Retroperitoneal fibrosis, Stenosis, venous, Endoprostheses, vascular

F/74 A 74 years old woman was admitted to the hospital with a severe back pain and bilateral leg swelling. She complained that her symptoms had started a month ago and had a history of an operation due to gall bladder (GB) cancer at the other hospital 3 years before. She had been managed with vertebroplasty at the lumbar spine due to back pain. On physical examination, she showed a back pain pointed at lower lumbar vertebrae and swelling of both lower extremities with bilateral pitting edema on pre－tibial areas. Simple radiograph revealed a compression fracture at the third lumbar vertebral body and bone cement inside. CT scans revealed recurrent GB cancer with metastatic lesions at bilateral adrenal glands and retroperitoneal lymph nodes. Diffusely thickened soft tissue mass was noted encapsulating the aorta and inferior vena cava (IVC) from the infrarenal aorta to aortic bifurcation with compromising IVC and iliac veins. Small focus of tumor in－growth mimicking thrombus was also noted at the IVC. The radiologic diagnosis was retroperitoneal fibrosis, but no pathologic confirmation was achieved because of the patient’s refusal. Then she was referred to interventional radiology for the relief of leg swelling. After sterile draping, both femoral veins were accessed at inguinal areas and stenotic right common iliac and occlusive left common iliac veins were negotiated with a 5－Fr narrow angle tip catheter (DAV, Cook, Bloomington,IN, USA) and a guide wire (Anlged, Radifocus, Tokyo, Japan), After passing these lesions primary stenting was done with same sized two stents (Niti-S,Taewoong medical, Seoul) having the diameter of 12 mm and length of 120 mm. Meticulous and synchronous deployment was done bilaterally with the tip located at the same height to prevent overexpansion of one or collapse of the other expanding stent. No predilatation was done for fear of possible wall injury or rupture. Exact positioning was successful after deployment of stents, but the lumen inside of the inserted stent was not fully gained at the most stenotic portion of the common iliac vein. Then balloon dilatation was applied with 10 mm diameter balloon catheter (Bluemax, Boston Scientific Corporation, Watertown, MA, USA). After balloon dilatation the internal lumen was expanded and venous flow was restored. Anticoagulation treatment with intravenous heparinization and continuing per－oral coumadinization was continued after removal of vascular sheaths. Grade 2 compression stockings were applied to her both legs and legs elevation during lying down on her bed was taught to relieve leg edema. She showed partial improvement of leg swelling, but did not showed improvement of back pain. After a week she discharged hopelessly.

Kissing stents insertion for the management of iliocaval stenosis in the patient of retroperitoneal fibrosis due to recurrent GB cancer

Retroperitoneal fibrosis, the fibrotic mass formation in the retroperitoneal space causing obstructive complications of the retroperitoneal structures, is mainly caused idiopathic. But it is reported related to several malignancies such as non-Hodgkin’s lymphoma, Signet－ring cell carcinoma of the urinary bladder, breast cancer, peritoneal mesothelioma and others and related to other conditions such as sclerosing mesenteritis, autoimmune pancreatocholangitis, fibrous pseudotumor of pancreas, medications with an ergot－derivative, amphetamines, antihistamines, vasopressive and beta blockers, hemorrhage, surgery, infection, abdominal aneurysm, and connective tissue disease. Retroperitoneal fibrosis involves mainly ureter, vascular and nervous system, but symptomatic venous involvement is very rare. Symptoms are mainly due to venous obstruction and reflux of the flow and those are limb swelling, varicosities, skin changes and venous claudication. For the symptomatic improvement, surgical venous reconstruction and endovascular management have been performed, but endovascular management became more popular due to higher success rate of the procedure and mid－ to long－term follow up. Kissing stents is a method of technique mainly used for arterial angioplasty at aortic bifurcation stenosis or occlusion with varied clinical success rate. In the iliocaval lesion, it could be applicable because it has similar in shape and angle at bifurcation. Even though it is important for arterial stenting at aortic bifurcation to be accurately locate at the same height of the proximal end, it is questionable in case of iliocaval stenting because venous flow is reverse to arterial that. We adopted kissing stents in iliocaval venous stenosis and the procedure was successful without collapse of anyone. Self expandable stents should be considered because of possible deformity at iliac veins even though relatively low expansile force than balloon expandable stent. Juhan et al. reported a crushed balloon expandable stent inserted in a pregnant woman. There are three well known risk factors considered as a cause of the failure after endovascular treatment, such as the presence of thrombotic disease, positive thrombophilia test and long stent extending below the inguinal ligament. In this patient, she had no risk factors listed above, but she did not show symptomatic improvement completely even after successful endovascular therapy. Her complaining symptom of the back pain could be considered caused by involvement of nervous system by retroperitoneal fibrosis, but any other causes of not completely improving leg swelling were unknown. In spite of our unsatisfied clinical result of partial symptomatic improvement, kissing stents insertion in the patient of venous stenosis or occlusion due to retroperitoneal fibrosis is minimally invasive, technically successful and promising in clinical results based on several other reports. The only one should have to be kept in mind is that all successful radiologic findings do not mean clinical success.

1. Yilmaz S, Sindel T, Golbasi I, Turkay C, Mete A, Luleci E. Aortoiliac kissing stents: longterm results and analysis of risk factors affecting patency. J Endovasc Ther 2006;13:291-301 2. Hartung O, Alimi YS, Di Mauro P, Portier F, Juhan C. Endovascular treatment of iliocaval occlusion caused by retroperitoneal fibrosis: late results in two cases. J Vasc Surg 2002;36:849-852 3. Aissi K, Rossi P, Demoux AL, Hartung O, Frances Y. Endovascular treatment of iliocaval occlusion due to idiopathic retroperitoneal fibrosis. Eur J Intern Med 2004;15:534-536 4. Vorwerk D, Guenther RW, Wendt G, Neuerburg J, Schurmann K. Iliocaval stenosis and iliac venous thrombosis in retroperitoneal fibrosis: percutaneous treatment by use of hydrodynamic thrombectomy and stenting. Cardiovasc Intervent Radiol 1996;19:40-42 5. Mohamed F, Sarkar B, Timmons G, Mudawi A, Ashour H, Uberoi R. Outcome of "kissing stents" for aortoiliac atherosclerotic disease, including the effect on the non－diseased contralateral iliac limb. Cardiovasc Intervent Radiol 2002;25:472-475 6. Kerwin G, Silverstein M, Lewis C. Percutaneous stent treatment for arterial occlusion caused by retroperitoneal fibrosis. Am J Roentgenol 2000;175:1283-1285 7. Vivas I, Nicolas AI, Velazquez P, et al. Retroperitoneal fibrosis: typical and atypical manifestations. Br J Radiol 2000;73:214-222 8. Jost CJ, Gloviczki P, Cherry KJ Jr, et al.nSurgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease. J Vasc Surg 2001;33:320-327 9. Zamora CA, Sugimoto K, Mori T, et al. Use of the wallstent for symptomatic relief of malignant inferior vena cava obstructions. Radiat Med 2005;23:380-385

Fig, 1 Initial CT scan shows diffusely thickened soft tissue mass encapsulating the aorta and IVC at the aortic bifurcation level, compromising IVC and iliac veins. Extensive infiltrations suggesting soft tissue edema around buttock and subcutaneous fat layer are also noted.

Fig, 2A and B Bilateral iliac venographies prior to stent insertion show extrinsically compressive right common iliac and occlusive left common iliac veins. After these lesions were negotiated with an angiocatheter and a guide wire, coincidental deployments of two stents were done.

Fig, 2A and B Bilateral iliac venographies prior to stent insertion show extrinsically compressive right common iliac and occlusive left common iliac veins. After these lesions were negotiated with an angiocatheter and a guide wire, coincidental deployments of two stents were done.

Fig, 3 Final bilateral iliac venography with injecting contrast materials simultaneously shows restoration the internal lumen and venous flow.