Chronic Leg Swelling Due to Under-Recognized Pelvic Vascular Disorders

A 39-year-old female with a past medical history of depression and hypothyroidism complains of worsening left leg pain with swelling over the past year. The symptoms are exacerbated by periods of prolonged standing, which is required by her profession as a college professor. Her pain limits her in mobility and she often feels that her legs are fatigued. She states no alleviating factors other than a reduction in leg swelling after she takes hydrochlorothiazide (HCTZ), which was recently prescribed by her primary care physician for the symptoms. She complains of recent generalized fatigue and light-headedness. She does not state a history of deep vein thrombosis (DVT) or recent trauma. She noticed the swelling after the Caesarian-section birth of her second child. She takes levothyroxine and HCTZ. No other surgical history. Her blood pressure at initial presentation is 98/56 with a heart rate of 84 and is non-febrile. Her physical exam revealed 3+ pitting edema on her left leg with no other significant findings.

She was evaluated by vascular medicine and had a lower extremity venous duplex study performed. It revealed no signs of acute DVT; however, there was reflux noted in the left great saphenous vein (GSV) from the left sapheno-femoral junction to the proximal calf segment. After a successful trial of pantyhose compression stocking therapy and improvement in leg symptoms, she subsequently underwent endovenous ablative closure treatment to the left GSV. After 3 months, her symptoms did not improve. She went for a second vascular opinion and had the following diagnostic studies performed:

Figure 1: Venogram

Figure 1

Figure 2: Intravascular Ultrasound (IVUS)

The blue frame shows the left common iliac vein measurement. The green frame is a reference segment.
Figure 2

Which of the following is NOT a possible sequela of this vascular condition?

Show Answer