Seizures, deep vein thrombosis, and pulmonary emboli in a severe case of May-Thurner syndrome: a case report.

BACKGROUND: May-Thurner syndrome is a vascular disorder caused by the right common iliac artery compressing the left common iliac vein against the lumbar spine, causing distal venous stasis and potentially leading to fibrous change in the venous wall structure. Although May-Thurner syndrome is most commonly discovered in females upon investigation of new-onset deep vein thrombosis, we present the case of an otherwise healthy 29-year-old male with severe May-Thurner syndrome who presented with seizures, bilateral deep vein thrombosis, and diffuse pulmonary emboli. Seizures constituted the earliest presenting symptoms for the patient. Although it is difficult to prove that the patient's seizures were related to the May-Thurner syndrome, this possible association renders this case extraordinary. CASE PRESENTATION: This report describes the case of a 29-year-old previously healthy white male with a severe case of left-sided May-Thurner syndrome that required extensive medical and interventional treatment. The patient experienced two seizures, one month apart, both of which occurred while residing at high altitude. The patient had no prior history of seizures, and epilepsy was ruled out. Three weeks after the second seizure, he presented to the emergency room with hemoptysis, dyspnea, and severe leg pain. Sites of thrombus were confirmed in both legs and diffusely in the lungs. Etiological work-up after treatment with intravenous tissue plasminogen activator revealed May-Thurner syndrome. Hematology workup including genetic testing showed no evidence of coagulopathy. Bilateral common iliac venous stents were placed to attempt definitive treatment. Despite stenting, the patient had another thrombotic event with associated sequelae after discontinuation of anticoagulation. The patient has not had another seizure since the stents were placed. Despite the negative testing, the patient remains on lifelong chemoprophylaxis in the event of an undiscovered hypercoagulopathy. CONCLUSIONS: The care team theorizes that the seizures resulted from hypoxia due to May-Thurner syndrome-induced hemostasis and associated thrombotic events, the high-altitude location of his residence at the time he experienced the seizures, and shallow breathing during sleep. For patients with lower limb venous thrombosis, May-Thurner syndrome should be considered in the differential diagnosis. Endovascular treatment followed by extended prophylactic anticoagulation therapy until the patient is determined to be no longer at risk for thrombosis is recommended. Post-venoplasty thrombosis is a common complication of endovascular treatment of May-Thurner syndrome and should be carefully monitored.

[May-Thurner syndrome as a cause of abdominal pain: Case report]. / Síndrome de May-Thurner como causa de dolor abdominal: caso clínico.

BACKGROUND: The May-Thurner syndrome consists of an anatomical anomaly of the iliac veins that predisposes the person presenting it to the appearance of venous insufficiency and recurrent thrombotic episodes of the lower limbs. The aim of this article was to present a case of this pathology, highlighting a rare symptom that led to its diagnosis. CASE REPORT: 46-year-old woman with severe abdominal pain in the right iliac fossa not associated with other gastrointestinal symptoms or fever. Contrast tomography of the abdomen and pelvis reported bilateral common iliac vein thrombosis. After ruling out acute surgical abdomen or immunological pathologies, an abdominal-pelvic angiography was performed, which led to the diagnosis of May-Thurner syndrome. It was performed endovascularly, pharmaco-mechanical thrombolysis, balloon plasty, and stent installation. CONCLUSIONS: This type of abdominal vascular compression syndromes are rare and require a high index of suspicion to be diagnosed, which is why publications of this type of pathology take on relevance since they teach readers about the pathology.

INTRODUCCIÓN: el síndrome de May-Thurner consiste en una anomalía anatómica de las venas ilíacas que predispone a quien la presenta a la aparición de insuficiencia venosa y episodios trombóticos recurrentes de los miembros inferiores. El objetivo de este trabajo fue presentar un caso de esta patología, destacando un síntoma poco frecuente que motivó su diagnóstico. CASO CLÍNICO: mujer de 46 años con dolor abdominal severo en fosa ilíaca derecha, no asociado a otros síntomas gastrointestinales ni fiebre. La tomografía con contraste de abdomen y pelvis ayudó a diagnosticar trombosis de las venas ilíacas comunes bilaterales. Tras descartar abdomen agudo quirúrgico o patologías inmunológicas, se realizó una angiotomografía abdómino-pélvica que condujo al diagnóstico de síndrome de May-Thurner. Se realizó endovascularmente, trombólisis fármaco-mecánica, angioplastia con balón e instalación de stent. CONCLUSIONES: este tipo de síndromes de compresión vascular abdominal son poco comunes y requieren de un alto índice de sospecha para ser diagnosticados, es por ello que publicaciones de este tipo de patología adquieren relevancia, dado que ilustran a los lectores sobre la patología en cuestión.

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)

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. METHOD: Retrospective observational study that included patients older than 18 diagnosed with acute DVT and MTS. RESULTS: Among 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. CONCLUSIONS: May-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.

Novel typing of iliac vein compression in asymptomatic individuals evaluated by contrast enhanced CT.

PURPOSE: Compression of the iliac vein between the iliac artery and lumbosacral vertebra can cause iliac vein compression syndrome (IVCS). The purpose of this study is to assess compression characteristics and establish a new sub-typing in asymptomatic IVCS individuals using contrast-enhanced CT. METHODS: A retrospective analysis of abdomen contrast-enhanced CT images from 195 asymptomatic subjects with iliac vein compressed was investigated. Patients had no history of venous pathology, and images were collected from June 2018 to January 2019. Qualitative and quantitative characteristics of compression were examined including the location, pattern, minor diameter, area, and the percentage compression on an orthogonal section by the post-processing of multiple planar reconstruction and volume rendering. RESULTS: There were 107 females and 88 males with age range 18-92 years. The most common site of iliac vein compression was localized to the left common iliac vein (LCIV) (178/195, 91.3%). Notably, four compression types (type I-IV) were established according to the compression location, with type II being the most common. The four compression types had differences in the upper limit and fluctuation range of compression. It was found that the average level of iliac vein compression was below 25%. The compression degree of the left common iliac vein in type II was relatively concentrated, and the upper limit of compression was close to 70%. CONCLUSION: Asymptomatic iliac vein compression was categorized according to compression location. The proposal of four types might help clinicians to predict which IVCS patients would benefit from interventional therapy.

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.

May-Thurner Syndrome Results in Life-Threatening Condition: Phlegmasia Cerulea Dolens and Rhabdomyolysis.

Venography alone may underestimate the extent of common iliac vein compression in May-Thurner syndrome. Peripheral intravascular ultrasound is mandatory to better assess common iliac vein compression.

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.

A case of May-Thurner Syndrome: An old anomaly but, a new suggestion: A case report.

May-Thurner syndrome (MTS) is an anatomical condition resulting in compression of the left common iliac vein between the right common iliac artery and the underlying spine. MTS is rarely diagnosed because diagnostic workup is seldom continued once the diagnosis of a deep vein thrombosis (DVT) has been established. Furthermore, patients with DVT generally have several well-known confounding risk factors. We report a 16-year-old girl with a history of left leg swelling who was incidentally diagnosed with MTS. We hope that our case report will create awareness of vascular abnormalities in sports medicine and suggest that routine venous Doppler ultrasound screening may help to detect MTS or associated anatomical prior to the formation of early thrombosis.

Trombosis de miembro inferior como presentación de síndrome de May-Thurner / Lower limb thrombosis as a presentation of May-Thurner syndrome

No disponible

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.

Acute bilateral pulmonary embolism in a 21-year-old: is May-Thurner syndrome in our differential?

May-Thurner syndrome (MTS) is a clinical condition where the left common iliac vein gets compressed by the overlying right common iliac artery anterior to the fifth lumbar vertebra and the sacral promontory. It results in vessel wall injury and predisposition to thrombosis. We present a case of a 21-year-old African-American man with no significant past medical history who came to the emergency department with left lower limb swelling associated with shortness of breath, and was eventually diagnosed to have extensive left lower extremity deep vein thrombosis (DVT) along with acute bilateral extensive pulmonary embolism (PE) as a consequence to MTS. MTS should be considered in the differential when young patients present with unprovoked or recurrent left-sided DVT. Diagnosis of this anatomical variant is critical as it may need long-term anticoagulation and consideration of pharmaco-mechanical intervention such as mechanical thrombectomy and venoplasty with or without stenting.