Chronic common femoral vein occlusion secondary to endometriosis

A 26-year-old female presented to an outside hospital with right lower extremity swelling and groin pain. Her symptoms were unrelated to menses. A diagnosis of right external iliac and common femoral vein thrombosis was made. An asymptomatic subsegmental pulmonary embolus was also found. Although her grandmother had a history of DVT, there was none in her immediate family members. The patient had a 4 pack-year smoking history, and quit smoking immediately after her initial presentation. She had never been on oral contraceptives. At the outside hospital, an inferior vena cava filter was inserted, and the patient had an unsuccessful trial of thrombolysis followed by warfarin therapy. Her hypereoagulable workup was negative. Five months later, her local surgeon attempted excision of a mass in the right groin that was causing compression on her vein. The operation was aborted due to difficulties in dissection. The biopsy performed revealed endometriosis. Six months after the initial diagnosis of DVT, repeated computed tomography angiography and magnetic resonance angiography at our hospital both revealed a soft tissue mass (2.2 cm × 2.6 cm) in the right inguinal region medial to the right common femoral artery with external compression of the right common femoral vein ( Fig 1 ). Thrombi were identified in the right common femoral vein, but the right femoral and iliac veins were patent without filling defects. Bilateral gonadal veins were dilated and tortuous. Gynecology consultation determined that medical therapy would be ineffective to reduce the size of the mass. Because of her persistent severe groin pain, and the external compression of the common femoral vein caused by this mass, resection with possible femoral vein repair or bypass was recommended. The procedure started with a right groin crease incision over the previously created surgical scar. Extensive dissection had to be performed, as there was severe fibrodc tissue surrounding the mass. Frozen section of the mass and femoral vein revealed fibrosis with endometriosis and chronic inflammation without pathologic change of the vascular wall. The mass arose from the femoral canal and adhered to surrounding planes ( Fig 2 ), The femoral nerve and artery were dissected from the mass. Attempts to separate the mass from the common femoral vein failed. It was evident that the involved segment of the common femoral vein (7 cm) was completely fibrotic and encased circumferentially by the mass, and had to be resected en bloc. The external iliac vein was exposed and controlled by dissecting underneath the inguinal ligament. The distal common femoral vein was also controlled with vessel loop. Intravenous heparin was given prior to clamping. The common femoral vein was transected proximally and distally Subsequently, an end-to-end common femoral to external iliac vein bypass was performed using contralateral spiral great saphenous vein ( Fig 3 ). The distal portion of the great saphenous vein was used with the intention of preserving the proximal great saphenous vein so that a future crossover bypass could be available if needed. A temporary arteriovenous fistula (AVF) was made using 6-mm polytetrafluoroethylene graft to the superficial femoral artery. The profunda femoris was not used, as it was extremely small and in severe spasm. The fistula was only 3 cm in length and was looped in a way to be accessible for percutaneous endovascular occlusion weeks later. Because of the short distance and sharp turn of the AVF, polytetrafluoroethylene instead of a venous conduit was used to avoid kinking and to facilitate percutaneous interruption using an intraluminal occluder. Anticoagulation was started the night of surgery. General surgery was called to repair the large femoral canal defect, which was the communication between the pelvis and groin that had allowed endometriosis to sit on the femoral vessels. It was impossible for simple closure of the defect using native tissue as the neurovascular bundle sitting posteriorly and laterally to the defect. Therefore, several sutures were placed between the medial edge of the external oblique and the inguinal ligament to the Cooper’s ligament to close the medial space. Then, a large polypropylene plug was placed into the defect and tacked in place without impinging on the bypass ( Fig 3 ). In addition, gynecology performed diagnostic laparoscopy. The uterus appeared to be completely normal with a smooth anterior surface. Both adnexa were grossly normal with no signs of endometriosis, only a small functional cyst. The uterosacral ligaments on the cul-de-sac were found to have diffuse endometriosis with tiny small pearl-appearing lesions. The diffuse disease and scar tissue on the posterior aspect made excision difficult, and the decision was made to pursue future hormonal therapy with leuprolide injection for 6 to 12 months. Two weeks later, the patient presented with a large groin bulge. Duplex ultrasound revealed a large seroma. Her venous bypass and AVF were widely patent. The patient underwent a right sartorius transposition muscle flap to cover the large seroma cavity. A decision was made to ligate the AVF during this procedure, thus obviating subsequent endovascular occlusion. The inferior vena cava filter was removed 1-month status post venous bypass surgery. Warfarin was continued for 3 months, and then it was exchanged for clopidogrel, which, at the 20th month visit, was changed to aspirin. Follow-up venous duplexes at the 1st, 3rd, 8th, and 20th postoperative months revealed patent venous bypass with no evidence of thrombosis The patient remains asymptomatic 24 months after venous bypass surgery.

Endometriosis consists of ectopic implants of functioning endometrial glands and stroma tissue outside of the uterine cavity. Although it can be found throughout the body, venous occlusion due to endometriosis is extremely rare. 3 , 4 Endometriosis is an estrogen-responding condition that is usually treated medically. Medications such as progestin, danazol, oral contraceptives, nonsteroidal anti-inflammatory drugs, and gonadotropin-releasing hormone agonists have all been used to treat the symptoms. 5 – 9 There are only few reported cases of endometriosis involving iliac and/or femoral vein. 10 – 12 It is believed that the presence of a femoral hernia allows spillage of endometrial tissue from the pelvis into the groin. Endometriosis in the groin can theoretically cause catamenial pain and mass-related symptoms. Prior case reports have reported cyclical edema during menses due to endometriomas encircling the iliac vein. 11 For patients with such symptoms and in the absence of complete venous occlusion, medical therapy appears appropriate. In the current case, the femoral vein was completely occluded, and the burden of disease made medical therapy unlikely to be effective. The options of resection with patch angioplasty, venous bypass with or without AVF, or even endovascular recanalization or anticoagulation alone are all viable ones. Because of the recurrent nature of endometriosis, we elected to perform a radical resection. Once this was completed, the discontinuity that remained in the vein made a bypass necessary in order to restore in-line venous flow. The size mismatch with her saphenous vein was resolved by the use of a spiral conduit technique, and a temporary AVF was created with the goal of improved patency.

DVT is one of the most commonly diagnosed conditions. Rarely, it is caused by intrinsic or extrinsic compressing masses such as endometrioma. 2 However, DVT can be successfully treated with endometrioma resection and venous reconstruction.