Complex Revascularization in a Patient with Recurrent Deep Vein Thrombosis and Chronic Iliac Stent Occlusions Utilizing the Kodiak Co-Axial Reinforced Introducer System : A Case Report

This case report presents the clinical complexities and synergistic interventional strategies in the management of a 62-year-old male with a significant medical history complicated by recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE). Despite a history of extensive therapeutic interventions including anticoagulation failures, iliocaval reconstruc- tion, and peripheral thrombectomy, the patient exhibited recurrent symptoms related to venous stent occlusions. The intricacies of his case are accentuated by a multi-faceted medi- cal background including hypertension, heart failure with reduced ejection fraction (HFrEF), hyperlipidemia, hypothyroidism, anxiety, depression, peptic ulcer disease, and a history of diverticulitis requiring sigmoidectomy and colostomy.Following an episode of lower gastrointestinal bleeding which necessitated the temporary cessation of anticoagulation therapy, the patient developed progressive right lower extremity pain, nonspecific abdominal pain, constipation, and occasional small volume lower GI bleed- ing. Diagnostic evaluation with CT imaging indicated possible occlusion of his previously placed right iliac stents and distension of ventral wall varices. These findings prompted a coordinated interventional response.The interventional procedure utilized a range of novel and traditional devices and tech- niques. Initial vascular access was achieved via the right internal jugular and bilateral groin approaches. The use of the Contego Excipio XL device as an IVC embolic protection showcased a novel approach to managing potential embolic risks during complex revas- cularizations. Despite challenges in navigating the occluded stents, advanced techniques including the use of Kodiak Reinforced Co-Axial Introducer System and Mustang balloons facilitated the creation of a new luminal pathway. This was followed by extensive thrombec- tomy using the Penumbra FLASH 16 and Excipio XL systems, culminating in successful revascularization as confirmed by repeat venography and intravascular ultrasound (IVUS). IVUS findings revealed synechia and stenosis, which were managed with targeted venoplasty and the strategic placement of an Abre 12mm stent extension, resulting in restored brisk venous flow.This case demonstrates the intricate decision-making and adjunctive techniques required in managing severe, recurrent vascular conditions in patients with complex medical histories.