RESUMEN
BACKGROUND: May-Thurner syndrome (MTS) is an extrinsic venous compression by the arterial system against bony structures in the iliocaval territory. The most common variant of MTS is due to compression of the left iliac vein between the overlying right common iliac artery and the fifth lumbar vertebrae. The prevalence of MTS is unknown; therefore, there are only a few publications about MTS in kidney transplant recipients. Risk factors that may progress from usually asymptomatic to symptomatic MTS are female sex, scoliosis, dehydration, coagulation disorders, and radiation. Clinical presentations include acute extremity pain and swelling, venous claudication, and chronic signs of venous insufficiency. METHODS: We describe a 63-year-old man who underwent kidney transplantation (left iliac fossa). Four days after transplantation, a graftectomy was done due to graft rupture caused by renal vein thrombosis. After imaging studies, a diagnosis of MTS was established. The patient had no typical symptoms of MTS. However, an incidence of right lower limb thrombosis was observed, and due to vertebral discopathy, the patient underwent surgery with implantation of a vertebral implant. RESULT: After a successful second transplantation on the right side, incidents of thrombosis were observed: superficial thrombosis of the upper limbs and massive deep vein thrombosis of the right lower limb. Thrombophilia was recognized, the graft function is stable, and anticoagulation therapy is being continued. CONCLUSION: Asymptomatic MTS in the case of coincidence of other risk factors, such as coagulation disorders, history of vertebral operation, and additional pressure of the graft, can result in graft failure.
Asunto(s)
Trasplante de Riñón , Síndrome de May-Thurner , Humanos , Trasplante de Riñón/efectos adversos , Persona de Mediana Edad , Masculino , Síndrome de May-Thurner/cirugía , Síndrome de May-Thurner/complicacionesRESUMEN
Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed. Salient imaging features of each entity are illustrated through imaging examples using multiple modalities including ultrasound, fluoroscopy, CT, and MRI.
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Síndrome de Cascanueces Renal , Humanos , Síndrome de Cascanueces Renal/diagnóstico por imagen , Síndrome del Ligamento Arcuato Medio/diagnóstico por imagen , Diagnóstico por Imagen/métodos , Abdomen/diagnóstico por imagen , Abdomen/irrigación sanguínea , Diagnóstico Diferencial , Enfermedades Vasculares/diagnóstico por imagen , Pelvis/diagnóstico por imagen , Pelvis/irrigación sanguínea , Síndrome de May-Thurner/diagnóstico por imagen , Síndrome de May-Thurner/complicaciones , Síndrome de la Arteria Mesentérica Superior/diagnóstico por imagenRESUMEN
Background: May-Thurner syndrome (MTS) is iliac vein compression syndrome associated with postoperative deep vein thrombosis (DVT) resulting from chronic compression of the left iliac vein against lumbar vertebrae by the overlying right or left common iliac artery. MTS is not well known as a risk factor for DVT after total hip arthroplasty (THA). We evaluated the incidence of DVT after THA and analyzed if the MTS is a risk factor for DVT after THA. We hypothesized that MTS would be associated with an increased risk of developing DVT after THA. Methods: All patients > 65 years of age who underwent THA between January 1, 2009, and January 12, 2017, were identified. Among them, the patients who presented for postoperative DVT of the lower extremity were reviewed with medical record data. MTS was diagnosed with computed tomography (CT) angiography of the lower extremity. We analyzed the demographic data, symptoms, diagnoses, and treatment of MTS patients. Results: A total of 492 consecutive patients aged > 65 years who underwent operation for THA were enrolled. Among them, 5 patients (1.0%) presented for postoperative DVT of the lower extremity. After reviewing the CT angiography of the lower extremity, 4 out of 5 DVT patients (80%) were identified as having MTS. All MTS patients were female and presented with pain and swelling of the left leg. All MTS patients were treated with systemic anticoagulation, aspiration thrombectomy, and percutaneous transluminal angioplasty. Complete resolution of thrombus was observed in all patients. Conclusions: If the diagnosis of MTS is delayed, the morbidity and mortality rates are significantly increased. Orthopedic surgeons should be aware of MTS as a risk factor for DVT after THA. Moreover, preoperative evaluation with duplex sonography or CT angiography to confirm MTS should be considered. In this regard, this study is considered to have sufficient clinical value for early diagnosis and appropriate treatment of MTS after THA.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Síndrome de May-Thurner , Trombosis de la Vena , Humanos , Femenino , Anciano , Masculino , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/diagnóstico por imagen , Síndrome de May-Thurner/epidemiología , Artroplastia de Reemplazo de Cadera/efectos adversos , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/epidemiología , Trombosis de la Vena/etiología , Tomografía Computarizada por Rayos X , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Factores de RiesgoRESUMEN
Iliac vein stenting for the treatment of iliac vein compression syndrome (IVCS) has been gradually developed. This article investigated the long-term patency and improvement of clinical symptoms after endovascular stenting for iliac vein obstruction patients. From 2020 to 2022, 83 patients at a single institution with IVCS underwent venous stent implantation and were divided into two groups: non-thrombotic IVCS (n = 55) and thrombotic IVCS (n = 28). The main stent-related outcomes include technical success, long-term patency, and thrombotic events. The technical success rate of all stent implantation was 100%. The mean length of hospital stay and cost were higher in the thrombotic IVCS group than in the non-thrombotic ICVS group, as well as the length of diseased vessel segment and the number of stents implanted were higher than in the control non-thrombotic group. The 1-, 2-, and 3-year patency rates were 85.4%, 80% and 66.7% in the thrombosis group, which were lower than 93.6%, 88.7%, and 87.5% in the control group (P = .0135, hazard ratio = 2.644). In addition, patients in both groups had a foreign body sensation after stent implantation, which resolved spontaneously within 1 year after surgery. Overall, there were statistically significant differences in long-term patency rate outcome between patients with thrombotic and non-thrombotic IVCS, the 1-, 2-, and 3-year patency rates in non-thrombotic IVCS patients were higher than those in thrombotic IVCS patients.
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Síndrome de May-Thurner , Trombosis , Trombosis de la Vena , Humanos , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/cirugía , Trombosis de la Vena/etiología , Trombosis de la Vena/cirugía , Trombosis de la Vena/diagnóstico , Resultado del Tratamiento , Estudios Retrospectivos , StentsRESUMEN
In this report, we describe a rare case: deep vein thrombosis due to May-Thurner syndrome with a spontaneous pelvic extraperitoneal hematoma. This unique challenge highlights balancing thrombosis treatment and bleeding risk. Endovascular treatment with delayed anticoagulation may be an alternative to surgery for stable retroperitoneal hematoma in May-Thurner syndrome patients.
Asunto(s)
Anticoagulantes , Hematoma , Síndrome de May-Thurner , Trombosis de la Vena , Humanos , Hematoma/etiología , Hematoma/diagnóstico por imagen , Hematoma/terapia , Síndrome de May-Thurner/diagnóstico por imagen , Síndrome de May-Thurner/terapia , Síndrome de May-Thurner/complicaciones , Anticoagulantes/uso terapéutico , Anticoagulantes/efectos adversos , Resultado del Tratamiento , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología , Trombosis de la Vena/terapia , Angiografía por Tomografía Computarizada , Femenino , Flebografía/métodos , Procedimientos Endovasculares , Masculino , Persona de Mediana Edad , Espacio RetroperitonealRESUMEN
Late thrombosis of the renal graft vein is a rare complication that results in graft loss in the majority of cases. We describe the case of a 57-year-old female patient who had a kidney transplant 32 years ago and developed a late thrombosis of the graft vein, accompanied by extensive thrombosis in the common femoral and iliac veins. Risk factors included severe malnutrition, chronic inflammation due to an anal fistula, and Cockett syndrome. The treatment consisted of mechanical thrombectomy of the iliac vein, placement of a stent in the common iliac vein, partial thromboaspiration of the renal vein thrombus with local thrombolysis, followed by systemic anticoagulation. With this approach, renal function fully recovered without major complications.
La thrombose tardive de la veine du greffon rénal est une complication rare qui conduit à la perte du greffon dans la majorité des cas. Nous présentons le cas d'une femme de 57 ans, transplantée depuis 32 ans, qui a développé une thrombose de la veine du greffon, se manifestant par une insuffisance rénale aiguë anurique. Cette thrombose compliquait une thrombose extensive débutant dans la veine fémorale superficielle et s'étendant dans les veines fémorale commune et iliaque. La patiente présentait plusieurs facteurs de risque de thrombose veineuse, tels qu'un état de malnutrition sévère, une inflammation chronique due à une fistule anale chronique et un syndrome de Cockett. La patiente a été traitée en plusieurs étapes successives : une thrombectomie mécanique de toute la veine iliaque a d'abord été réalisée, suivie de la mise en place d'un stent dans la veine iliaque commune gauche en raison du syndrome de Cockett, puis d'une thrombo-aspiration partielle du thrombus de la veine rénale combinée à une thrombolyse locale (par urokinase) de la veine rénale via un cathéter, et enfin d'une anticoagulation systémique. Cette approche a permis une récupération complète de la fonction rénale sans complication notable. Nous rapportons cette prise en charge in situ d'une thrombose tardive de la veine d'un greffon rénal chez une patiente avec un syndrome de Cockett, ayant permis une issue favorable.
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Síndrome de May-Thurner , Trombosis , Femenino , Humanos , Persona de Mediana Edad , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/terapia , Venas Renales/diagnóstico por imagen , Trombosis/etiología , Vena Ilíaca/diagnóstico por imagen , Riñón , Resultado del TratamientoAsunto(s)
Síndrome de May-Thurner , Tromboembolia Venosa , Femenino , Humanos , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/diagnóstico por imagen , Síndrome de May-Thurner/terapia , Tromboembolia Venosa/tratamiento farmacológico , Tromboembolia Venosa/etiología , Terapia TrombolíticaAsunto(s)
Síndrome de May-Thurner , Embolia Pulmonar , Trombosis de la Vena , Humanos , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/diagnóstico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/diagnóstico por imagen , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/diagnóstico por imagen , Infarto Cerebral/complicacionesRESUMEN
Spontaneous iliac vein rupture (SIVR) is extremely rare and can lead to serious complications, including death. Etiologies include inflammatory processes and hormonal and mechanical triggers, with concomitant May-Thurner syndrome (MTS) being a rare cause. Management can be challenging due to the difficult balance between reducing thrombotic burden and life-threatening hemorrhage that can result from aggressive anticoagulation. Furthermore, surgical interventions are associated with high mortality, making conservative management more desirable. We report a case of SIVR with retroperitoneal hematoma and concurrent MTS that was successfully managed using conservative measures. We further provide a narrative review of the current literature addressing the diagnosis, management, and outcome of SIVR focusing on cases with concurrent MTS.
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Síndrome de May-Thurner , Trombosis , Trombosis de la Vena , Humanos , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/diagnóstico por imagen , Síndrome de May-Thurner/terapia , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología , Trombosis de la Vena/terapia , Vena Ilíaca/diagnóstico por imagen , Vena Ilíaca/cirugía , Trombosis/complicaciones , Hematoma/diagnóstico por imagen , Hematoma/etiología , Hematoma/terapia , Rotura Espontánea/complicacionesRESUMEN
OBJECTIVE: Computed tomography venography (CTV) is not routinely used to screen patients presenting with a presumed lower extremity lymphedema diagnosis for left iliac vein obstruction (IVO) or May-Thurner syndrome (MTS). The objective of this study is to determine the utility of routine CTV screening for these patients by evaluating the proportion presenting with clinically significant CTV-identified left IVO. METHODS: We retrospectively reviewed 121 patients who had presented to our lymphedema center with lower extremity edema between November 2020 and May 2022. Information regarding demographics, comorbidities, lymphedema characteristics, and imaging reports was collected. Cases of IVO present on CTV were reviewed by a multidisciplinary team to determine the clinical significance of the CTV findings. RESULTS: Of the patients with complete imaging studies, 49% (n = 25) had abnormal lymphoscintigraphy findings, 45% (n = 46) had reflux on ultrasound, and 11.4% (n = 9) had IVO on CTV. Seven patients (6%) had CTV findings of IVO and edema of either the isolated left (n = 4) or bilateral (n = 3) lower extremities. Cases of IVO on CTV were determined by the multidisciplinary team to be the predominant cause of lower extremity edema for three of these seven cases (43%; or 2.5% of all 121 patients). CONCLUSIONS: Six percent of patients presenting to a lymphedema center with lower extremity edema had left-sided IVO on CTV suggestive of MTS. However, the cases of IVO were determined to be clinically significant <50% of the time or for 2.5% of all patients. CTV should be reserved for patients with isolated left-sided or bilateral lower extremity edema with a greater left-sided component and a history of findings that raise clinical suspicion for MTS.
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Linfedema , Síndrome de May-Thurner , Enfermedades Vasculares , Humanos , Flebografía/métodos , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Edema/diagnóstico por imagen , Edema/etiología , Linfedema/diagnóstico por imagen , Linfedema/complicaciones , Síndrome de May-Thurner/complicaciones , Enfermedades Vasculares/complicaciones , Extremidad InferiorRESUMEN
INTRODUCTION: Spontaneous iliac vein rupture is a rare, but frequently lethal condition. It is important to timely recognize its clinical features and immediately start adequate treatment. We aimed to increase awareness to clinical features, specific diagnostics, and treatment strategies of spontaneous iliac vein rupture by evaluating the current literature. METHODS: A systematic search was conducted in EMBASE, Ovid MEDLINE, Cochrane, Web of Science, and Google Scholar from inception until January 23, 2023, without any restrictions. Two reviewers independently screened for eligibility and selected studies describing a spontaneous iliac vein rupture. Patient characteristics, clinical features, diagnostics, treatment strategies, and survival outcomes were collected from included studies. RESULTS: We included 76 cases (64 studies) from the literature, mostly presenting with left-sided spontaneous iliac vein rupture (96.1%). Patients were predominantly female (84.2%), had a mean age of 61 years, and frequently presented with a concomitant deep vein thrombosis (DVT) (84.2%). After various follow-up times, 77.6% of the patients survived, either after conservative, endovascular, or open treatment. Endovenous or hybrid procedures were frequently performed if the diagnose was made before treatment, and almost all survived. Open treatment was common if the venous rupture was missed, for some cases leading to death. CONCLUSION: Spontaneous iliac vein rupture is rare and easily missed. The diagnose should at least be considered for middle-aged and elderly females presenting with hemorrhagic shock and concomitant left-sided DVT. There are various treatment strategies for spontaneous iliac vein rupture. An early diagnose brings options for endovenous treatment, which seems to have good survival outcomes based on previously described cases.
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Síndrome de May-Thurner , Choque Hemorrágico , Trombosis de la Vena , Persona de Mediana Edad , Anciano , Humanos , Femenino , Masculino , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/terapia , Trombosis de la Vena/complicaciones , Vena Ilíaca/diagnóstico por imagen , Resultado del Tratamiento , Rotura Espontánea/complicaciones , Síndrome de May-Thurner/complicacionesRESUMEN
May-Thurner syndrome (MTS) is a relatively rare condition involving mechanical compression of a vein between an artery and a bone which may result in venous stenosis, reflux, occlusion, or deep vein thrombosis (DVT). The most common location for MTS to occur is the left iliocaval confluence, specifically where the left common iliac vein crosses under the right common iliac artery and becomes compressed against a vertebral body. Our case represents a unique presentation of MTS where a missed diagnosis of MTS during a presentation of acute LLE DVT over 15 years ago which would later progress to chronic bilateral iliac vein occlusion and IVC obliteration. This also ultimately contributed to recurrent left lower extremity (LLE) DVT. The hypothesis for this case is that our patient had May-Thurner syndrome at the time of his original LLE DVT 15 years ago that went undiagnosed. He likely had "spillover" thrombus that occluded the right iliac venous system and resulted in IVC thrombosis at that time. What resulted was obliteration of the IVC between the iliac vein confluence and the renal vein level and bilateral iliac veins. The chronicity of the occlusion creates a uniqueness to this case as there are sparse reports of such longstanding ileo-caval occlusion being recanalized after such a prolonged duration.
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Síndrome de May-Thurner , Enfermedades Vasculares , Trombosis de la Vena , Masculino , Humanos , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/cirugía , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/cirugía , Vena Ilíaca/diagnóstico por imagen , Vena Ilíaca/cirugía , Trombosis de la Vena/etiología , Trombosis de la Vena/cirugíaRESUMEN
INTRODUCTION: This study aimed to identify whether iliac vein compression syndrome(IVCS) is associated with deep vein thrombosis(DVT) after total knee arthroplasty(TKA) and whether lower lumbar degenerative changes were risk factors for IVCS. MATERIALS AND METHODS: A total of 259 consecutive patients who underwent TKA from January 2019 to March 2022 was retrospectively reviewed. Preoperative plain radiographs of lumbar spines and CT venography (CTV) for DVT diagnosis at postoperative 7 days were performed in all patients. Imaging findings of lower lumbar degenerative changes were analyzed on plain radiograph including lateral osteophytes, scoliosis, lateralolisthesis, retrolisthesis, anterolisthesis, and lower lumbar lordosis angle (LLLA). Percent compression at the left common iliac vein (LCIV) and right common iliac vein (RCIV) as well as DVT were evaluated on CTV. Moreover, IVCS was defined as greater than 50% of compression of the iliac vein on CTV. RESULTS: DVT occurred in 79 patients (30.5%) after TKA. The overall occurrence of DVT was significantly higher in patients with IVCS of LCIV (52.8%) than those without (18.8%, P < 0.001). When DVT was further subdivided, compared to non-IVCS, IVCS of LCIV was significantly associated with bilateral DVT (P < 0.001, both), especially distal DVT (P < 0.001, both), and IVCS of RCIV was significantly associated with right-side DVT (P = 0.031), especially popliteal (P = 0.008) and distal DVT(P = 0.011). Female patients (OR: 3.945, P = 0.039), presence of left osteophyte (OR: 2.348, P = 0.006), and higher LLLA (OR: 1.082, P < 0.001) were significantly associated with IVCS of LCIV, and presence of right osteophyte (OR: 3.494, P = 0.017) was significantly associated with IVCS of RCIV. CONCLUSION: IVCS was significantly associated with DVT after TKA and lumbar degenerative changes with lateral osteophytes and hyperlordosis were significant risk factors for IVCS.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Síndrome de May-Thurner , Osteofito , Trombosis de la Vena , Humanos , Femenino , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/diagnóstico por imagen , Artroplastia de Reemplazo de Rodilla/efectos adversos , Estudios Retrospectivos , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiologíaRESUMEN
PURPOSE: To explore the risk factors of failure for modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval in the treatment of iliac vein compression with iliofemoral vein thrombosis. METHODS: During September 2017 to September 2021, 278 patients with DVT were retrospectively analyzed and 203 were eligible for inclusion. All patients were tried to take modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval treatment. The perioperative factors were analyzed between groups: group 1-modified single-session therapy succeed, and group 2-modified single-session therapy failed. The high risk factors of failure group were evaluated by logistic regression analysis. RESULTS: 48 patients failed in modified single-session therapy, up to 23.64%. Single factor analysis indicated that there were five independent risk factors related with the failure (p < 0.05), including course of disease longer than 7 days, lumbar degeneration-related iliac vein compression syndrome (dIVCS), antegrade vein access, balloon-assisted cracking thrombus, and suction time. Logistic regression analysis indicated that course of disease longer than 7 days (OR = 19.642.95%CI:6.776â¼56.933), dIVCS (OR = 11.586.95%CI:4.016â¼33.427) were high risk factors for modified single-session therapy failed, antegrade vein access (OR = 0.171.95%CI:0.047â¼0.614) and balloon-assisted cracking thrombus (OR = 0.157.95%CI:0.045â¼0.542) were protective factors for therapy failure (p < 0.05). CONCLUSIONS: Long course of disease and dIVCS are the high risk factors for failure of modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval in the treatment of iliac vein compression syndrome (IVCS). But, antegrade vein access and balloon-assisted cracking thrombus intraoperatively may improve the success rate of modified single-session treatment.
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Vena Ilíaca , Síndrome de May-Thurner , Trombectomía , Trombosis de la Vena , Humanos , Vena Ilíaca/cirugía , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/cirugía , Estudios Retrospectivos , Factores de Riesgo , Stents , Trombectomía/efectos adversos , Trombectomía/métodos , Factores de Tiempo , Resultado del Tratamiento , Trombosis de la Vena/etiología , Trombosis de la Vena/cirugía , Insuficiencia del TratamientoRESUMEN
The purpose of this study is to analyze predictive factors for long-term clinical outcomes after catheter-directed thrombolysis (CDT) combined with stent implantation for acute deep vein thrombosis (DVT) secondary to iliac vein compression (IVC). A retrospective analysis was performed to review clinical data and follow-up information on 52 patients who underwent CDT combined with stent implantation for acute DVT secondary to IVC from June 2015 to March 2020. Clinical outcomes including stent patency and incidence of postthrombotic syndrome (PTS) were investigated using Kaplan-Meier analysis. All included patients were categorized into 2 groups according to the presence of PTS. Potential risk factors, including age, gender, degree of iliac vein stenosis, time from onset to treatment, dosage of thrombolytic agent, stent extending below the inguinal ligament, and duration of anticoagulation for PTS were evaluated using multivariate logistic regression analysis. Over a median follow-up of 24 months, 4 individuals underwent reintervention due to in-stent stenosis or stent compression. Primary stent patency was 98.1% at 1 month, 94.2% at 6 months, 90.4% at 12 months, and 88.5% at 24 months. Freedom from PTS was 98.1% at 6 months, 84.6% at 12 months, and 75% at 24 months. No treatment-related mortality or morbidity was observed. Based on the development of PTS, 13 patients with PTS were classified into group A and 39 patients without PTS were regarded as group B. Upon multivariate logistic regression analysis, key prognostic factors for PTS were degree of iliac vein stenosis and time from onset to treatment. CDT combined with stent implantation is safe and effective for acute DVT secondary to IVC in the long-term perspective. Severe iliac vein stenosis and longer period from onset to treatment may be associated with a higher risk of PTS.
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Síndrome de May-Thurner , Trombosis de la Vena , Humanos , Terapia Trombolítica/efectos adversos , Constricción Patológica/terapia , Constricción Patológica/complicaciones , Vena Ilíaca , Estudios Retrospectivos , Resultado del Tratamiento , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/terapia , Trombosis de la Vena/complicaciones , Trombosis de la Vena/terapia , Stents/efectos adversos , Catéteres/efectos adversosRESUMEN
Literature regarding the management of thrombus refractory to first-line treatment in the setting of pregnancy is limited, and management is made even more complicated in the context of thrombophilia. This case reviews the management of a patient with antithrombin deficiency who developed a massive thrombus during pregnancy, which was complicated by May-Thurner syndrome, lack of improvement with heparin, and preterm labor. The patient received multidisciplinary care throughout the pregnancy. At 35 weeks, anticoagulation was paused as she underwent induction of labor and delivery followed by postpartum placement of inferior vena cava filter and restarting heparin. Successful management of our pregnant patient with thrombus refractory to heparin hinged on individualized treatment for medical optimization with anticoagulation and antithrombin concentrate prior to labor followed by immediate postpartum placement of inferior vena cava filter.
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Deficiencia de Antitrombina III , Síndrome de May-Thurner , Filtros de Vena Cava , Trombosis de la Vena , Embarazo , Femenino , Recién Nacido , Humanos , Trombosis de la Vena/complicaciones , Trombosis de la Vena/tratamiento farmacológico , Síndrome de May-Thurner/complicaciones , Periodo Periparto , Deficiencia de Antitrombina III/complicaciones , Deficiencia de Antitrombina III/tratamiento farmacológico , Heparina/uso terapéutico , Anticoagulantes/uso terapéutico , Antitrombinas , Filtros de Vena Cava/efectos adversos , Vena Cava InferiorRESUMEN
OBJECTIVE: Double-barrel iliocaval reconstruction is performed by deploying two stents simultaneously in a side-by-side, or "double-barrel," configuration in the inferior vena cava (IVC) with extension into the bilateral common iliac veins. The aim of this study was to examine the outcomes of double-barrel reconstruction using closed-cell dedicated venous stents for the treatment of iliocaval deep venous thrombosis and iliac vein compression syndrome. METHODS: All endovascular procedural reports comprising vascular surgery and interventional radiology operators from a single urban academic hospital between May 1, 2019, and April 30, 2021, were retrospectively searched. A cohort of 22 consecutive patients who underwent double-barrel iliocaval stenting with closed-cell dedicated venous stents for chronic or acute-on-chronic iliocaval venous disease without prior endovascular iliocaval repair was identified. Baseline characteristics, procedural data, and patient outcomes were determined via a manual review of preprocedure clinical notes, diagnostic imaging studies, procedure notes and images, and follow-up clinical notes. RESULTS: The median (range) age was 59 (27-81) years, and the cohort consisted of 59.1% female. The most common presenting symptoms of venous disease were lower extremity swelling (90.9%) and pain (50.0%). CEAP clinical classification was C3 in 86.4% of patients, whereas the remainder had C4 disease. Most patients (72.7%) had post-thrombotic syndrome, 22.7% had a nonthrombotic iliac vein lesion, and one patient (4.5%) had the congenital absence of the infrarenal IVC. A total of 40.9% of patients had a pre-existing IVC filter at the time of treatment. Six of the 22 patients underwent concurrent pharmacomechanical thrombectomy during the index iliocaval reconstruction and stenting procedure. The number of stents placed ranged from 2 to 5. With a mean follow-up period of 7.1 months, ranging from 12 days to 16.7 months, the freedom from reintervention rate was 90.9%. Twenty of 22 patients achieved subjective improvement or resolution of symptoms. The major adverse event rate was 9.1%, as two patients had access site complications requiring intervention. CONCLUSIONS: Double-barrel iliocaval reconstruction with closed-cell dedicated venous stents for the treatment of post-thrombotic syndrome or iliac vein compression syndrome is technically feasible and clinically effective with a low reintervention rate.
Asunto(s)
Procedimientos Endovasculares , Síndrome de May-Thurner , Síndrome Posflebítico , Síndrome Postrombótico , Enfermedades Vasculares , Trombosis de la Vena , Humanos , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Masculino , Trombosis de la Vena/terapia , Síndrome de May-Thurner/complicaciones , Estudios Retrospectivos , Resultado del Tratamiento , Enfermedades Vasculares/terapia , Stents/efectos adversos , Síndrome Postrombótico/etiología , Procedimientos Endovasculares/efectos adversos , Síndrome Posflebítico/etiología , Vena Ilíaca/cirugía , Vena Cava Inferior/cirugíaRESUMEN
OBJECTIVES: To explore the etiology of May-Thurner syndrome (MTS) with acute iliofemoral deep vein thrombosis (DVT) regarding imaging findings and clinical features. METHODS: We retrospectively analyzed 57 patients with acute left iliofemoral DVT from 2015 to 2020. The diameter of left common iliac vein (LCIV) at the maximal compression site and its percent compression regarding the average diameter of the uncompressed iliac vein were recorded in central and distal portions of the LCIV according to the location in the quadrant of lumbar vertebral body. Compression was categorized into simple and bony MTS; Simple MTS as LCIV compressed by the right common iliac artery (RCIA) versus Bony MTS as LCIV by lower lumbar degenerative changes regardless of RCIA compression. Initial computed tomographic venography (CTV) regarding chronic change of LCIV such as fibrotic atrophy or cordlike obliteration, extent of thrombus, and lumbar degenerative changes were evaluated. Therapeutic effect after initial therapy was assessed in follow-up CTVs after 3-6 months. RESULTS: All patients showed LCIV compression with 19 simple MTS (mean age, 42.8 ± 14.1 years [23-67 years]; 12 females; symptom for 4.4 ± 5.5 days) and 38 bony MTS (mean age, 73.0 ± 10.2 years [49-85 years]; 26 females; symptom for 5.5 ± 4.8 days). There was significant difference in age (p < .001) and no significant difference in sex or symptom duration between two groups (p = .691 and 0.415, respectively). All simple MTS showed compression only in the central LCIV and half of bony MTS showed compression in both central and distal LCIV (p < .001). Among the lumbar degenerative changes, symmetric anterolateral osteophyte (p < .001) and asymmetric osteophyte (p < .001) were significantly associated with bony MTS, but not scoliosis (p = .799), compared to simple MTS. Although there was no significant difference in chronic change of LCIV, thrombosis extent, and therapeutic effect between two groups (p > .05), chronic change of LCIV showed significant difference between single and dual compression (23.7% vs. 57.9%, p = .024) and residual thrombus after initial therapy was occurred in 21.1% of single compression and 47.4% in dual compression with non-significant trend (p = .082). CONCLUSION: Bony MTS related to lumbar degenerative changes with acute iliofemoral DVT occurs in older patients, presenting more than one stenosis at LCIV, inducing more chronic change with possibly weaker therapeutic effect than simple MTS.