May-Thurner syndrome and deep vein thrombosis: A series of 8 patients

Objectives: To analyze the prevalence of May-Thurner syndrome (MTS) among patients with deep vein thrombosis (DVT) of left lower limb (LLL), and outcomes after long-term follow-up.MethodRetrospective observational study that included patients older than 18 diagnosed with acute DVT and MTS.ResultsAmong 760 patients diagnosed with DVT in the LLL, 8 patients were diagnosed with MTS (1.05%), with a mean age of 39 years. All patients received long-term anticoagulation, with a mean of 31.9 (±25.2) months. Invasive treatment with pharmaco-mechanical thrombectomy was performed in 5 patients (62.5%). During follow-up (mean of 32.4 months), 25% of patients suffered DVT recurrence. Only 1 case presented major bleeding, and no deaths were registered.ConclusionsMay-Thurner syndrome constitutes a permanent and underdiagnosed risk factor for the development of DVT of LLL. Our findings suggest that long-term anticoagulation therapy might be considered in selected cases. (AU)

Objetivos: Analizar la prevalencia del síndrome de May-Thurner (SMT) en una cohorte de pacientes con trombosis venosa profunda (TVP) en el miembro inferior izquierdo (MII), y las complicaciones durante el seguimiento a largo plazo.MétodosEstudio observacional retrospectivo que incluyó a pacientes mayores de 18 años con diagnóstico de TVP en el MII y SMT.ResultadosEntre los 760 pacientes diagnosticados de TVP en el MII, ocho pacientes fueron diagnosticados de SMT (1,05%), con una media de edad de 39 años. Todos los pacientes recibieron tratamiento anticoagulante a largo plazo, con una media de 31,9 (± 25,2) meses. Se realizó tratamiento invasivo con trombectomía fármaco-mecánica en cinco pacientes (62,5%). Durante el seguimiento (media de 32,4 meses), el 25% de los pacientes sufrieron recurrencia de TVP. Solo se registró un sangrado mayor y no se registraron muertes.ConclusionesEl síndrome de May-Thurner constituye un factor de riesgo infradiagnosticado y permanente para el desarrollo de TVP en el MII. Nuestros hallazgos sugieren que la anticoagulación a largo plazo podría ser considerada en casos seleccionados. (AU)

Endovascular Repair of a Post-Renal Transplant Internal Iliac Artery Pseudoaneurysm.

Anastomotic site pseudoaneurysm following renal transplantation is a rare vascular complication. Its etiology include defective suture techniques and infections. The clinical presentation includes allograft dysfunction, local mass effect, exsanguination, and rupture. Open surgical repair is associated with significant morbidity and allograft dysfunction. Endovascular stent-graft can be a less invasive, alternative approach. We describe a case of large pseudoaneurysm arising from the internal iliac artery in a post-renal transplant patient. It was successfully treated with the stent-graft. The externally compressed right common iliac vein was also treated with a self-expanding non-graft stent. Thus, endovascular approach can be an effective alternative to open repair for post-renal transplant iliac artery pseudoaneurysm.

A Novel Approach to a Patient with both Aortoiliac and Venous Occlusive Disease.

Radiation-induced arteritis is a well-recognized complication of radiotherapy; however, radiation-induced venous stenosis is very rare (Zhou W, Bush RL, Lin PH, et al. Radiation-associated venous stenosis: endovascular treatment options. J Vasc Surg 2004;40:179-182). We describe a case of mixed aortoiliac arterial occlusive disease and iliac venous outflow obstruction secondary to radiation-induced vascular disease. Several endovascular procedures were undertaken to treat aortoiliac occlusive disease, which was followed by stenting for venous occlusive disease.

Pelvic kidney as a cause of May-Thurner syndrome.

Deep venous thrombosis is a common clinical problem with significant morbidity and mortality. Since the iconic publication by Virchow in 1856, which placed all known causes of deep venous thrombosis into three groups, namely venous stasis, vascular injury and hypercoagulability, numerous causes have been added to each category. This case report highlights the importance of an anatomical imaging study of the pelvis in cases of recurring, proximal deep venous thrombosis of the lower limb.

Trombosis venosa asociada a síndromes compresivos venosos / Venous thrombosis associated with venous compression syndromes

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A case report of May-Thurner syndrome induced by anterior lumbar disc herniation: Novel treatment with radiofrequency thermocoagulation.

RATIONALE: Lumbar degeneration-related May-Thurner syndrome (dMTS) is characterized by venous compression induced by degenerated lower lumbar structures. Treatment strategies for May-Thurner syndrome (MTS) include clearing the thrombus and correcting venous compression. Despite having different etiological factors from other MTS types, treatments for dMTS are similar, including endovascular angioplasty and continuous anticoagulation therapies. Thus, a particular treatment was designed herein to focus on compressive lumbar structures instead of intravenous management. PATIENT CONCERNS: A 59-year-old female patient with dMTS, which was induced by inferior vena cava (IVC) stenosis compressed by L4-5 anterior disc herniation. DIAGNOSIS: The patient was diagnosed with IVC stenosis and L4-5 lumbar disc herniation based on abdominal computed tomography, ultrasound, and lumbar magnetic resonance imaging findings. INTERVENTIONS: Radiofrequency thermocoagulation (RF) was applied to the patient to decrease the compression caused by anterior disc herniation. OUTCOMES: After surgery, the patient's swelling started to improve within 5 hours and completely diminished after 48 hours. Postsurgical abdominal ultrasound showed that her IVC patency increased by 20%. On follow-up, her leg symptoms did not recur at 12 months after surgery. LESSONS: We provided a novel idea in the treatment of dMTS, in which we shifted the treatment focus from endovascular patency restoration to extravascular decompression. Our case proved that RF was effective in treating dMTS, which is a complementary treatment modality to angioplasty.

Virchow's triad in "silent" deep vein thrombosis.

OBJECTIVE: While determining the incidence of chronic deep vein thrombosis (DVT) and the hypercoagulation profiles of patients who underwent venous stenting for symptomatic venous insufficiency, we assessed the significance of Virchow's triad in the setting of proximal venous outflow obstruction and DVT. METHODS: Within our registry of 500 patients who underwent venous stenting for proximal venous outflow obstruction between 2013 and 2016, we selected the first 152 consecutive patients who had routine hypercoagulation profile testing performed preoperatively. Statistical analysis was performed using independent t-tests, χ2 tests, and multiple logistic regressions. RESULTS: By history or intraoperative chronic postphlebitic changes (CPPCs), 77 patients (50.7%) were positive for remote DVT; 51 (33.6%) had intraoperative findings of CPPCs without a history of DVT, 20 (13.2%) had intraoperative CPPCs with a history of DVT, and 6 (3.9%) had a history of DVT without intraoperative findings. The χ2 tests were significant for increased findings of CPPCs among patients with a history of DVT (81% vs 38%; P < .01). The χ2 tests were also significant for increased rates of intraoperative findings of CPPCs in patients with one or more positive hypercoagulation markers (67% vs 42%; P < .01). The most significant predictor for findings of CPPCs or DVT history was the presence of at least one hypercoagulation marker (n = 148; odds ratio, 2.41; P = .022). CONCLUSIONS: Remote history of DVT and intraoperative findings of CPPCs were prevalent. CPPC findings were found in many patients with no history of DVT. Hypercoagulation markers conferred significant predictive value for DVT. This information may influence our understanding of Virchow's triad and DVT etiology.

Late-Onset Nonthrombotic Left Common Iliac Vein Compression Secondary to Degenerative Lumbar Disc: A Case Report of May-Thurner Variant.

May-Thurner syndrome (MTS) refers to venous outflow obstruction caused by extrinsic compression of the left common iliac vein (LCIV) by the overlying pulsatile right common iliac artery against lumbar vertebrae. The classic clinical presentation is acute unilateral left leg painful swelling due to deep venous thrombosis in a young woman in the second or third decade of life. We present a case of a 66-year-old woman who presented with late-onset left leg swelling caused by nonthrombotic venous hypertension due to degenerative lumbar disc bulge leading to LCIV compression against the left common iliac artery which was confirmed by computed tomography and intravascular ultrasound. Our case highlights the importance of high index of suspicion for MTS in elderly patients with unilateral leg swelling and the importance of multimodality imaging for understanding the mechanism and appropriate treatment of MTS.

Bilateral May-Thurner syndrome refractory to iliac aneurysm repair.

Venous complications of iliac artery aneurysms are rare. We report the case of bilateral iliac aneurysms that resulted in iliac vein outflow obstruction despite endovascular aneurysm repair. In our patient, bilateral iliac vein stenting resulted in symptom resolution.

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.

Venous Compression Syndromes.

Venous compression syndromes occur due to extrinsic compression causing complications of venous hypertension or venous thrombosis. This review focuses on 4 venous compression syndromes involving the left common iliac vein, subclavian vein, left renal vein, and popliteal vein. Clinical presentation, diagnostic methods, and management options are reviewed. When properly diagnosed and treated, long-term consequences can be avoided.

Thrombosis of the Inferior Vena Cava after Endovascular Aortic Repair in a Patient with May-Thurner Syndrome: Case Report and Literature Review.

Inferior vena cava (IVC) thrombosis is a rare complication of abdominal aortic aneurysm (AAA). A 70-year-old male patient of Italian origin presented with a 9.3 × 8.4 cm infrarenal AAA, which was treated by endovascular aortic repair (EVAR). He reported a history of ulcerative colitis and was on prednisolone 80 mg daily. Seven weeks postoperatively the patient was readmitted with a deep vein thrombosis including both iliac veins and IVC, and bilateral pulmonary embolism. Venous thrombectomy and decompression of the IVC were performed by partial resection of the aneurysm sac. A covered stent was intraoperatively placed in the left common iliac vein to treat compression of the left iliac vein (May-Thurner Syndrome). Enoxaparin (2 × 0.8 mg) and antiplatelet agent with aspirin were administered, as well as intermittent compression therapy to the left leg. This case report describes vena cava thrombosis as a rare complication after EVAR in a patient with May-Thurner syndrome.

Pharmacomechanical catheter-directed thrombolysis for pregnancy-related iliofemoral deep vein thrombosis.

PURPOSE: Pharmacomechanical catheter-directed thrombolysis (PCDT) is relatively contraindicated during pregnancy and postpartum. The purpose of this study was to evaluate outcomes of PCDT in this population. MATERIALS AND METHODS: Data for 11 consecutive patients (aged 21-35 y) undergoing PCDT at a tertiary center for symptomatic pregnancy-related iliofemoral deep vein thrombosis (DVT) were retrospectively reviewed. Details regarding patient presentation, location and extent of thrombus, the PCDT procedure, outcomes, frequency of postthrombotic syndrome (PTS), and subsequent pregnancies were recorded. Two patients who presented in the first trimester terminated their pregnancies after PCDT, 2 patients who presented in the third trimester delayed PCDT until after delivery, and 7 patients who presented with postpartum DVT underwent immediate PCDT. RESULTS: Thrombus extended into the inferior vena cava in 5 patients (45%) and into popliteal/tibial veins in 7 (64%). Four patients (36%) had synchronous pulmonary embolism and three had May-Thurner compression. Median interval from diagnosis to PCDT was 5 days (range, 2-68 d); median duration of urokinase infusion was 27 hours (range, 16-72 h). Greater than 90% clot lysis was achieved in 9 of 11 patients (82%). Metal stents were placed in 8 of 11 patients (73%). A self-limiting popliteal hematoma developed in 1 patient, and 2 had early recurrent thrombosis requiring repeat PCDT. At median 20-month follow-up, nonocclusive thrombus was seen in 5 patients. No patient developed PTS. Three patients, all with stents, had uneventful pregnancies after PCDT. CONCLUSIONS: Pharmacomechanical catheter-directed thrombolysis achieved encouraging initial outcomes in this series. Validation in prospective trials with larger enrollment and longer follow-up is needed.

May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery.

Acute and chronic venous disorders of the lower extremities affect millions of people and cause substantial disability. Long ago, surgeons and pathologists identified the presence of 'spur-like' abnormalities of the left common iliac vein; these abnormalities were hypothesized to result from compression and/or irritation from the adjacent crossing right common iliac artery. In the 1990s, physicians, starting to perform catheter-directed thrombolysis to treat extensive deep vein thrombosis (DVT), observed that about 50% of patients had an iliac vein stenosis. Vascular physicians have become aware of the occasional patient with otherwise-unexplained extremity swelling and/or pain but without a DVT history who is subsequently found to have an iliac vein abnormality. These 'lesions' have been hypothesized to elevate ambulatory venous pressures and thereby produce lower-extremity symptoms, increase the risk of initial and recurrent DVT episodes, and increase the risk of treatment failure with medical and endovascular therapies for thrombotic and non-thrombotic venous conditions. As a result, many practitioners now actively seek iliac venous obstructive 'lesions' when evaluating patients with known or suspected venous disease. However, for many patients, it continues to be unclear what degree of obstruction to venous blood flow is being caused by such lesions, how clinically significant they are, how much emphasis should be placed on identifying them, and when they should be treated. This article seeks to improve the knowledge base of vascular practitioners who make clinical decisions about the diagnosis and treatment of obstructive iliac vein lesions.