Challenges in the management of iliofemoral deep vein thrombosis in a resource limited setting: a case series

Iliofemoral deep vein thrombosis is a medical emergency associated with pulmonary embolism, severe postthrombotic morbidity and increased rates of recurrence. We present 3 cases of iliofemoral deep vein thrombosis managed in a setting of limited resources. Results of 2-D Ultrasound scan which suggested proximal DVT was confirmed by Doppler ultrasound scan. Patients were all managed by systemic anticoagulation alone. In experienced hands, it is possible to diagnose iliofemoral DVT with 2-D Ultrasound scan and treatment with systemic anticoagulation alone still has a role. However recent studies have proved clearly the superiority of thrombectomy over systemic anticoagulation alone. There is a need to improve the infrastructure and expertise of clinicians managing these conditions in underdeveloped settings to enable them offer the best to their patients.


Introduction
Iliofemoral deep vein thrombosis (DVT) is a subset of proximal DVT defined by involvement of the common femoral vein (CFV) and or iliac veins irrespective of thrombus involvement in veins below the CFV or above the iliac vein [1]. It is a severe debilitating problem with high risk of pulmonary embolism (PE) and postthrombotic syndrome.
Venous thromboembolism was generally thought to be rare in Africans; however an autopsy study by Sotunmbi PT et al showed a prevalence rate of 2.9% [2] and 78% mortality for patients admitted with PE was noted by Elegbeleye OO and Femi-Pearse D [3]. Hence the recognition and treatment of iliofemoral DVT becomes absolutely important to prevent morbidity and mortality from DVT. In the absence of colour doppler USS, a Toshiba scanner (B-mode, 2D) Model Justvision 400 with probe frequency of 6.5MHz was used for 2 patients and a Siemens Sonoline S1-400 with a probe frequency of 7.5MHz for one patient. The diagnosis was confirmed by Doppler ultrasound scan in 2 patients and contrast abdominal CT scan in one patient. These investigations were done in another facility. All the patients were placed on subcutaneous enoxaparin 90-180mg and warfarin. They were followed up in the outpatient clinic after discharge.

Results
Over the 3 year period, we treated 3 male patients with proximal deep vein thrombosis. The age range was between 17-62 years. All the patients presented with sudden painful right lower limb swelling of about one week duration. Two of the patients were on admission prior to the development of symptom. One was being managed for hypertensive heart disease while the other was being managed for respiratory tract infection. The examination finding that was common among all the patients was a swollen right lower limb with differential warmth. D-dimer, a degradation product of cross-linked fibrin, is the best recommended biomarker for the initial assessment of VTE. It is useful in excluding DVT especially in a patient with probability score of less than or equal to 1 [4], however this is not available in our center.
Ultrasonography is an alternative modality for diagnosis of iliofemoral DVT to angiography, being non-invasive and without complication of ionizing radiation. Colour Doppler scan is the technique of choice but in the absence of this; especially in a resource limited setting like ours, B-mode 2D ultrasound scan has been reliable in making diagnosis as seen in our 3 cases. In these cases, non-compressibility of the affected proximal veins of the lower limb using a Toshiba scanner (B-mode, 2D) Model Justvision 400 with probe frequency of 6.5MHz for 2 patients and a Siemens Sonoline S1-400 with a probe frequency of 7.5MHz for one patient. Thrombectomy was associated with reduced risk of developing postthrombotic syndrome, venous reflux and a trend for reduction in the risk of venous obstruction [7]. This advantage persisted after 10 years of management [8]. Thrombectomy has been shown to be more effective when delivered within 3 days of onset of symptom [9]. Till date, none of these patients has developed postthrombotic syndrome but this complication is known to occur many years after treatment.

Conclusion
These three cases have been presented to highlight the inadequacies that physicians in the underdeveloped world encounter while managing proximal deep vein thrombosis. We have also discussed the ideal management of these cases.
4 revised and corrected the manuscript. All the authors have read and approved the final version of the manuscript. Figure 1: shows extensive thrombus formation in the popliteal vein