A Comprehensive Review of the Pathophysiology and Clinical Importance of Iliac Vein Obstruction.

OBJECTIVE: The purpose of this comprehensive review is to give a historical account of iliac vein compression and to analyse the pathophysiological aspects and their clinical implications. METHODS: An extensive search of the databases was performed from inception until 2019. The patterns, length and site of compression, wall and luminal changes, and anatomical variations were some of the factors recorded and analysed. RESULTS: Twenty-seven studies were included in this review, divided into cadaveric, histological, and imaging. According to the literature 22%-32% of the asymptomatic population shows "spurs" at the origin of the left common iliac vein (LCIV). Imaging studies also show the presence of direct and indirect compression signs such as the presence of collateral venous flow in axial, transpelvic, or ascending lumbar collaterals, and >50% compression in 37%-44% of the asymptomatic population. In patients without thrombosis it is unknown what produces the signs and symptoms, as the obstruction pre-exists their development. Haemodynamic evaluation is found in only a few studies often including patients with previous deep vein thrombosis. Furthermore, most of the tests are performed with the patient in the supine position and therefore the haemodynamic information is relatively poor. CONCLUSION: Patients with venous obstruction have various clinical presentations from being asymptomatic to having venous claudication and skin damage. Obstruction should be placed into clinical context, together with other contributing factors. Proper evaluation and clinical judgement are important in selecting patients for treatment. Given that such selection is not always clear, further work is needed.

[A case of successful endovascular treatment of a patient with chronic pelvic pain and recurrent varicocele]. / Sluchai uspeshnogo éndovaskuliarnogo lecheniia patsienta s khronicheskoi tazovoi bol'iu i retsidivom varikotsele.

Described in the article is a clinical case report regarding diagnosis and treatment of pelvic varicose veins in a 34-year-old male patient presenting with compressive stenosis of the left common iliac vein (May-Thurner syndrome). The man had developed clinical symptoms of the disease as varicocele when he was 17 years old. Multiple surgical interventions on the veins of the spermatic cord failed to result in significant success. The diagnosis was verified by means of ultrasound examination and contrast X-ray phlebography. The patient was subjected to balloon angioplasty and stenting of the compressive stenosis of the left common iliac vein. The endovascular treatment performed was followed by the patient's improved condition, confirmed by methods of instrumental diagnosis, as well as by regression of clinical symptomatology.

O caminho das pedras no diagnóstico e tratamento da síndrome obstrutiva ilíaca venosa crônica / Best practices in diagnosis and treatment of chronic iliac vein obstruction

Resumo A obstrução venosa ilíaca ocorre em 20% a 30% da população. Nos portadores de insuficiência venosa crônica grave, essa prevalência é ainda maior, podendo chegar a 50% a 90% dos pacientes, situação em que essa obstrução é investigada pelo ultrassom intravascular. Métodos diagnósticos menos invasivos, como o Doppler vascular, ou mesmo invasivos, como a flebografia, podem falhar em seu diagnóstico. O tratamento endovascular dessas obstruções tem se demonstrado eficaz, seguro e associado a excelente resultado clínico e de perviedade, desde que princípios anatômicos e técnicos fundamentais sejam considerados e aplicados.

Abstract Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

Recurrent unilateral cellulitis: is it May-Thurner syndrome (MTS)?

May-Thurner syndrome (MTS) is a differential diagnosis to be considered in a patient with recurrent unilateral cellulitis. A 73-year-old woman initially presented with recurrent unilateral cellulitis of her left lower limb. A CT scan demonstrated a stenosed left common iliac vein (CIV) narrowed at its origin by the proximal right common iliac artery consistent with MTS. The chronicity of the condition at the time of diagnosis made attempts to recanalise the CIV unsuccessful. A diagnosis of MTS should be considered in a patient with chronic unilateral limb oedema/cellulitis as it represents a potentially treatable condition if detected early.

A New-Proposal Physical Examination Test for Unilateral Lower Extremity Edema.

OBJECTIVE: Patients with iliac vein compression syndrome (IVCS) usually present to the hospital with left-sided leg edema. We looked for an answer to the question: ''Can iliac vein compression syndrome (IVCS) be predicted with a reliable physical examination test in the differential diagnosis?'' Methods: We tested a new physical examination on patients with only left-sided lower extremity edema. In this physical examination the widest area of the calf point (just below tuberosity of the tibia) and medial malleolus was measured in both legs on the Trendelenburg position at 30°and repeated in standing position. Then the iliac venography was performed. RESULTS: The test was performed on 32 (N = 32) patients with left extremity edema. IVCS was observed on 18 (n = 18) (56%) patients. The test was found to have 88% sensitivity and 92% specificity in IVCS. CONCLUSION: This new physical examination finding, which may be valuable in diagnosing IVCS, is proposed for use in patients with unilateral left-sided edema to preclude unnecessary use of expensive diagnostic imaging methods.

Systematic review of May-Thurner syndrome with emphasis on gender differences.

OBJECTIVE: May-Thurner syndrome (MTS) is increasingly recognized as a frequent source of leg swelling and a precipitating factor for venous thromboembolism. This paper is a systematic review of the English literature on MTS with an analysis focusing on gender differences in presentation and treatment. METHODS: A systematic review of the English literature between April 1967 and December 2014 was performed using the following terms: "May-Thurner syndrome," "Cockett syndrome," and "iliac vein compression syndrome." After review, there were 174 articles in the analysis. We first analyzed all presented cases, followed by a gender comparison if case reports and case series had detailed description. Asymptomatic patients with just anatomic compression without symptoms were excluded. Statistical differences between data sets were assessed using χ2 test and Student t-test. RESULTS: There were 1569 patients with MTS after exclusion of articles based on our criteria. The female to male ratio was 2:1 (976 [67.1%] vs 480 [32.9%]). Women presented at a younger age compared with men (38.7 ± 14.0 years vs 46.2 ± 16.9 years; P = .02). Gender comparison at presentation, which was available for 254 patients, showed that men had significantly more reported leg swelling (92.7% vs 80.8%; P = .037) and more leg pain (88% vs 74.3%; P = .045) compared with women. There was no difference in the reported proportion of patients presenting with deep venous thrombosis between the two groups (88.9% vs 81.7%; P = .14). However, women were significantly more likely to have a pulmonary embolus on presentation compared with men (9.9% vs 1.6%; P = .035). Treatment modalities included endovascular interventions without thrombolysis (53%) or with thrombolysis (33.2%), open surgery (6.8%), and medical management (7%). Endovascular treatment was more common than surgical or medical treatment (P < .001). Because of lack of granularity in the data, it was not possible to distinguish treatment methods between female and male patients. There was no statistically significant difference in complication rate between men and women based on the articles that provided that information (P = .34). However, open procedures had significantly higher complications compared with endovascular interventions (P = .021). CONCLUSIONS: Based on the reported literature, MTS is more common in women and is at least twice as frequent in women as in men. Men tend to have more pain and swelling in the legs, whereas women tend to be younger and more likely to have a pulmonary embolus on presentation. MTS and iliac vein compression are sometimes used interchangeably in an inaccurate manner.

Symptomatic compression of right iliac vein after right iliac artery stent placement.

Right lower extremity edema can be a presenting symptom of iliocaval compression syndrome, even in the absence of deep vein thrombosis. It has been reported in idiopathic and rarely, iatrogenic, cases secondary to variant anatomy, arterial stents, and bony hardware. Classically seen in the more confined left common iliac vein as May-Thurner syndrome, it is rare on the right side. We report an unusual case of acute right common iliac vein compression after right iliac stent placement leading to symptomatic right leg edema. Venous stenting resulted in resolution of symptoms at the 6-month follow-up.

Tratamento endovascular de trombose venosa profunda associada à Síndrome de May-Thurner / Endovascular treatment of deep venous thrombosis related to May-Thurner syndrome

A trombose venosa profunda (TVP) é a causa mais frequente e mais evitável de óbitos intra-hospitalares em todo o mundo. Descreve-se, neste relato, paciente feminina, de 43 anos de idade, que desenvolveu TVP em membro inferior esquerdo sem, aparentemente, fatores de risco associados. O diagnóstico de TVP aguda em mulher adulta ou adulta-jovem, sobretudo à esquerda, inclui a possibilidade de se associar com a variação anatômica da Síndrome de May-Thurner, o que torna menos adequado o seu tratamento isolado e conservador com anticoagulantes, uma vez que não aborda a sua causa base. Nesta situação clinico-cirúrgica, é necessária intervenção cirúrgica para retirar a compressão mecânica extrínseca da veia ilíaca comum esquerda pela artéria ilíaca comum direita, como revelada neste relato, por intermédio da angioplastia transluminal percutânea com colocação de stent auto-expansível. Este relato alerta para a importância da busca de diagnóstico etiopatogênico correto para a decisão terapêutica apropriada, o que permite a abordagem mais efetiva e condizente com a melhor recuperação e retorno à higidez. (AU)

Deep venous thrombosis (DVT) is the most frequent and most preventable cause of in-hospital deaths worldwide. We described in this report a 43-year-old female patient who developed DVT in the lower left limb without apparently associated risk factors. The diagnosis of acute DVT in an adult or young adult woman, especially on the left, includes the possibility of being associated with the anatomical variation of the May-Thurner Syndrome, which makes her isolated and conservative treatment with anticoagulants less suitable, because does not address its underlying cause. In this clinical-surgical situation, surgical intervention is required to remove the extrinsic mechanical compression of the left common iliac vein by the common iliac artery, as revealed in this report, through percutaneous transluminal angioplasty with selfexpanding stent placement. This report alerts to the importance of the correct etiopathogenic diagnostic search for the appropriate therapeutic decision, which allows the most effective approach, consistent with the best recovery and return to health. (AU)

May-Thurner syndrome presenting as spontaneous left iliac vein rupture.

Spontaneous iliac vein rupture resulting in a retroperitoneal hematoma is extremely rare and can present as a life-threatening emergency. There is often a delay in diagnosis with no established treatment recommendations. We report the case of a 39-year-old woman who presented with hypovolemic shock, a large left retroperitoneal hematoma, and left lower extremity phlegmasia in the setting of a previously asymptomatic May-Thurner syndrome. She was successfully treated with a combined open and endovascular approach. We also reviewed the literature on the evolution of diagnosis and treatment of this rare condition and present our recommendations for management.

Short-Term Clinical Experience with a Dedicated Venous Nitinol Stent: Initial Results with the Sinus-Venous Stent.

OBJECTIVE: Deep venous stenting has become the primary treatment option for chronic venous obstructive disease, both for iliac vein compression and post-thrombotic venous lesions. Until recently, only stents aimed at arterial pathology were used, because no dedicated venous stents were available. However, three such stents have now become available. These venous stents are characterized by increased length, diameter, flexibility, and radial force. This study reports an early experience with one of these devices; the sinus Venous stent (OptiMed GmbH, Ettlingen, Germany). METHODS: Between March 2012 and July 2014, 75 patients were treated with the sinus Venous stent: 35 cases of iliac vein compression syndrome and 40 cases of unilateral chronic obstruction in post-thrombotic syndrome (PTS). Diagnosis of relevant obstruction was made using clinical evaluation, duplex ultrasound, and magnetic resonance venography. Patency during follow up was assessed with duplex ultrasound. Clinical improvement was assessed by VCSS, Villalta score, rate of ulcer healing, and improvement of venous claudication. RESULTS: The cumulative patency rates at 3, 6, and 12 months were 99%, 96%, and 92%, respectively. The cumulative assisted primary patency rates were 99% at 3, 6, and 12 months. The cumulative secondary patency rate at 12 months was 100%. Differences exist in patency rate between the subgroups of non-thrombotic and post-thrombotic, with the first showing no re-occlusions. All re-thromboses in the PTS group were treated by ancillary treatment modalities. VCSS and Villalta score decreased significantly after stenting, as did venous claudication. Morbidity was low without clinically relevant pulmonary embolism, and mortality was nil. Although two out of seven ulcers healed temporarily, no ulcer remained healed at 12 months follow up. CONCLUSION: Short-term clinical results using the sinus Venous stent are excellent, with significant symptom reduction, low morbidity rates, and no mortality. Loss of stent patency is seen less often compared with arterial stents described in the literature.

A case of May-Thurner syndrome with inconsistent radiological and surgical findings.

May-Thurner syndrome is the result of compression of the left common iliac vein between the right common iliac artery and the overlying vertebrae. In this case report, we describe an 11-year-old boy presenting with swelling of the left lower extremity. An iliac MR venography showed compression of the left proximal iliac vein between the vertebra and the left iliac artery. In surgery, it was seen that the left common iliac vein was connected to the postero-inferior part of the inferior vena cava, and it was compressed between the right common iliac artery and the columna vertebralis, which was inconsistent with the radiological findings. An interposition of the great saphenous vein graft between the left common iliac vein and the inferior vena cava was made, with a successful outcome. Our case is interesting in that it showed inconsistent findings between the radiological images and surgery.

Iliac vein compression syndrome: literature review / Síndrome de compressão da veia ilíaca: revisão de literatura

Iliac vein compression syndrome is a clinical condition in which the right common iliac artery extrinsically compresses the left common iliac vein. The syndrome predominantly affects young women between their 2nd and 4th decades of life. In view of the syndrome's potential complications, it should be recognized/diagnosed and treated in symptomatic patients before it causes irreversible damage to patients' venous systems. Noninvasive methods, such as venous color Doppler US are reasonable screening methods, but angiotomography and magnetic resonance angiography are more reliable diagnostic tools and the method of choice for confirmation of diagnosis remains multi-plane phlebography with measurement of pressure gradients. Endovascular treatment (angioplasty with placement of self-expanding stents) is safe and effective and can replace open surgical reconstruction and/or anticoagulation alone...

A Síndrome de Compressão da Veia Ilíaca (SCVI) é uma situação clínica na qual a artéria ilíaca comum direita comprime extrinsecamente a veia ilíaca comum esquerda. Há uma predominância em mulheres jovens, entre a segunda e a quarta décadas de vida. Levando-se em consideração as complicações potenciais da síndrome, esta deve ser reconhecida/diagnosticada e tratada, em pacientes sintomáticos, antes que cause alterações irreversíveis no sistema venoso do paciente. Métodos não invasivos, como o US-Doppler colorido, quando realizados por examinadores experientes, são métodos de triagem razoáveis; porém, a angiotomografia e a angiorressonância são mais fidedignas. O método de escolha para a confirmação diagnóstica consiste na flebografia, em múltiplas incidências, com aferição de gradientes pressóricos. O tratamento endovascular (angioplastia com colocação de stent autoexpansível) é seguro e efetivo, podendo substituir a reconstrução cirúrgica aberta e/ou a anticoagulação isolada...

Endovascular treatment for symptomatic iliac vein compression syndrome: a prospective consecutive series of 48 patients.

BACKGROUND: We sought to assess the prevalence of iliac vein compression syndrome (IVCS) in patients with unilateral left lower limb chronic venous disease and evaluate the feasibility and effectiveness of endovascular treatment for IVCS. METHODS: We conducted a prospective cohort study of 48 consecutive patients diagnosed with IVCS between December 2008 and May 2012. We divided the patients into 2 groups: thrombotic IVCS (n = 12) and nonthrombotic IVCS (n = 36). We evaluated the perioperative, 30-day, and 1-year outcomes of endovascular treatment. We estimated the stent patency rate using the Kaplan-Meier method. RESULTS: The prevalence of IVCS within our cohort was 14.8% (48/324). The technical success rate of the endovascular treatment was 95.8%. There was no death, pulmonary embolism, or contrast-induced nephropathy among the patients. The 1-year primary patency rate was 93.0%. There was no significant difference between the thrombotic and nonthrombotic IVCS groups (P = 0.156). Perioperative complications were minor and improved quickly. The median pain level recorded on a visual analogue scale declined from 4.5 to 1.2 (P < 0.05) in the thrombotic ICVS group and from 3.3 to 0.3 (P < 0.05) in the nonthrombotic ICVS group. The edema relief rates in the thrombotic and nonthrombotic ICVS groups were 81.8% and 58.5%, respectively. The cumulative recurrence free ulcer healing rate was 71.4% 12 months after treatment. CONCLUSIONS: IVCS is more common than previously thought among patients with unilateral left lower limb chronic venous disease. Endovascular therapy, a minimally invasive approach to treating venous lesions, is a feasible and effective treatment for left-sided IVCS and has a high technical success rate and an acceptable complication profile.

Iatrogenic May-Thurner syndrome after EVAR.

May-Thurner syndrome (MTS) is caused by compression of the left iliac vein between the right common iliac artery and the body of the fifth lumbar vertebra, resulting in hemodynamic compromise to venous return and intimal hyperplasia of the vein from chronic pulsatile compression. We report a case of MTS resulting from placement of an aortic stent graft for aneurysm repair. A higher index of suspicion and a more comprehensive initial venous duplex investigation, which should include the suprainguinal veins, should be considered in those patients with new onset of unilateral limb swelling after endovascular aneurysm repair (EVAR).

Catheter-directed thrombolysis and stenting in the treatment of iliac vein compression syndrome with acute iliofemoral deep vein thrombosis: outcome and follow-up.

BACKGROUND: The purpose of this study was to evaluate the safety and effectiveness of catheter-directed thrombolysis (CDT) and stenting in the treatment of iliac vein compression syndrome (IVCS) with acute iliofemoral deep vein thrombosis (DVT). METHODS: A retrospective analysis was conducted in 61 patients (36 women, 25 men, age range 32-90 years, mean 64 years) who had IVCS with acute iliofemoral thrmobosis (≤10 days) and were treated by CDT and stenting between June 2006 and August 2011. All patients presented with IVCS with a median duration of 4.1 days and were treated with CDT (urokinase: initial dose of 125,000-250,000 U followed by 20,000-60,000 U/hr) followed by stent placement. Filters were implanted in those patients with existing pulmonary embolism (PE), inferior caval vein thrombosis, or in accordance with the patients' request. The patency, the pressure gradient crossing the stenosis of the iliac vein, both thigh and calf limb circumferences, and complications were assessed before and after CDT and stenting. A Duplex ultrasound was used to perform follow-up examinations at 1 month, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years after the operation. RESULTS: Three patients had PE before CDT as assessed by the computed tomography angiography. A total of 28 patients had a filter implanted (25 patients had a Cordis permanent filter and 3 patients had a Braun temporary filter). A total of 68 stents were implanted in 61 patients. Overall, the 1-month, 6-month, 1-year, 2-year, 3-year, and 5-year primary patency rates were 96.7%, 95.1%, 91.8%, 90.2%, 88.5%, and 85.2%, respectively. The pressure gradient crossing the stenosis of the iliac vein decreased significantly after CDT and stenting (7.22 ± 4.64 vs. 1.82 ± 2.78 cm H2O, P < 0.001). The reductions of thigh and calf circumferences were 66.7% (6.19 ± 2.67 vs. 1.98 ± 1.43 cm) and 61.6% (4.36 ± 2.10 vs. 1.46 ± 1.10 cm), respectively. Reocclusion occurred in 7 patients within 1-27 months. Four patients (7%) experienced minor bleeding and were treated successfully with sandbag compression. One patient felt light pain on the left waist after 3 months of stenting. No large hematoma, stent migration, or acute thrombosis complications occurred during the procedure. Two patients died from nonvascular causes during a follow-up of 2-62 months (mean, 31.0 months). Four patients were found with limb swelling and three patients felt heaviness. The incidence rate of postthrombotic syndrome was 11.5% (7/61). CONCLUSIONS: Treatment with CDT for IVCS with acute DVT achieves good patency and vein function after 5 years of follow-up in this study. However, further evidence is required to establish longer term benefits.

Percutaneous manual aspiration thrombectomy followed by stenting for iliac vein compression syndrome with secondary acute isolated iliofemoral deep vein thrombosis: a prospective study of single-session endovascular protocol.

OBJECTIVE: To evaluate the feasibility, safety, and effectiveness of single-session endovascular treatment with manual aspiration thrombectomy (MAT) as the first-line method of thrombus removal for iliac vein compression syndrome (IVCS) with secondary acute isolated iliofemoral deep vein thrombosis (DVT). METHODS: This was a prospective clinical study. Twenty-six patients (19 women, 7 men, mean age 54 years) with left-sided acute iliac-common femoral DVT secondary to IVCS were enrolled. All patients presented with leg swelling or pains. Endovascular treatment, consisting of MAT, balloon angioplasty, and stent placement, was performed in the same setting. Overnight antegrade thrombolysis was performed in patients with residual thrombus after MAT. Patients were followed up by ultrasonography. The mean follow-up period was 17.8 months (12-25 months). RESULTS: Single-session endovascular procedures were performed successfully in all patients. The mean procedure time was 67 minutes (ranging from 45 to 90 minutes). Complete thrombus removal, including almost 100% of removal in 24 patients and little residual thrombus (<5%) in two, was achieved after repeated MAT. Thrombolysis was used in these two patients. Complete symptomatic relief was achieved in 25 patients (96%) and partial relief in one. The hospital stay ranged from 2 to 4 days (mean 2.7 days). Recurrent thrombosis within the stent was observed in one case and recanalized with thrombolysis. The 1-year primary and secondary patency rate was 96% and 100%, respectively. No symptomatic pulmonary embolization, bleeding, and venous reflux were observed. Five patients complained about transitory low back pains during balloon angioplasty. CONCLUSION: Single-session endovascular treatment with MAT as the first-line thrombus removal method is feasible, safe, and effective for IVCS with secondary acute isolated iliofemoral DVT. Although limited, our experience suggests that patients thought to be at high risk of bleeding may be candidates for the present single-session endovascular protocol.

Surgical thrombectomy and simultaneous stenting for deep venous thrombosis caused by iliac vein compression syndrome (May-Thurner syndrome).

PURPOSE: Iliac vein compression syndrome (May-Thurner syndrome) is characterized by left iliac vein obstruction secondary to compression by the right common iliac artery against the fifth-lumbar vertebra, which increases incidence of deep venous thrombosis (DVT). We treated the patients with DVT due to May-Thurner syndrome (MTS) by surgical thrombectomy and simultaneous stenting, and this study is to evaluate the outcomes of this procedure. METHODS: From January 2009 to December 2011, a total of 8 patients underwent surgical thrombectomy with stenting. All patients were admitted for acute DVT involving the left iliofemoral segment, and diagnosed MTS. Patients were followed-up, and stent patency was assessed by means of duplex sonography. RESULTS: In all patients, the procedure was successful in achieving re-canalisation of the iliofemoral veins at the end of the operation. Perioperatively, there was no mortality and there was no case of clinically detected pulmonary embolism. Rethrombosis occurred within seven days of operation in 2 patients. During the follow-up period (mean; 16 months), 6 of 8 patients kept patent stents. CONCLUSION: Venous thrombectomy with simultaneous stenting is a potent technique to treat acute iliofemoral DVT due to MTS. This technique can restore venous patency and provide relief of the acute symptoms.