**2.2 Arteriovenous malformations post venous thrombosis**

Patients who start to develop lower extremity pain post DVT that is not controlled by compression therapy should be evaluated. Some patients will show arterial signals on duplex distal to venous occlusions. The high flow inflow from the AVM can be found with duplex. The natural history of the neovasularity in the thrombus in unknown but has been described in the cerebral sinus post thrombosis and in the peripheral veins (Link, Garza et al. ; Chikamatsu, Nagashima et al. 2001; Aboian, Daniels et al. 2009). Many of these patients have been found to be factor V Leiden positive (Link, Garza et al.). There is evidence that the veins are not passive and may play a significant and dynamic role in revascularization through angiogenesis (Aboian, Daniels et al. 2009). It is unclear whether the AVF/AVM in thrombus is transitory or may remain permanent. Figure 10A shows a chronic occlusion of the left internal iliac vein (presumably May-Thurner Syndrome (May R 1957; Fazel, Froehlich et al. 2007) in a patient followed by her primary care physician for many years without a specific, etiologic diagnosis. She developed large open and painful ulcers. The large collateral veins on her abdomen were unsightly but was not her concern, Figure 10. (Link 2011)

Fig. 10A. Patient with chronic left iliac vein occlusion after more than 20 years.

Late Complications of Deep Venous Thrombosis:

Painful Swollen Extremities and Non Healing Ulcers 107

Fig. 10C. Duplex of left common femoral vein showing high flow with arterial pulses.

Fig. 11. Foam Sclerotherapy procedure in above patient (Figure 10).

Fig. 10B. Non healing ulcers, extremely painful, patient's main compliant.

Fig. 10B. Non healing ulcers, extremely painful, patient's main compliant.

Fig. 10C. Duplex of left common femoral vein showing high flow with arterial pulses.

Fig. 11. Foam Sclerotherapy procedure in above patient (Figure 10).

Late Complications of Deep Venous Thrombosis:

**3. References** 

339-349.

1: 2-8.

26(1): 8-13.

349(9054): 759-762.

Med 357(1): 53-59.

Semin Vasc Surg 18(1): 36-40.

Clin Exp Dermatol 24(6): 473-478.

Nephrol 18(4): 162-165.

87-97.

Painful Swollen Extremities and Non Healing Ulcers 109

hypertension with transcatheter embolization of the arteriovenous channels from the feeding arteries (Chikamatsu, Nagashima et al. 2001). Successful treatment of the pain has been achieved in localized femoral vein AVM lesions by transcatheter injection of the feeding arteries with anhydrous alcohol combined with tissue adhesive (n-Butyl Cyanoacylate, nbca, Trufill, Cordis neurovascular, Miami Lakes, Florida)(Link, Garza et al.). Non healing painful ulcers can be seen in end stage renal disease patients as a result of

Patients who develop DVT should be followed for complications during and after the period of anticoagulation. Emphasis on compression and lymph edema treatment should lead to improved outcomes. Severe post thrombotic syndrome patients should be managed

Aboian, M. S., D. J. Daniels, et al. (2009). "The putative role of the venous system in the

Ashrani, A. A., M. D. Silverstein, et al. (2009). "Risk factors and underlying mechanisms for

Bekou, V., D. Galis, et al. (2011). "Unilateral leg swelling: deep vein thrombosis?" Phlebology

Bollinger, A., G. Isenring, et al. (1982). "Lymphatic microangiopathy: a complication of severe chronic venous incompetence (CVI)." Lymphology 15(2): 60-65. Bradbury, A. W. (2010). "Epidemiology and aetiology of C4-6 disease." Phlebology 25 Suppl

Brandjes, D. P., H. R. Buller, et al. (1997). "Randomised trial of effect of compression

Caps, M. T., R. A. Manzo, et al. (1995). "Venous valvular reflux in veins not involved at the

Chikamatsu, E., T. Nagashima, et al. (2001). "Pelvic arteriovenous malformation with iliac vein thrombosis. A case report." J Cardiovasc Surg (Torino) 42(1): 115-118. Corley, G. J., B. J. Broderick, et al. (2010). "The anatomy and physiology of the venous foot

Fazel, R., J. B. Froehlich, et al. (2007). "Clinical problem-solving. A sinister development--a

Felty, C. L. and T. W. Rooke (2005). "Compression therapy for chronic venous insufficiency."

Franks, P. J., C. J. Moffatt, et al. (1995). "Factors associated with healing leg ulceration with

George, P., M. S. Jhawar, et al. (2008). "All that is swollen and red is not infection!" Indian J

Hanrahan, L. M., C. T. Araki, et al. (1991). "Evaluation of the perforating veins of the lower

Hern, S. and P. S. Mortimer (1999). "Visualization of dermal blood vessels--capillaroscopy."

extremity using high resolution duplex imaging." J Cardiovasc Surg (Torino) 32(1):

time of acute deep vein thrombosis." J Vasc Surg 22(5): 524-531.

pump." Anat Rec (Hoboken) 293(3): 370-378.

high compression." Age Ageing 24(5): 407-410.

venous stasis syndrome: a population-based case-control study." Vasc Med 14(4):

stockings in patients with symptomatic proximal-vein thrombosis." Lancet

35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma." N Engl J

venous hypertension from their arteriovenous access,(George, Jhawar et al. 2008).

in a vascular group and some will respond to ablative and injection therapies.

genesis of vascular malformations." Neurosurg Focus 27(5): E9.

Fig. 11B. Photograph showing complete healing of ulcers; patient now pain free.

Duplex examination Figure 10C showed high velocity flow in the patient, s femoral vein distal to the occluded external iliac vein. An arteriogram showed a large pelvic AVM with outflow to the deep pelvic veins and to the distal veins in the left lower extremity. Occlusion of the AVM was performed with injectable ethyl vinyl alcohol polymer dissolved in DMSO (Onyx, EV3 Neurovascular, Irvine, CA) (Link 2011). The pain in the ulcerated areas improved but persisted despite compression dressings being applied weekly. Endovenous Laser Ablation (EVLT) of the veins deep to the ulcers and foam sclerotherapy (0.5% Sodium tetradecyl *Sotradecol*, angiodynamics, Queensbury, NY was then performed on this patient). Following the procedures the ulcers healed and the patient was pain free. Interventions for this condition have included an outflow procedure to reduce the venous hypertension with transcatheter embolization of the arteriovenous channels from the feeding arteries (Chikamatsu, Nagashima et al. 2001). Successful treatment of the pain has been achieved in localized femoral vein AVM lesions by transcatheter injection of the feeding arteries with anhydrous alcohol combined with tissue adhesive (n-Butyl Cyanoacylate, nbca, Trufill, Cordis neurovascular, Miami Lakes, Florida)(Link, Garza et al.). Non healing painful ulcers can be seen in end stage renal disease patients as a result of venous hypertension from their arteriovenous access,(George, Jhawar et al. 2008).

Patients who develop DVT should be followed for complications during and after the period of anticoagulation. Emphasis on compression and lymph edema treatment should lead to improved outcomes. Severe post thrombotic syndrome patients should be managed in a vascular group and some will respond to ablative and injection therapies.
