A man in his early 60s presented with worsening intermittent claudication and new-onset rest pain in his left leg. He had experienced sudden pain during soccer six months earlier but was initially misdiagnosed as musculoskeletal. The symptoms did not improve with topical treatments such as pain relief patches, and he was referred to our hospital six months after onset. On examination, left femoral and pedal pulses were absent, while the right side was normal.

CT angiography showed total occlusion of the left external iliac artery (EIA) with preserved flow to the distal superficial femoral artery (SFA) via collaterals. Electrocardiography revealed a normal sinus rhythm without arrhythmia. Echocardiography was normal, and laboratory data showed no evidence of hypercoagulable disorder.

First EVT: Via right femoralcrossover approach, total EIA occlusion was confirmed by angiography. Thrombusaspiration with a TVAC catheter (Nipro, Osaka, Japan)  restored partial flow, and two bare-metalstents (BMS, Smart, Cordis, Miami Lakes, FL) were implanted in the EIA.Intravascular ultrasound (IVUS) demonstrated that the EIA lesion was thromboticrather than atherosclerotic. In addition, residual thrombus was detected in theproximal SFA, and POBA was performed for this segment.Second EVT (2 weeks later from the first EVT): Re-occlusionof the EIA stent was observed. Indigo aspiration retrieved large amounts of redthrombi. Residual thrombus remained at both stent edges; two additional BMSswere placed proximally and distally. SFA thrombus attachment was noted, andtriple therapy (a low-dose direct oral anticoagulant plus dual antiplatelettherapy) was initiated.Third EVT (4 weeks later from the first EVT): Recurrentin-stent occlusion occurred. After thrombus aspiration with TVAC, persistentSFA stenosis was identified as a thrombogenic source. A stent graft (Viabahn,W. L. Gore & Associates, Flagstaff, AZ) was implanted in the SFA, and oneadditional Smart stent was deployed overlapping the distal edge of the Viabahnand the previous EIA stents. Final angiography showed excellent flow with noresidual thrombus. The patient remained symptom-free with confirmed stentpatency at follow-up.

Repeatedstent thrombosis in the EIA was successfully managed by treating the residualSFA lesion, which had impaired runoff and promoted thrombosis. This caseunderscores the importance of addressing both inflow and outflow lesions fordurable revascularization outcomes in recurrent thrombotic iliac arterydisease.