Acute deep vein thrombosis (aDVT) due to compression by an iliac aneurysm is seldom reported, and there are no guidelines for the treatment of this condition. We report the case of a patient with severe ilio-femoral aDVT of the right leg caused by external compression from a right common iliac aneurysm (CIA). The management combined distal CIA endovascular exclusion and endovascular venous thrombectomy. The aim of this report is to share our experience in managing associated iliac arterial aneurysmal and acute venous thrombotic disease.

An 82-year-old male with a 10-year history of chronic mild right leg swelling presented with an acutely worsened swollen, bluish, and ulcerated leg. Duplex sonography and contrast-enhanced CT confirmed an aDVT of the ilio-femoral veins and identified a 55 mm right CIA causing external compression of the iliac vein. Anticoagulant therapy with unfractionated heparin was initiated. Four days later, two main procedures were performed in a single session: deployment of an endoprosthesis from the common to external iliac arteries to exclude the aneurysm through bilateral percutaneous femoral access, with prior internal iliac embolization, and endovascular ilio-femoral venous thrombectomy using a Clottriever® device through percutaneous popliteal access, followed by iliac venous angioplasty and stenting. Post-operative treatment included 100mg/day Aspirin, high-molecular-weight heparin anticoagulation, and compressive stockings. Recovery was uneventful.

Leg swelling and discoloration began to resolve within 24 hours post-procedure. Post-operative ultrasound confirmed the absence of venous residual thrombus. Clinical examination, duplex, and CT angiography at 1-month follow-up demonstrated sustained reduction of leg swelling, patency of the veins, and correct positioning of the endoprosthesis without endoleak.

This case illustrates that this combination of arterial iliac endoprosthesis and mechanical endovascular venous thrombectomy without lytic agent can be an effective treatment strategy for aDVT due to aneurysmal compression. This total endovascular approach can resolve the underlying arterial pathology and restore normal venous function. It might increase the success and patency of the venous reconstruction with a reduced risk of bleeding complications despite an uninterrupted therapeutic anticoagulation.