42 year old male presents with bilateral lower extremity swelling for few years. His significant medical history included chronic venous insufficiency s/p bilateral great saphenous veins (GSV) ablation at outside hospital 5 years ago and later 2 years ago found to have bilateral iliac veins DVT treated with anticoagulation therapy. Physical exam showed bilateral lower extremity swelling with skin changes (CEAP – class IV). Lower extremity venous Duplex US showed bilateral external Iliac veins chronic DVT and other deep venous system were compressible without respiratory phasic variation and significant deep venous reflux. He also noted to have absent bilateral GSV’s. He underwent MRV that showed similar findings without any abdominal/pelvic pathology. Now planned for IVUS guided bilateral iliac veins stenting.