Improvement in Recurrent Ascites From Multilevel Venous Obstruction With Transcatheter Caval and Iliac Vein Recanalization.

BACKGROUND: Ascites commonly results from portal hypertension, malignancy, or cardiac disease. Systemic venous obstruction is an uncommon mechanism. CASE SUMMARY: A 40-year-old woman with 2 prior kidney transplants, remote venous thromboembolism, and small bowel adenocarcinoma presented with recurrent ascites. Imaging revealed chronic superior vena cava (SVC) occlusion with collateralization to the inferior vena cava (IVC), IVC stenosis, and left iliac vein stenosis. Hemodynamics showed elevated SVC pressure, gradient from the left femoral vein to the IVC, and normal right atrial pressure. She underwent staged endovascular recanalization and stenting of the SVC, IVC, and left iliac vein, with repeated interventions for restenosis. DISCUSSION: Multilevel systemic venous obstruction can produce clinically significant ascites through venous hypertension. Symptom relief is possible, but may require technically complex recanalization and repeat interventions. TAKE-HOME MESSAGES: Systemic venous obstruction should be considered in unexplained refractory ascites. Endovascular therapy can be effective, but often necessitates repeat procedures.