lymphat Disord janv 2(1):8–14 Launois R, Mansilha A, Jantet G (2010) International Psychometric Validation of the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20). Eur J Vasc Endovasc Surg déc 40(6):783–789 Gahide G, Bui BT, Beland M (2021) The Cupidon’s Strike Technique: How to Never Miss a Rendezvous While Going on SAFARI. Ann Vasc Surg janv 70:555–558 Frenk NE, Choi TJ, Park LS, Cohen EI, Lynskey GE, Sabri SS (2023) Safety and Feasibility of Gun-Sight Technique for Transjugular Intra-hepatic Portosystemic Shunt (TIPS) Creation. Cardiovasc Intervent Radiol sept 46(9):1238–1248 Fiddes R, Khattab M, Abu Dakka M, Al-Khaffaf H (2010) Patterns and management of vascular injuries in intravenous drug users: a literature review. Surg J R Coll Surg Edinb Irel déc 8(6):353–361 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7541593","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514189695,"identity":"61c9413c-e3c4-46bc-86fd-af46ca43f8e7","order_by":0,"name":"Paul Segui","email":"","orcid":"","institution":"CHRU de Montpellier: Centre Hospitalier Universitaire de Montpellier","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Segui","suffix":""},{"id":514189696,"identity":"97739ce9-ded2-4cc4-b1e9-6e2324432fc6","order_by":1,"name":"Valérie Monnin-Bares","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYPACCQZ+Bh44j/HAAwMgxXwAvxbJBqgWEHUgAaSFLQG/PQYHULQw4NZicIA78XHhDos84+Nnj0kw5tjk2Us3HziQUGCTz8DG+wC7Ft7NxjPPSBSbnclLk2DcllbMI3MsAeiwNMsGNnYDbFok57/dJs3bJpG47QaPmfTfbYcTeyRyDIBaDhswyLdhdZhkAy9Ey+YZPGZAW0Ba8j8Atfw3YGBjw6qFnwGqZYMEXEsOKMQO4NOy2RikZcaZHGMLoF8Se+4cAzks2YANhxY2Bt6Nj3nb6hL7288Y3mDcZpPYPrv54YMPf+wM+HFowQIk4KYRDSQIKxkFo2AUjIKRBQBcc1aH1qJoCQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-0405-0614","institution":"CHRU de Montpellier: Centre Hospitalier Regional Universitaire de Montpellier","correspondingAuthor":true,"prefix":"","firstName":"Valérie","middleName":"","lastName":"Monnin-Bares","suffix":""},{"id":514189697,"identity":"0cd5ce6f-a6f9-4672-9e0e-a334f9819e0f","order_by":2,"name":"Hamid Zarqane","email":"","orcid":"","institution":"CHRU de Montpellier: Centre Hospitalier Universitaire de Montpellier","correspondingAuthor":false,"prefix":"","firstName":"Hamid","middleName":"","lastName":"Zarqane","suffix":""},{"id":514189698,"identity":"5b401d8b-ead0-473c-88a1-3b649246b754","order_by":3,"name":"Juliette Vanovershelde","email":"","orcid":"","institution":"CHRU de Montpellier: Centre Hospitalier Universitaire de Montpellier","correspondingAuthor":false,"prefix":"","firstName":"Juliette","middleName":"","lastName":"Vanovershelde","suffix":""},{"id":514189699,"identity":"e149d142-cd00-4fb1-af5d-68d9df9860d5","order_by":4,"name":"Sébastien Bommart","email":"","orcid":"","institution":"CHRU de Montpellier: Centre Hospitalier Universitaire de Montpellier","correspondingAuthor":false,"prefix":"","firstName":"Sébastien","middleName":"","lastName":"Bommart","suffix":""},{"id":514189700,"identity":"4e0bb5c9-b1b1-42e4-98f8-555e04382ca2","order_by":5,"name":"Hélène Vernhet-Kovacsik","email":"","orcid":"","institution":"CHRU de Montpellier: Centre Hospitalier Universitaire de Montpellier","correspondingAuthor":false,"prefix":"","firstName":"Hélène","middleName":"","lastName":"Vernhet-Kovacsik","suffix":""}],"badges":[],"createdAt":"2025-09-05 07:10:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7541593/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7541593/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91931496,"identity":"46df664e-9360-4979-bdcf-ea935758e49f","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":461267,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURES.docx","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/846f23aa758ff260ac700a25.docx"},{"id":91931488,"identity":"421b3b09-7626-41b7-94ff-e05e9de2e125","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9469,"visible":true,"origin":"","legend":"","description":"","filename":"cireCIRED2500318.xml","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/adaf6e983e440f792b70e850.xml"},{"id":91931492,"identity":"92b75e57-6e42-4f03-87d9-f1ce2ea6af7e","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":959,"visible":true,"origin":"","legend":"","description":"","filename":"CIRED25003185969.go.xml","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/db738a5c8777f0cc7f38c9e3.xml"},{"id":91933937,"identity":"c1a6790a-86bb-45fd-95e2-8251f7874924","added_by":"auto","created_at":"2025-09-23 02:39:09","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":951,"visible":true,"origin":"","legend":"","description":"","filename":"CIRED2500318Import.xml","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/2e14ebc4cb960d9e2f3f7875.xml"},{"id":91931494,"identity":"bf671234-78ca-474d-8b77-07d9ab406f4c","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":31772,"visible":true,"origin":"","legend":"","description":"","filename":"CIRED25003180enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/f6ace7e96bbf209890825a5a.xml"},{"id":91931493,"identity":"bd762d2f-f842-449c-b694-174c5ac456ad","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"emf","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":20820,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.emf","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/977ef1cd4e74182ab656943a.emf"},{"id":91936364,"identity":"c7f3ad6e-180f-4ad5-bf67-6064d81c0f14","added_by":"auto","created_at":"2025-09-23 02:47:09","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":422894,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/274bd7f6c7706912416f5d5d.jpeg"},{"id":91931506,"identity":"42131e9b-3c15-4e80-be11-bc48eb58e22c","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":574247,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/cf43e62e39757421bdcb0278.jpeg"},{"id":91933944,"identity":"1e4f21a3-990c-4af1-af62-65c2c4819989","added_by":"auto","created_at":"2025-09-23 02:39:09","extension":"jpeg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":501491,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/f47428e3ee499e5700c141c6.jpeg"},{"id":91933954,"identity":"80038f4f-8cd4-4f29-aeef-253ef55d454a","added_by":"auto","created_at":"2025-09-23 02:39:09","extension":"jpeg","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111122,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/c1d0b1d9e0994b05b17290ca.jpeg"},{"id":91931503,"identity":"8b786996-9de3-4afe-af1b-8fbe16dca574","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17371,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/f07e4830bfcf5aa724a34f63.png"},{"id":91931500,"identity":"63aef9bc-1242-496f-a160-28c0c0ec4a8e","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127084,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/6bde368d742d9b7d310f7054.png"},{"id":91931498,"identity":"8f1ecffb-93ef-4ee6-900b-40ef853ff559","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":867470,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/b9712fe228fd5cdea7459fe6.png"},{"id":91933939,"identity":"8a42583c-e915-4cb6-a2e4-492b516cdd66","added_by":"auto","created_at":"2025-09-23 02:39:09","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":846230,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/d567c9651af0711d08eca6b2.png"},{"id":91931507,"identity":"48e0e149-fc2a-4a02-86fd-81ef6e99cfe0","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":400432,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/f20d62b61e8e49d7ef387cbf.png"},{"id":91931505,"identity":"e6f3a799-2f30-4fb9-b9ae-4b1519d0b64a","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":30886,"visible":true,"origin":"","legend":"","description":"","filename":"CIRED25003180structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/6a22e66a12205785eba2a1cc.xml"},{"id":91933941,"identity":"0583a5b4-e89a-4d99-b772-6155593d06aa","added_by":"auto","created_at":"2025-09-23 02:39:09","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":35000,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/5cf5d9d278a9a7db21d59860.html"},{"id":91931487,"identity":"fec63087-a1a1-407e-be25-1ea66d10d8c2","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29147,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA \u003c/strong\u003eDirect CT venography with VRT reconstruction shows complete occlusion of left common femoral vein in projection of the femoral head with post thrombotic stenosis of iliac vein with a preserved femoropopliteal axis. \u003cstrong\u003eB \u003c/strong\u003eAxial native image shows fibrotic peri venous tissue in the groin (\u003cem\u003earrows\u003c/em\u003e), due to previous intravenous femoral drug use\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/2e86a7f47cd2f48c86db8325.jpg"},{"id":91931491,"identity":"412fc555-3162-4b09-a5dc-37b68ceaf6c9","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20863,"visible":true,"origin":"","legend":"\u003cp\u003eFirst endovascular procedure: venogram \u003cstrong\u003e(A/B)\u003c/strong\u003econfirms total occlusion of the left common femoral vein with failure of antegrade and retrograde attempts to cross it despite using the back end of the guidewire and guiding sheath \u003cstrong\u003e(C)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/3d4926e6ec98ef660900d841.jpg"},{"id":91931490,"identity":"fb3f6cdb-985e-4159-ac5d-23e926905b33","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28266,"visible":true,"origin":"","legend":"\u003cp\u003eSecond endovascular procedure: (\u003cstrong\u003eA)\u003c/strong\u003e Two 10 mm Amplatz Goose Neck snares are placed via each access upon contact with each venous stump above and below the fibrotic block. (\u003cstrong\u003eB)\u003c/strong\u003e The needle is gradually advanced under fluoroscopic guidance using different angles, endovenously as close as possible, crossing the occlusion. (\u003cstrong\u003eC)\u003c/strong\u003e The 0.018-inch guidewire inserted through the needle and upper snare is tightened over its tip. (\u003cstrong\u003eD)\u003c/strong\u003e Pre-dilatation of the newly created tract with a 4 mm balloon. (\u003cstrong\u003eE) \u003c/strong\u003eEndovascular stenting and angioplasty. \u003cstrong\u003e(F)\u003c/strong\u003e Completion venography shows the restoration of flow with disappearance of collaterals\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/f95484076b4bfb8cb4035f30.jpg"},{"id":91931489,"identity":"6c567ef3-e828-4df4-a253-c18a1bd03b8a","added_by":"auto","created_at":"2025-09-23 02:31:09","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":17070,"visible":true,"origin":"","legend":"\u003cp\u003eLast endovascular procedure: \u003cstrong\u003e(A)\u003c/strong\u003e Venography shows irregularity of the intrastent lumen like a fatty protrusion through the stent mesh on extravascular segment. \u003cstrong\u003e(B)\u003c/strong\u003e Completion venography shows the restoration of stent patency and disappearance of collaterals.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/f39d746724d3b60296bee9c1.jpg"},{"id":92695232,"identity":"4ba833bd-5b54-480a-988d-d5b171c409fd","added_by":"auto","created_at":"2025-10-03 06:44:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":406571,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7541593/v1/396072db-5898-43e7-957c-be36e4c14c38.pdf"}],"financialInterests":"","formattedTitle":"Challenging case of iliofemoral venous occlusion due to previous intravenous drug abuse crossed by sharp recanalization technique with subsequent endovascular stenting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndovascular treatment is currently the first-line approach in post-thrombotic syndrome management (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, recanalization of chronic venous occlusions is sometimes technically challenging. Sharp recanalization can help when obstructive lesions cannot be crossed with conventional techniques (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). We report the case of a hard fibrotic occlusion due to previous intravenous drug use, successfully crossed with a modified Chiba needle assisted sharp recanalization technique.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 51-year-old man presented with post-thrombotic syndrome of the left lower limb with an active venous ulcer and severe venous claudication with CIVIQ score of 77 and Villalta score of 22 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). He had a history of deep vein thrombosis in 2010 in the context of intravenous drug use, with femoral vein injection complicated by local infection in groin area.\u003c/p\u003e\u003cp\u003eDirect CT venography revealed post-thrombotic obstruction extending from the common femoral vein to the common iliac vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFirst endovascular procedure was scheduled under local anesthesia and sedation. Right internal jugular and left femoral vein were accessed by ultrasound-guided puncture. Retrograde recanalization was achieved to the level of the acetabulum but failed beyond it, despite using the back end of the guidewire and guiding sheath. Antegrade attempts were also unsuccessful and painful, with an extremely hard fibrous occlusion about 1 to 2 cm high in projection of the femoral head, which cannot be crossed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eCT venography review identified a perivenous fibrous thickening likely linked to prior intravenous drug use in the groin, corresponding to the area not crossed during first recanalization (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003eA multidisciplinary discussion led to a second attempt under general anesthesia 6 months later.\u003c/p\u003e\u003cp\u003eWe performed again a double jugular and left femoral venous access. Inspired by the Cupidon\u0026rsquo;s strike technique described in arterial recanalization(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), we placed two 10 mm Amplatz Goose Neck snares (EV3) via each access above and below the fibrotic block (after prior balloon angioplasty to widen the lumen of the upper venous stump to allow proper opening of the loop) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Under ultrasound guidance, we punctured the left femoral vein upstream from the lower snare with a 20G Chiba needle (88 mm). The needle was first inserted through the lower loop snare. Under fluoroscopic guidance using different angles, the needle was advanced endovenously as close as possible, crossing the occlusion. A 0.018-inch guidewire was inserted through the needle and upper snare was tightened over its tip. The tightened snare and the guidewire were moved en-bloc cephalad up to the jugular sheath placed through-and-through from the skin entry. The newly created tract was pre-dilated using 4- and 5-mm balloons. Then, a 4F CXI support catheter (Cook) was introduced from the jugular approach up to the lower snare. A 0.014-inch guidewire was inserted in the catheter and its soft tip was snared up to the femoral sheath with the 4F catheter. The 0.014-inch guidewire was then exchanged for a 0.035-inch stiff Amplatz wire and we performed a balloon angioplasty with 9 mm and 12 mm high-pressure balloons (Conquest, Bard), with final breakthrough achieved at 30 atm. After an additional 12 mm balloon angioplasty on iliac vein, we performed an ilio-femoral stenting with two overlapping 14x100 mm and 14x150 mm nitinol self-expanding stents (Optimed Sinusflex), dilated with 12- and 14-mm high pressure balloons. Completion venography demonstrated the restoration of rapid flow with washing and disappearance of collaterals.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePatient initially showed clinical improvement in both scores (Villalta from 22 to 10; CIVIQ from 72 to 29). Doppler at day one demonstrated patency of stenting but the control at two weeks showed an occlusion confirmed by CT venography, also demonstrating an extravascular tract behind the fibrotic granuloma. A new intervention was planed two days later (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). No material could be aspirated during the thrombectomy attempt. Venography showed irregularity of the intrastent lumen like a fatty protrusion through the stent mesh on extravascular segment. We decided to place a self-expandable covered stent (Viabahn, Gore) into the nitinol stent with an excellent angiographic result and stent patency on Doppler monitoring at day one. However, thrombosis recurred two weeks later due to insufficient radial force of the covered stent with an aspect of plication of the Viabahn compressed by the fibrotic granuloma on CT venography. Further stenting with a nitinol device was considered, but the patient already showed partial improvement and was poorly cooperative. Medical staff therefore rejected additional procedure.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSharp recanalization of occluded veins has been previously described, mainly for central venous recanalization (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Most of post-thrombotic femoro-iliac occlusions can be crossed with conventional techniques with possible help of sheaths or triaxial catheters system.\u003c/p\u003e\u003cp\u003eIn this case, the uncrossable occlusion was due to a rock-solid fibrotic tissue of the groin due to previous drug injections in femoral vein. Indeed, chemical effect of injected drugs can lead to endothelial damage, thrombosis and destruction of surrounding soft tissues(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eChiba needle assisted sharp recanalization is usually performed through a 4F sheath placed in the upstream vein. Due to the short and superficial nature of this occlusion and because of the venous curvature, we opted for a direct percutaneous puncture between two loop snares, placed via each access, enabling accurate orientation of the needle trajectory and successful passage through the rigid fibrotic occlusion. The use of a transseptal needle could have been discussed, with possible adjustable curvature, but a limitation of this device is the increased difficulty in penetrating heavily fibrotic occlusions. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe should have used a covered stent from the first procedure because of the partially extravascular tract but we chose nitinol self-expanding dedicated venous stent with open-cell design for its radial strength. The best solution would probably have been to use a covered stent from the outset, strengthened by a nitinol stent inside. Procedural CBCT images would have allowed us to better understand the recanalization path and thus guide the choice of stents.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSharp recanalization of challenging occlusions may require creative approaches. Despite the disappointing mid-term patency outcomes associated with this procedure, this original approach initially made it possible to successfully cross an extremely hard occlusion related to drug crystals without complication.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eEthics approval and consent to participate\u0026nbsp;: NA\u003c/li\u003e\n \u003cli\u003eConsent for publication\u0026nbsp;: Written informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/li\u003e\n \u003cli\u003eAvailability of data and materials\u0026nbsp;: My manuscript has no associated data\u003c/li\u003e\n \u003cli\u003eCompeting interests\u0026nbsp;: No Competing interests are at stake and there is “No Conflict of Interest” with other people or organizations that could inappropriately influence or bias the content of the paper\u003c/li\u003e\n \u003cli\u003eFunding\u0026nbsp;: NA\u003c/li\u003e\n \u003cli\u003eAuthors' contributions\u0026nbsp;: All authors have seen and approved the manuscript and have contributed significantly for the paper.\u003c/li\u003e\n \u003cli\u003eAcknowledgements : None\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eQiu P, Zha B, Xu A, Wang W, Zhan Y, Zhu X et al (2019) Systematic Review and Meta-Analysis of Iliofemoral Stenting for Post-thrombotic Syndrome. Eur J Vasc Endovasc Surg Off J Eur Soc Vasc Surg mars 57(3):407\u0026ndash;416\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavid A, Thony F, Del Giudice C, Goyault G, Loffroy R, Guillen K et al (2022) Short- and Mid-Term Outcomes of Endovascular Stenting for the Treatment of Post-Thrombotic Syndrome due to Iliofemoral and Caval Occlusive Disease: A Multi-Centric Study from the French Society of Diagnostic and Interventional Cardiovascular Imaging (SFICV). Cardiovasc Intervent Radiol f\u0026eacute;vr 45(2):162\u0026ndash;171\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuillen K, Falvo N, Nakai M, Chevallier O, Aho-Gl\u0026eacute;l\u0026eacute; S, Galland C et al (2020) Endovascular stenting for chronic femoro-iliac venous obstructive disease: Clinical efficacy and short-term outcomes. Diagn Interv Imaging janv 101(1):15\u0026ndash;23\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMahnken AH, Thomson K, De Haan M, O\u0026rsquo;Sullivan GJ CIRSE Standards of Practice Guidelines on Iliocaval Stenting. Cardiovasc Intervent Radiol [Internet]. 15 mars 2014 [cit\u0026eacute; 23 f\u0026eacute;vr 2024]; Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://link.springer.com/\u003c/span\u003e\u003cspan address=\"http://link.springer.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00270-014-0875-4\u003c/span\u003e\u003cspan address=\"10.1007/s00270-014-0875-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRizk T, Gayed A, Stringfellow S, Younan Y, Yamada R, Guimaraes M (2024) Review of Sharp Recanalization Techniques in Central Venous Occlusions. Cardiovasc Intervent Radiol d\u0026eacute;c 47(12):1626\u0026ndash;1641\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLattimer CR, Kalodiki E, Azzam M, Geroulakos G (2014) Validation of the Villalta scale in assessing post-thrombotic syndrome using clinical, duplex, and hemodynamic comparators. J Vasc Surg Venous Lymphat Disord janv 2(1):8\u0026ndash;14\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLaunois R, Mansilha A, Jantet G (2010) International Psychometric Validation of the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20). Eur J Vasc Endovasc Surg d\u0026eacute;c 40(6):783\u0026ndash;789\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGahide G, Bui BT, Beland M (2021) The Cupidon\u0026rsquo;s Strike Technique: How to Never Miss a Rendezvous While Going on SAFARI. Ann Vasc Surg janv 70:555\u0026ndash;558\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrenk NE, Choi TJ, Park LS, Cohen EI, Lynskey GE, Sabri SS (2023) Safety and Feasibility of Gun-Sight Technique for Transjugular Intra-hepatic Portosystemic Shunt (TIPS) Creation. Cardiovasc Intervent Radiol sept 46(9):1238\u0026ndash;1248\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFiddes R, Khattab M, Abu Dakka M, Al-Khaffaf H (2010) Patterns and management of vascular injuries in intravenous drug users: a literature review. Surg J R Coll Surg Edinb Irel d\u0026eacute;c 8(6):353\u0026ndash;361\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Iliofemoral obstruction, Post-thrombotic syndrome, Sharp recanalization, Endovascular therapy, Venous stenting.","lastPublishedDoi":"10.21203/rs.3.rs-7541593/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7541593/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eRecanalization of chronic venous occlusions is sometimes technically challenging. We present a rare case of venous occlusion, due to previous intravenous femoral drug use, with a fibrotic peri venous tissue in the groin, hard to cross. This patient presented severe venous claudication with active ulcer. After failure of conventional attempts, we opted for a more aggressive strategy using a modified Chiba needle assisted sharp recanalization technique. We achieved initial technical success in recanalization, but thrombosis eventually recurred due to residual compression on the created extravascular tract.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e","manuscriptTitle":"Challenging case of iliofemoral venous occlusion due to previous intravenous drug abuse crossed by sharp recanalization technique with subsequent endovascular stenting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 02:31:04","doi":"10.21203/rs.3.rs-7541593/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"118d04d4-7592-4b93-a03d-e8d7e1ab0de3","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-03T06:36:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 02:31:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7541593","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7541593","identity":"rs-7541593","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}