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Rochon PJ, Reghunathan A, Kapoor BS, Kalva SP, Fidelman N, Majdalany BS, Abujudeh H, Caplin DM, Eldrup-Jorgensen J, Farsad K, Guimaraes MS, Gupta A, Higgins M, Kendi AT, Khilnani NM, Patel PJ, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease. J Am Coll Radiol 2023; 20:S481-S500. [PMID: 38040466 DOI: 10.1016/j.jacr.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Arun Reghunathan
- Research Author, University of Colorado Denver, Denver, Colorado
| | | | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicholas Fidelman
- Panel Vice-Chair, University of California, San Francisco, San Francisco, California
| | - Bill S Majdalany
- Panel Vice-Chair, University of Vermont Medical Center, Burlington, Vermont
| | - Hani Abujudeh
- Detroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan
| | - Drew M Caplin
- Zucker School of Medicine at Hofstra Northwell, Hempstead, New York
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | | | | | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | | | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging
| | - Neil M Khilnani
- Weill Cornell Medicine-NewYork Presbyterian Hospital, New York, New York; American Vein and Lymphatic Society
| | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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Kato T, Fuke M, Nagai F, Nomi H, Kanzaki Y, Yui H, Maruyama S, Nagae A, Sakai T, Saigusa T, Ebisawa S, Okada A, Motoki H, Kuwahara K. Successful endovascular treatment with a stent graft for chronic deep vein thrombosis with multiple arteriovenous fistulas: a case report. J Med Case Rep 2022; 16:257. [PMID: 35778762 PMCID: PMC9250182 DOI: 10.1186/s13256-022-03480-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background Deep vein thrombosis with arteriovenous fistulas is rare, with few therapeutic options available for chronic-phase deep vein thrombosis. Moreover, the effectiveness of endovascular treatment for chronic-phase deep vein thrombosis with arteriovenous fistulas has not been established. We describe herein a case of successful endovascular treatment for chronic deep vein thrombosis with multiple arteriovenous fistulas. Case presentation We describe the case of a 72-year-old Asian woman who had begun experiencing left leg swelling and intermittent claudication 2 years prior. Enhanced computed tomography revealed left common iliac vein occlusion with vein-to-vein collateral formation and several arteriovenous fistulas. Angiography and ultrasound showed the arteriovenous fistulas to run from the common and internal iliac arteries to the external iliac and superficial femoral veins. We opted against surgical repair for the arteriovenous fistulas due to their complex nature and complicated morphology. Since her condition was progressive, endovascular treatment with a stent graft was performed for the deep vein thrombosis, after which her symptoms gradually improved. Four months following the procedure, enhanced computed tomography confirmed remarkable reduction of the vein-to-vein collaterals and arteriovenous fistulas. Conclusions In the present case, enhanced computed tomography with a stent graft was effective in improving symptoms. This strategy may therefore be a treatment option for intractable chronic deep vein thrombosis with arteriovenous fistulas.
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Affiliation(s)
- Tamon Kato
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Megumi Fuke
- Division of Cardiovascular Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Fumio Nagai
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hidetomo Nomi
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yusuke Kanzaki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hisanori Yui
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Shusaku Maruyama
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Ayumu Nagae
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takahiro Sakai
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Ayako Okada
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
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Zahid M, Nepal P, Nagar A, Ojili V. Abdominal vascular compression syndromes encountered in the emergency department: cross-sectional imaging spectrum and clinical implications. Emerg Radiol 2020; 27:513-526. [DOI: 10.1007/s10140-020-01778-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
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Cyrek AE. Eine außergewöhnliche Therapie der Vena-iliaca-externa-Hypoplasie bei einer Patientin mit Klippel-Trénaunay-Syndrom – ein Fallbericht. PHLEBOLOGIE 2020. [DOI: 10.1055/a-1134-8807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
ZusammenfassungDas Klippel-Trénaunay-Syndrom (KTS) ist eine seltene und komplexe Fehlbildung. Sie zeigt die typische Trias aus vaskulärer Malformation, Knochen- und Weichteilhypertrophie sowie venöser Varikosis. Die Systemmanifestationen werden in einem individuell variablen Muster beobachtet. Eine isolierte angeborene Hypoplasie des venösen Systems tritt jedoch in den seltensten Fällen auf. Aus diesem Grund spielt die Früherkennung eine wichtige Rolle für die weitere Behandlungsplanung. So können durch rechtzeitige Behandlung schwere Krankheitsverläufe oder Spätfolgen vermieden werden. Eine isolierte angeborene Hypoplasie ist extrem selten und prädisponiert insbesondere im jungen Erwachsenenalter für Becken- oder Beinvenenthrombosen. Bei dieser Krankheit wird selten eine chirurgische Rekonstruktion durchgeführt.Wir beschreiben einen sehr seltenen Fall einer 60-jährigen Frau mit KTS, die vor 28 Jahren einen venösen Crossover-Bypass (Palma) mittels Vena saphena magna bei Hypoplasie der Vena iliaca externa rechts erhalten hat. Das Ziel des vorliegenden Berichts ist das klinische Erscheinungsbild, den diagnostischen Prozess und das Krankheitsmanagement vorzustellen sowie eine Literaturübersicht zum operativen Behandlungsverfahren darzustellen.
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Affiliation(s)
- Anna Ewa Cyrek
- Sektion Gefäßchirurgie und Endovaskuläre Chirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen
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5
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Bi Y, Yu Z, Chen H, Ren J, Han X. Long-term outcome and quality of life in patients with iliac vein compression syndrome after endovascular treatment. Phlebology 2019; 34:536-542. [PMID: 30665328 DOI: 10.1177/0268355518825090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purpose Deep venous thrombosis induced by iliac vein compression syndrome often interferes with patients’ work or daily living. This study aims to investigate the long-term outcome and quality of life in patients with iliac vein compression syndrome after endovascular treatment. Methods From October 2011 until June 2016, 28 patients with acute deep venous thrombosis diagnosed as iliac vein compression syndrome by ultrasonography were enrolled in this perspective study. Fifteen patients underwent balloon dilation and stent insertion (group A); 13 patients received anticoagulation treatment, thrombolysis, or balloon dilation without stenting (group B). The Medical Outcomes Study-Short Form-36 was used to assess the quality of life preoperatively and after endovascular treatment. The follow-up of Short Form-36 questionnaire was obtained within 12.13 ± 12.04 months after repair. Results There was no operative mortality in two groups, and technical success was achieved in 14 (93.3%) patients in group A. Thirteen (86.7%) patients were cured in group A, which was significantly higher than that of group B (46.2%, p = 0.042). Only one patient showed occlusion of stent in group A, with a secondary patency rate of 93.3%. Except for ‘Role emotion’, all remaining domains were significantly improved in group A when compared with preoperative score ( p < 0.01). The scores of ‘Physical functioning’, ‘Role physical’, and ‘General health’ in group A were significantly higher than those of group B ( p < 0.05). Conclusions Endovascular stenting to treat iliac vein compression syndrome shows beneficial clinical outcome, cumulative patency rate, and quality of life, with high technical success and low complications.
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Affiliation(s)
- Yonghua Bi
- 1 Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zepeng Yu
- 1 Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongmei Chen
- 2 Department of Ultrasound, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Jianzhuang Ren
- 1 Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinwei Han
- 1 Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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6
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Baloch ZQ, Hussain M, Ayyaz M, Dagli N, Abbas SA. May-Thurner Syndrome Presenting as Acute Unexplained Deep Venous Thrombosis. Ann Vasc Surg 2018; 53:266.e1-266.e3. [PMID: 29793013 DOI: 10.1016/j.avsg.2018.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/16/2018] [Accepted: 03/10/2018] [Indexed: 11/26/2022]
Abstract
May-Thurner syndrome (MTS) is a rare cause of deep venous thrombosis and occurs due to an anatomic anomaly which produces chronic compression of the left common iliac vein by the overlying right common iliac artery when it passes between the right common iliac artery and the spine. Prolonged compression on the vein potentiates thrombus formation by impairing the intima and by leading to the development of membranes within the lumen that may decrease and/or block venous flow. In this case presentation, we elaborate on a case of a 43-year-old woman who presented with worsening left leg swelling and pain. The patient was diagnosed with MTS and underwent successful stent placement to relieve the compressed vein.
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Affiliation(s)
| | | | - Muhammad Ayyaz
- Department of Internal Medicine, Brandon Regional Hospital, Brandon, FL
| | - Nishant Dagli
- Department of Internal Medicine, Brandon Regional Hospital, Brandon, FL
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Kiguchi MM, Abramowitz SD. Open Surgical Management of Deep Venous Occlusive Disease. Tech Vasc Interv Radiol 2018; 21:117-122. [PMID: 29784120 DOI: 10.1053/j.tvir.2018.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular techniques have revolutionized the management of deep venous occlusive disease. Open surgery, however, is still required for cases that prove refractory to endovascular interventions. The surgical management of deep venous occlusive disease typically involves venous bypass. Preoperative planning before open venous surgery relies upon dynamic imaging to clarify the location and severity of venous obstruction, the assessment of infrainguinal reflux, and the delineation of bypass origination and target vessels. Adjunct arteriovenous fistulas and anticoagulation may improve patency rates of open surgical venous bypass. The timely recognition and management of complications improves secondary patency rates.
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Affiliation(s)
- Misaki M Kiguchi
- Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, DC.
| | - Steven D Abramowitz
- Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, DC
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Abstract
Lower extremity deep venous thrombosis is a leading cause of morbidity and mortality. The mainstay of therapy is medical. However, anticoagulation does not remove the thrombus and restore venous patency. In select patients, early thrombus removal and anticoagulation can restore venous patency, preserve venous valve function, and may reduce the incidence of postthrombotic syndrome. Catheter-directed therapies are minimally invasive with low complication rates. However, in patients with a contraindication to thrombolytic agents who can receive anticoagulation, open thrombectomy should be considered if indications for thrombus removal are met and patients are good operative risks.
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9
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Schleimer K, Barbati ME, Gombert A, Wienert V, Grommes J, Jalaie H. The Treatment of Post-Thrombotic Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:863-870. [PMID: 28098065 DOI: 10.3238/arztebl.2016.0863] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 05/24/2016] [Accepted: 09/01/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) arises in 20-50% of patients who have sustained a deep vein thrombosis and markedly impairs their quality of life. METHODS This review is based on pertinent publications retrieved by a selective literature search in PubMed and the Cochrane Library, and on the guidelines of the German Societies of Phlebology and Vascular Surgery (Deutsche Gesellschaft für Phlebologie, Deutsche Gesellschaft für Gefässchirurgie). RESULTS The treatment options are conservative treatment with compression and patient exercises, endovascular recanalization with stent angioplasty, and open bypass surgery of the iliac obstructions. The endovascular techniques yield patency rates of 73 to 100%, with thrombotic stent occlusion and hematoma as potential complications. The open operations have only been documented in studies with small case numbers (3 to 85 cases per study, patency rates 58 to 100%). The complications of these invasive procedures can include thrombotic bypass occlusion, hematoma, and wound infection. There have been randomized trials of conservative treatment, but not of surgical treatment. The American Heart Association, in its guidelines, gives the same weak recommendation for all surgical methods (IIb). CONCLUSION All conservative options should be exhausted as the first line of treatment. If PTS symptoms persist and markedly impair the patient's quality of life, the possible indication for surgery should be considered. As PTS hardly ever leads to death or limb loss, its treatment should be as uninvasive as possible. Endovascular recanalization is an attractive option in this respect. A conclusive evaluation of the role of endovascular procedures in PTS must await randomized trials of this form of treatment and of the optimal stent configuration.
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10
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Abstract
Background Cockett and Thomas described and named Cockett's syndrome in 1965, commonly referred to as iliac vein compression syndrome (IVCS). It is often found as underlying cause in iliofemoral deep venous thrombosis (DVT). They described the syndrome mostly seen on the left side and predominantly in women during the second to the fourth decade of life. In this article, we present a patient with a Cockett's syndrome on the right side. Case presentation Our patient is a 52-year old female with edema of the right leg since 4 months. She had no signs of a DVT and did not benefit from a 3-month compression therapy. She was diagnosed using a CT-scan. Endovascular treatment was performed with a venous stent in the right common iliac vein (CIV). No postoperative complications were seen. After a 6-month follow-up, patient was free of pain and had no residual edema of the right leg. Conclusions Our patient presented with a non-complicated right-sided Cockett's syndrome. She was successfully treated with balloon dilatation and additional stenting of the right common iliac vein. Because of the clinical improvement of the patient together with the excellent long-term results and good patency results of the stenting, guidelines nowadays advise more and more venous stenting to prevent DVT and to relieve symptoms in case of vein compression syndromes.
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Lamba R, Tanner DT, Sekhon S, McGahan JP, Corwin MT, Lall CG. Multidetector CT of vascular compression syndromes in the abdomen and pelvis. Radiographics 2015; 34:93-115. [PMID: 24428284 DOI: 10.1148/rg.341125010] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Certain abdominopelvic vascular structures may be compressed by adjacent anatomic structures or may cause compression of adjacent hollow viscera. Such compressions may be asymptomatic; when symptomatic, however, they can lead to a variety of uncommon syndromes in the abdomen and pelvis, including median arcuate ligament syndrome, May-Thurner syndrome, nutcracker syndrome, superior mesenteric artery syndrome, ureteropelvic junction obstruction, ovarian vein syndrome, and other forms of ureteral compression. These syndromes, the pathogenesis of some of which remains controversial, can result in nonspecific symptoms of epigastric or flank pain, weight loss, nausea and vomiting, hematuria, or urinary tract infection. Direct venography or duplex ultrasonography can provide hemodynamic information in cases of vascular compression. However, multidetector computed tomography is particularly useful in that it allows a comprehensive single-study evaluation of the anatomy and resultant morphologic changes. Anatomic findings that can predispose to these syndromes may be encountered in patients who are undergoing imaging for unrelated reasons. However, the diagnosis of these syndromes should not be made on the basis of imaging findings alone. Severely symptomatic patients require treatment, which is generally surgical, although endovascular techniques are increasingly being used to treat venous compressions.
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Affiliation(s)
- Ramit Lamba
- From the Department of Radiology, University of California, Davis Health System, 4860 Y St, Suite 3100, Sacramento, CA 95817 (R.L., D.T.T., S.S., J.P.M., M.T.C.); and Department of Radiology, University of California, Irvine Medical Center, Irvine, Calif (C.G.L)
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Duran C, Rohatgi S, Wake N, Rybicki FJ, Steigner M. May-thurner syndrome: a case report. Eurasian J Med 2015; 43:129-31. [PMID: 25610179 DOI: 10.5152/eajm.2011.29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 06/24/2011] [Indexed: 01/15/2023] Open
Abstract
May-Thurner Syndrome (MTS) or iliac vein compression syndrome is caused by compression of the left common iliac vein by the right common iliac artery. This obstruction may cause leg swelling, varicosities, deep venous thrombosis, chronic venous stasis ulcers, or more serious complications, such as pulmonary embolism. Iliac vein compression can be assessed with computed tomography (CT) and iliac venography. The goals of treatment are to reduce symptoms and to reduce the risk of complications. Stent placement is an alternative method to a direct surgical approach. We present a case of MTS, treated with stent placement.
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Affiliation(s)
- Cihan Duran
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Saurabh Rohatgi
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicole Wake
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Frank J Rybicki
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Steigner
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Kahn SR, Comerota AJ, Cushman M, Evans NS, Ginsberg JS, Goldenberg NA, Gupta DK, Prandoni P, Vedantham S, Walsh ME, Weitz JI. The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies. Circulation 2014; 130:1636-61. [DOI: 10.1161/cir.0000000000000130] [Citation(s) in RCA: 349] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Goyal VD, Rana S, Verma V, Pal S, Nazar MF. Sapheno-femoral crossover venous bypass in a case of deep vein thrombosis: an uncommonly done procedure for a very common disease. Indian J Thorac Cardiovasc Surg 2013. [DOI: 10.1007/s12055-013-0240-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Anaya-Ayala JE, Adams MK, Telich-Tarriba JE, Dresser KL, Ismail N, Peden EK. Complex left profunda femoris vein to renal vein bypass for the management of progressive chronic iliofemoral occlusion. Ann Vasc Surg 2012; 27:112.e5-8. [PMID: 23122979 DOI: 10.1016/j.avsg.2012.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/15/2012] [Accepted: 05/17/2012] [Indexed: 11/28/2022]
Abstract
Chronic occlusions of the inferior vena cava (IVC) and iliofemoral veins are long-term sequelae of deep venous thrombosis (DVT) that can lead to postthrombotic syndrome (PTS). Patients may present with a wide spectrum of signs and symptoms, ranging from mild discomfort and swelling to severe venous hypertension and ulcerations. We report a 68-year-old man who had a history of left lower extremity DVT after a laminectomy and who developed PTS with nonhealing ulcers. The patient underwent a cross-pubic femorofemoral venous bypass that failed to improve his clinical status. After unsuccessful endovascular attempts for recanalization of the iliofemoral segment, a profunda femoris to IVC bypass was performed. The symptoms recurred 2 years later. Venography revealed restenosis at the caval anastomosis that did not resolve by endovascular means. A surgical revision was performed, and given the quality of the IVC, a jump bypass was created to the left renal vein. The swelling improved and the ulcers healed completely. Twenty-eight months after the complex reconstructions, he remains ulcer-free with mild edema controlled with stockings. Venous reconstructions remain a viable option for patients with symptomatic and recalcitrant nonmalignant obstruction of the large veins.
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Affiliation(s)
- Javier E Anaya-Ayala
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, 6550 Fannin Street, Houston, TX 77030, USA
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Chronic iliac vein occlusion and painful nonhealing ulcer induced by high venous pressures from an arteriovenous malformation. Case Rep Radiol 2011; 2011:514721. [PMID: 22606547 PMCID: PMC3350292 DOI: 10.1155/2011/514721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 09/25/2011] [Indexed: 11/17/2022] Open
Abstract
Chronic femoral vein compression (May-Thurner Syndrome) is a known rare cause of deep venous thrombosis. Subsequent angiogenesis and the development of arteriovenous malformation (AVM) in the setting of chronic venous thrombosis is by itself a rare and poorly understood phenomenon. We report a case in which elevated venous pressures resulting from such compression appear to have resulted in the development of a pelvic arteriovenous malformation, which was further complicated by chronic, nonhealing painful lower extremity ulcers, and the development of extensive subcutaneous venous collaterals. Following successful embolization of the pelvic AVM and ablation of veins under the ulcers with laser and sclerotherapy, the patient's ulcers healed and she became pain-free.
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Gutzeit A, Zollikofer CL, Dettling-Pizzolato M, Graf N, Largiadèr J, Binkert CA. Endovascular stent treatment for symptomatic benign iliofemoral venous occlusive disease: long-term results 1987-2009. Cardiovasc Intervent Radiol 2010; 34:542-9. [PMID: 20593287 PMCID: PMC3096768 DOI: 10.1007/s00270-010-9927-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 06/04/2010] [Indexed: 11/28/2022]
Abstract
Venous stenting has been shown to effectively treat iliofemoral venous obstruction with good short- and mid-term results. The aim of this study was to investigate long-term clinical outcome and stent patency. Twenty patients were treated with venous stenting for benign disease at our institution between 1987 and 2005. Fifteen of 20 patients (15 female, mean age at time of stent implantation 38 years [range 18-66]) returned for a clinical visit, a plain X-ray of the stent, and a Duplex ultrasound. Four patients were lost to follow-up, and one patient died 277 months after stent placement although a good clinical result was documented 267 months after stent placement. Mean follow-up after stent placement was 167.8 months (13.9 years) (range 71 (6 years) to 267 months [22 years]). No patient needed an additional venous intervention after stent implantation. No significant difference between the circumference of the thigh on the stented side (mean 55.1 cm [range 47.0-70.0]) compared with the contralateral thigh (mean 54.9 cm [range 47.0-70.0]) (p=0.684) was seen. There was a nonsignificant trend toward higher flow velocities within the stent (mean 30.8 cm/s [range 10.0-48.0]) and the corresponding vein segment on the contralateral side (mean 25.2 cm/s [range 12.0-47.0]) (p=0.065). Stent integrity was confirmed in 14 of 15 cases. Only one stent showed a fracture, as documented on x-ray, without any impairment of flow. Venous stenting using Wallstents showed excellent long-term clinical outcome and primary patency rate.
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Affiliation(s)
- A Gutzeit
- Department of Radiology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland.
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Moudgill N, Hager E, Gonsalves C, Larson R, Lombardi J, DiMuzio P. May-Thurner syndrome: case report and review of the literature involving modern endovascular therapy. Vascular 2010; 17:330-5. [PMID: 19909680 DOI: 10.2310/6670.2009.00027] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
May-Thurner syndrome is a rare clinical entity involving venous obstruction of the left lower extremity. Obstruction occurs secondary to compression of the left common iliac vein between the right common iliac artery and the underlying vertebral body. Current management largely involves endovascular therapy. A review was conducted of six studies containing at least five patients with May-Thurner syndrome treated by endovascular therapy. We compiled data on 113 patients, analyzing patient demographics, treatment details, and outcome. An 18-year-old female presented 1 week after the onset of left lower extremity pain and swelling. Duplex ultrasonography revealed extensive left-sided deep venous thrombosis (DVT). Thrombolysis followed by iliac vein stent placement restored patency to the venous system, with subsequent resolution of symptoms. Review of 113 patients revealed that the majority were females (72%) presenting with DVT (77%), most of which was acute in onset (73%). Therapy consisted of catheter-directed thrombolysis and subsequent stent placement in the majority of patients, resulting in a mean technical success of 95% and a mean 1-year patency of 96%. Endovascular therapy is the current mainstay of treatment for May-Thurner syndrome. Review of the current literature supports treatment via catheter-directed thrombolysis followed by stent placement with good early results.
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Affiliation(s)
- Neil Moudgill
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Teebken O, Puschmann C, Breitenbach I, Rohde B, Burgwitz K, Haverich A. Preclinical Development of Tissue-Engineered Vein Valves and Venous Substitutes using Re-Endothelialised Human Vein Matrix. Eur J Vasc Endovasc Surg 2009; 37:92-102. [DOI: 10.1016/j.ejvs.2008.10.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 10/20/2008] [Indexed: 11/28/2022]
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Abstract
Stable claudication has traditionally been treated conservatively by many clinicians as operative therapies involve considerable risk for a condition that is often slowly progressive and non-fatal. The relative safety of less invasive endovascular techniques brings potential survival benefits from the increased exercise tolerance that result. We aimed to revisit and clarify the aetiologies of intermittent claudication in a review of the rarer causes that can mimic atherosclerotic occlusive disease. An extensive search of Medline, Embase and the Cochrane databases was carried out to compile published work addressing the aetiology of claudication and specific non-atherosclerotic causes. The reference lists of these manuscripts were also searched for relevant articles. There are several vasculogenic and neurogenic causes for intermittent claudication, many of which are unrelated to atherosclerosis. Recognition of these rarer syndromes is essential when planning endovascular or operative management strategies. Consideration of non-atherosclerotic differential diagnoses is recommended when assessing the patient with intermittent claudication. This is particularly critical in the young patient whose pattern of symptoms and risk factors may not fit precisely with atherosclerosis.
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Affiliation(s)
- Ramon L Varcoe
- The Department of Surgery, The Sutherland Hospital, Kingsway, Caringbah, NSW, Australia
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21
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Hartung O, Otero A, Boufi M, De Caridi G, Decaridi G, Barthelemy P, Juhan C, Alimi YS. Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease. J Vasc Surg 2005; 42:1138-44; discussion 1144. [PMID: 16376204 DOI: 10.1016/j.jvs.2005.08.012] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Accepted: 08/09/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND The goal of this article is to present clinical and patency results of endovascular treatment of nonmalignant, iliocaval venous obstructive disease and to discuss the evolution of technical details. METHODS From November 1995 to June 2004, 44 patients (female-male ratio, 3.9:1; left-right lower limb ratio, 8.6:1; median age, 42 years; range, 21-80 years) had treatment for chronic disabling obstructive venous insufficiency with iliocaval stenosis or occlusion. The clinical class of CEAP was 2 in 11 limbs, 3 in 31, 4 in 4, 5 in 1, and 6 in 1; etiology was primary in 32 patients, secondary in 10, and congenital in 2. Anatomic involvement included superficial veins in 16 patients and perforator veins in 11. Obstruction was associated with superficial reflux in 4 patients, deep reflux in 13, and both in 13. Ten patients had occlusion. All procedures were performed in the operating room with perioperative angiography and angioplasty with or without self-expanding stent implantation. Venous clinical severity and disability scores were obtained before and after treatment. Patency and restenosis were evaluated by duplex Doppler ultrasonography. RESULTS No perioperative death or pulmonary embolism occurred. The technical success rate was 95.5% (two recanalization failures), and two (4.5%) perioperative stent migrations occurred. One early thrombosis (2.4%) was treated by thrombectomy and creation of an arteriovenous fistula. One late death and one thrombosis occurred. Restenoses were found in five patients and were all treated successfully (four needed iterative stenting). Median follow-up was 27 months (range, 2-103 months). Median venous clinical severity score improved from 8.5 to 2, and median venous disability score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 36 months were 73%, 88%, and 90%, respectively, in intention to treat. The survival rate was 100% at 12 months and 97.3% at 60 months. CONCLUSIONS Endovascular treatment of benign iliocaval occlusive disease is a safe and efficient minimally invasive technique with good mid-term patency rates. Moreover, it improves cases with obstruction only, as well as cases with associated reflux and obstruction. Primary stenting should always be performed by using self-expanding stents deployed under general anesthesia to avoid lumbar pain. In case of failure, the endovascular procedure does not preclude further surgical reconstruction.
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Affiliation(s)
- Olivier Hartung
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France.
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22
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Wiemer P, Gruys E, van Hoeck B. A study of seven different types of grafts for jugular vein transplantation in the horse. Res Vet Sci 2005; 79:211-7. [PMID: 15893349 DOI: 10.1016/j.rvsc.2004.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2004] [Revised: 11/15/2004] [Accepted: 12/04/2004] [Indexed: 11/15/2022]
Abstract
The aim of this study was to investigate the biological behaviour of vascular grafts replacing a section of the jugular vein in order to improve the results of the surgical treatment of complete thrombosis of the jugular vein in the horse. Seven graft types: fresh allograft, home frozen allograft, glutaraldehyde-fixed allograft, cryo-preserved allograft, PTFE-graft (Gore), small intestinal submucosa preparation (Cook) and fresh autograft, were randomly implanted in ponies. The grafts were removed after one month and examined histologically for: preservation of the graft structures, acceptance by the host, intima proliferation, presence of endothelium and patency. The glutaraldehyde- and cryopreserved grafts show reasonable results and the PTFE and autograft had the best results especially with respect to host acceptance, endothelium presence and patency. Further research is necessary to improve graft behaviour, especially to the aspect of endothelisation. Obstruction of the jugular vein in horses can be treated surgically.
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Affiliation(s)
- P Wiemer
- Equine Section, De Lingehoeve, Lienden, The Netherlands.
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Schmittling ZC, McLafferty RB, Ramsey DE, Hodgson KJ. Closure of a surgically created arteriovenous fistula with a covered stent-graft in a patient with venous ambulatory hypertension--a case report. Vasc Endovascular Surg 2005; 39:363-6. [PMID: 16079948 DOI: 10.1177/153857440503900411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this paper is to report the use of a covered stent-graft in the endovascular treatment of a surgically created arteriovenous fistula. A 37-year-old woman with symptomatic venous ambulatory hypertension underwent a left common femoral vein-to-right common iliac vein bypass using 10 mm ringed polytetrafluoroethylene (PTFE) with creation of an arteriovenous (AV) fistula from the superficial femoral artery to the PTFE graft. At 1 year postoperatively, recurrent symptoms thought to be due to the arteriovenous fistula were treated by placement of an 8 mm x 10 cm Viabahn covered stent-graft. Placement was via crossover technique from the right common femoral artery using a 9 French sheath. At 2 months' follow-up symptoms had resolved, the AV fistula was occluded, and venous bypass remained patent. Focal arteriovenous fistulas of the proximal superficial femoral artery can be treated safely with a covered stent-graft via an endovascular approach.
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Affiliation(s)
- Zachary C Schmittling
- Division of Vascular Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62794, USA
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Shebel ND, Whalen CC. Diagnosis and management of iliac vein compression syndrome. JOURNAL OF VASCULAR NURSING 2005; 23:10-7; quiz 18-9. [PMID: 15741959 DOI: 10.1016/j.jvn.2004.12.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Iliac vein compression syndrome (IVCS) is the most probable cause of iliofemoral deep venous thrombosis (DVT). One half to two thirds of patients with left-sided iliofemoral DVT have intraluminal webs or spurs from chronic extrinsic compression of the left iliac vein at the crossing point of the right common iliac artery. Approximately 2% to 5% of those with chronic deep venous insufficiency of the left leg may have IVCS. IVCS occurs when compression of the common iliac vein is severe enough to inhibit the rate of venous outflow. In its more severe manifestation, IVCS is known to cause acute iliofemoral DVT. IVCS is caused by the combination of compression and the vibratory pressure of the right iliac artery on the iliac vein that is pinched between the artery and the pelvic bone. With the advent of catheter-directed thrombolytic therapy for patients presenting with iliofemoral DVT, the underlying cause has been unveiled and IVCS is gaining recognition. Patients presenting with symptoms of chronic venous insufficiency often fail conservative treatment, and because of their crippling symptoms, they may have a high rate of work absence or are on permanent disability. If IVCS can be identified as the cause and corrected, the patients' quality of life would improve. With the advent of endovascular stenting, the underlying cause can be easily corrected, and long-term patency is acceptable. Diagnosis can be made by being highly suspicious when patients present in either the acute or chronic state and selecting the best diagnostic tool to confirm the diagnosis. This article discusses the prevalence of IVCS, its significance for the affected population, and the relevance of recognition, and reviews the best methods of its diagnosis and treatment. Special emphasis is placed on diagnostic tools and their efficacy, and our results to date are reported.
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Affiliation(s)
- Nancy D Shebel
- University of Southern California University Hospital, Center for Vascular Care, Los Angeles, CA 90033, USA
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Affiliation(s)
- Barbaros E Cil
- Department of Radiology, Hacettepe University, 06100 Sihhiye, Ankara, Turkey.
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Ley EJ, Hood DB, Leke MA, Rao RK, Rowe VL, Weaver FA. Endovascular Management of Iliac Vein Occlusive Disease. Ann Vasc Surg 2004; 18:228-33. [PMID: 15253261 DOI: 10.1007/s10016-003-0096-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Iliac vein occlusive disease presents with either acute or chronic symptoms, both of which can be managed with endovascular techniques. This report summarizes our experience in a small cohort of patients undergoing percutaneous treatment of iliac vein occlusive disease. Six women and one man with occlusive lesions in the iliac veins are included in this report. All patients reported leg pain and swelling, involving the right leg in one and the left leg in six. Symptoms were acute in one patient and chronic in six. Two patients presented with a chronic stasis ulcer. All patients with chronic symptoms were treated with self-expanding stents deployed across the occlusive lesion. The patient with acute symptoms was treated successfully with thrombolysis, which uncovered a fixed stenosis that was then stented. Post-procedure follow-up with duplex scanning was used for vein patency. No significant complications occurred. All patients reported symptomatic improvement, with four having complete resolution. Duplex scanning showed all treated venous segments to be patent at a mean of 12 months. Recanalization of obstructed iliac vein segments can be performed successfully and leads to improvement in pain and edema in the affected limb. Midterm patency rates are excellent.
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Affiliation(s)
- Eric J Ley
- Division of Vascular Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Dheer S, Joseph AE, Drooz A. Retroperitoneal hematoma caused by a ruptured pelvic varix in a patient with iliac vein compression syndrome. J Vasc Interv Radiol 2003; 14:387-90. [PMID: 12631646 DOI: 10.1097/01.rvi.0000058411.01661.2b] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
May-Thurner syndrome, or iliac vein compression syndrome (IVCS), is a rare but well-described entity. It refers to the formation of venous thrombus caused by compression of the left iliac vein, most commonly between the right iliac artery and lumbar vertebrae. Several variants of IVCS have been described, including unusual presenting symptoms, etiologies, and complications. The authors describe an unusual case of IVCS in which the patient presented with a left-sided retroperitoneal hematoma arising from a ruptured collateral venous varix shortly after the development of symptomatic left lower-extremity deep vein thrombosis.
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Affiliation(s)
- Sachin Dheer
- Department of Radiology, Inova Fairfax Hospital, Falls Church, Virginia, USA
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Abstract
We describe successful replacement of the iliac vein using a descending aortic homograft. The ilio femoral system was avulsed after recannulation of the femoral vein during a third cardiac reoperation.
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Affiliation(s)
- A Handa
- Department of Cardiothoracic Surgery, Oxford Heart Centre, John Radcliffe Hospital, United Kingdom
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Hurst DR, Forauer AR, Bloom JR, Greenfield LJ, Wakefield TW, Williams DM. Diagnosis and endovascular treatment of iliocaval compression syndrome. J Vasc Surg 2001; 34:106-13. [PMID: 11436082 DOI: 10.1067/mva.2001.114213] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical presentation, diagnosis, and endovascular treatment of iliocaval compression syndrome (ICS). PATIENTS AND METHODS During a 3-year period, 18 patients (17 women, 1 man; mean age, 42 years) presented with clinical and imaging findings consistent with ICS. All patients were evaluated with venography and Doppler ultrasound (DUS), 13 of 18 with intravascular pressure measurements, 12 of 18 with intravascular ultrasound, 9 of 18 with air plethysmography (APG), and 4 of 18 with magnetic resonance venography. Seventeen patients were treated with endovascular stenting, one was treated with angioplasty alone, and six received adjunct thrombolysis. RESULTS Despite the presence of stenosis or occlusion in all cases, APG indicated no iliac vein obstruction (outflow fraction > or = 40%) in nine patients. DUS revealed acute (6) or chronic (7) unilateral iliofemoral deep venous thrombosis in 13 of 18 patients, whereas the results of five of 18 DUS studies were normal. Recanalization and stent placement (n = 17) or angioplasty (n = 1) was achieved in all patients. The average pressure gradient was 5.6 mm Hg preprocedure and 0.6 mm Hg postprocedure. The primary patency rate demonstrated with DUS (n = 17) and venography (n = 7) at 6 months was 89%. The primary patency rate at 12 months was 79%. CONCLUSIONS ICS often presents as sudden unilateral left lower extremity pain and swelling in young to middle-aged female patients after pregnancy, surgery, or a period of inactivity. Venography, intravascular ultrasound, and magnetic resonance venography demonstrate high sensitivity, whereas APG-outflow fraction demonstrates low sensitivity in the diagnosis of ICS. Endovascular stenting and angioplasty provide safe and effective early and intermediate-term treatment of symptomatic ICS.
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Affiliation(s)
- D R Hurst
- Department of Radiology, Division of Vascular and Interventional Radiology, the University of Michigan Medical Center, Ann Arbor 48109-0326, USA
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Juhan C, Hartung O, Alimi Y, Barthélemy P, Valerio N, Portier F. Treatment of nonmalignant obstructive iliocaval lesions by stent placement: mid-term results. Ann Vasc Surg 2001; 15:227-32. [PMID: 11265088 DOI: 10.1007/s100160010048] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This report describes mid-term results of endovascular treatment of obstructive iliocaval lesions. Between November 1995 and December 1999, a total of 15 patients were treated by angioplasty and stent placement in the iliac vein. These patients were divided into two groups. Group I consisted of six patients with acute iliofemoral thrombosis of less than 10 days duration, with associated caval involvement in three cases. Angioplasty was performed after surgical thrombectomy, and creation of an arteriovenous fistula as a one-stage procedure in four cases and as a two-stage procedure in two cases. The underlying chronic lesion was stenosis of the left iliocaval junction (Cockett syndrome) in five cases and retroperitoneal fibrosis in one. Group II comprised nine patients with chronic symptomatic stenosis or occlusion. The etiology was Cockett syndrome in seven cases, post-thrombotic syndrome in three cases, including two associated with Cockett syndrome, and retroperitoneal fibrosis in one case. The mean number of stents per patient was 1.5. The mean duration of follow-up was 23.5 months. Evaluation of clinical outcome according to CEAP criteria for chronic syndromes showed significant improvement. Given good mid-term findings, venous angioplasty with stent placement appears to be a safe and effective technique for treatment of acute or chronic obstructive iliocaval lesions.
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Affiliation(s)
- C Juhan
- Service de Chirurgie Vasculaire, Hôpital Nord, Chemin des Bourrelly, 13915 Marseille Cedex 20, France.
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Jost CJ, Gloviczki P, Cherry KJ, McKusick MA, Harmsen WS, Jenkins GD, Bower TC. Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease. J Vasc Surg 2001; 33:320-7; discussion 327-8. [PMID: 11174784 DOI: 10.1067/mva.2001.112805] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. METHODS The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies. RESULTS Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P =.023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P =.16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P =.044). CONCLUSIONS Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial.
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Affiliation(s)
- C J Jost
- Division of Vascular Surgery, the Department of Diagnostic Radiology, and the Section of Biostatistics, Mayo Clinic, Rochester, Minn., USA
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O'Sullivan GJ, Semba CP, Bittner CA, Kee ST, Razavi MK, Sze DY, Dake MD. Endovascular management of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol 2000; 11:823-36. [PMID: 10928517 DOI: 10.1016/s1051-0443(07)61796-5] [Citation(s) in RCA: 263] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To evaluate the feasibility of endovascular techniques in treating venous outflow obstruction resulting from compression of the iliac vein by the iliac artery of the left lower extremity (May-Thurner syndrome). MATERIALS AND METHODS A retrospective analysis of 39 patients (29 women, 10 men; median age, 46 years) with iliac vein compression syndrome (IVCS) was performed. Nineteen patients presented with acute deep vein thrombosis (DVT) and 20 patients presented with chronic symptoms. All patients presented with leg edema or pain. In the acute group, patients were treated with catheter-directed thrombolysis (120,000-180,000 IU urokinase/h) and angioplasty followed by stent placement. In the chronic group, patients were treated with use of angioplasty and stent placement alone (n = 8), or in combination with thrombolysis (n = 12). Patients were then followed-up with duplex ultrasound and a quality-of-life assessment. RESULTS Initial technical success was achieved in 34 of 39 patients (87%). The overall patency rate at 1 year was 79%. Symptomatically, 85% of patients were completely or partially improved compared with findings before treatment. Thirty-five of 39 patients received stents. The 1-year patency rate for patients with acute symptoms who received stents was 91.6%; for patients with chronic symptoms who received stents, the 1-year patency rate was 93.9%. Five technical failures occurred. Major complications included acute iliac vein rethrombosis (< 24 hours) requiring reintervention (n = 2). Minor complications included perisheath hematomas (n = 4) and minor bleeding (n = 1). There were no deaths, pulmonary embolus, cerebral hemorrhage, or major bleeding complications. CONCLUSION Endovascular reconstruction of occluded iliac veins secondary to IVCS (May-Thurner) appears to be safe and effective.
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Affiliation(s)
- G J O'Sullivan
- Division of Cardiovascular-Interventional Radiology, Stanford University Medical Center, CA 94305, USA
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Simon C, Alvarez J, Becker GJ, Katzen BT, Benenati JF, Zemel G. May-Thurner syndrome in an adolescent: persistence despite operative management. J Vasc Surg 1999; 30:950-3. [PMID: 10550195 DOI: 10.1016/s0741-5214(99)70022-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe a patient with May-Thurner syndrome who underwent operative transection and transposition of the right common iliac artery without direct venous repair, because preoperative and intraoperative intravascular ultrasound scans were negative for "spurs" in the left common iliac vein. When symptoms and signs persisted, a postoperative magnetic resonance venogram (MRV) showed severe stenosis in the left common iliac vein. Progressive, but incomplete, clinical improvement occurred with conservative management.
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Affiliation(s)
- C Simon
- Division of Vascular Radiology, Miami Cardiac and Vascular Institute, FL, USA
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37
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Skinner RA, Ceraldi C. Bypass graft of an occluded inferior vena cava: report of a case with patency at five years. J Vasc Surg 1999; 29:727-9. [PMID: 10194505 DOI: 10.1016/s0741-5214(99)70323-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Venous reconstructive surgery for chronic occlusive disease has evolved slower than its arterial counterpart. Factors intrinsic to the venous system that have been implicated in discouraging experimental and clinical results include enhanced graft thrombogenicity, low velocity of blood flow, and wall collapsibility. 1,2 We present a case of a 24-year-old man with symptomatic occlusion of the inferior vena cava, treated with a prosthetic bypass graft to the supra diaphragmatic cava. The graft was patent 5 years later, and the patient remained asymptomatic.
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Affiliation(s)
- R A Skinner
- Department of Surgery, University of California, Davis East-Bay, Oakland, USA
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38
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Abstract
Palma and Esperon described the first femoro-femoral cross-over bypass for iliac vein obstruction in 1958, and Kistner performed the first valve reconstruction for deep vein reflux in 1968. Such surgical development has stimulated better diagnostic methods that now form the foundation for a classification of chronic venous disease, and surgery has been supported by, and sometimes replaced by, the rapid progress in endovascular procedures with angioplasty and stenting. The ability now exists to relieve obstruction and repair reflux in the deep veins, and the results in the successful cases demonstrate the improvement that follows correction of the physiologic abnormalities. The detail in workup required to achieve an accurate diagnosis that is adequate enough to guide surgical treatment in these cases has set a new standard for the diagnosis of chronic venous disease that incorporates the clinical state, etiology, pathophysiology and anatomic distribution of the venous problem, and is incorporated in the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification. The challenge at this time is to produce a reliable set of data that demonstrate the results of treatment in patients with chronic venous disease by conventional methods of bandaging, rest and elevation as well as specific surgical correction of venous obstruction and reflux and to follow these cases over a significant period of time.
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Affiliation(s)
- B G Eklof
- Department of Vascular Surgery, Straub Clinic and Hospital, Honolulu, Hawaii 96813, USA
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39
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Patel KR, Rabinowitz D, Hastings B, Dardik H. Femorocaval bypass with femoral crossover bypass for iliofemoral and caval occlusion. J Vasc Surg 1997; 26:989-93. [PMID: 9423714 DOI: 10.1016/s0741-5214(97)70011-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Progress in the management of major venous obstruction has lagged far behind advances in arterial reconstruction. As a result, literature reports consist of small numbers of patients, and most vascular surgeons have little or no experience in performing bypass procedures for major venous obstruction. In this setting, individual reports add to our cumulative knowledge in treating this disease. We therefore present our experience in the management of a patient with extensive bilateral femoropopliteal, iliac, and vena caval occlusion.
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Affiliation(s)
- K R Patel
- Vascular Institute, Englewood Hospital and Medical Center, NJ 07631, USA
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