May-Thurner Syndrome Resulting in Acute Iliofemoral Deep Vein Thrombosis in the Postpartum Period

May-Thurner syndrome: A case of extensive unprovoked left lower extremity deep vein thrombosis (DVT)

May-Thurner syndrome (MTS) also known as iliac vein compression syndrome, is a congenital anatomical variant, that results from the extrinsic compression of the left common iliac vein by the right iliac artery with resultant formation of left venous thrombosis. We report a case of a young man with recurrent unprovoked left lower extremity DVT in the setting of May Thurner syndrome who required endovascular intervention and was discharged on oral anticoagulation.

May-Thurner Syndrome in a Case of Left Iliofemoral Vein Thrombosis With Contralateral Tubo-Ovarian Abscess in the Post-postpartum Period

May-Thurner syndrome (MTS) is a rare, yet important, differential diagnosis in reproductive-age women with deep vein thrombosis (DVT). It is characterized by the compression of the left common iliac vein by the right common artery against the lumbar vertebra. The condition is complicated by recurrent DVT with pulmonary thromboembolism (PTE). Here is a case of multiparous women in early puerperium with right tubo-ovarian abscess and left lower limb DVT likely due to MTS. The diagnosis was further complicated by the presence of persistent thrombocytosis but a myeloproliferative neoplasm was ruled out by genetic mutation testing. She was given anticoagulants, and laparotomy was done for the excision of the tubo-ovarian mass in view of the persistent fever not responding to injectable antibiotics. PTE in the postoperative period was managed by anticoagulants followed by an inferior vena cava (IVC) filter for the risk of recurrent DVT and/or PTE in an MTS case.

Endovascular resolution of complete common iliac vein stenosis in a case of May-Thurner syndrome with underlying malignancy

INTRODUCTION AND IMPORTANCE

May-Thurner Syndrome (MTS) is an uncommon etiology of left common iliac vein thrombosis due to arterial compression. In this report, we describe a case of MTS with severe occlusion of the left common iliac vein in the context of a previously undiagnosed pancreatic cancer. We detail the endovascular resolution of the iliac vein compression and show long-term patency.

CASE PRESENTATION

A 33-year-old woman on oral contraceptive pills presented with extensive thrombosis of the left common iliac vein extending cephalad into the lower IVC and inferiorly to the femoral vein. The thrombus was refractory to therapeutic heparin. Mechanical thrombectomy removed the occluding thrombus. Intravenous ultrasound identified severe compression of the left common iliac vein by the right common iliac artery. Angioplasty and stenting provided complete resolution of the lesion. Imaging and hematologic workup revealed a pancreatic malignancy and concomitant hypercoagulable state that likely precipitated the patient's presentation.

CLINICAL DISCUSSION

Endovascular intervention provided complete resolution of severe iliac vein compression. Patency was maintained at 6-month follow-up. Research suggests that the anatomical lesion predisposing individuals to MTS is relatively common despite infrequent occurrence of the syndrome. This case highlights the importance of a high clinical suspicion for associated hypercoagulable states when MTS is discovered.

CONCLUSION

There is limited research exploring the relationship between severity of iliac vein compression and endovascular treatment outcome. This case documents endovascular resolution of a severe lesion with maintained patency.

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.

Unusual presentation of right-sided May-Thurner syndrome

May-Thurner syndrome commonly presents with left leg swelling. Right-sided venous compression syndromes are rare. We report a 49-year-old gentleman who presented with right lower extremity swelling after leg trauma. He was found to have right distal common iliac vein compression by the overlying right internal iliac artery. He was treated with an endovascular approach with balloon venoplasty and stenting. This is a unique presentation of May-Thurner syndrome variation affecting the right lower extremity with limited description in the literature.

May-Thurner syndrome

May-Thurner syndrome (MTS) is a venous compression syndrome in which the left common iliac vein (LCIV) is compressed between the lower lumbar spine and the right common iliac artery (RCIA). Variations are known where in the right lower limb can be affected. While most of the cases are asymptomatic, it can cause severe morbidity in symptomatic individuals, most commonly deep vein thrombosis and post thrombotic sequelae. In this article, we review the key clinical features, multimodality imaging findings and treatment options of this disorder. Our goal is to raise awareness of this under-diagnosed condition among clinicians in order to promote early detection and recognition to enhance positive and expedited outcomes.

May Thurner syndrome: Sixty years later

May-Thurner syndrome (MTS) was described sixty years ago. Once ignored for several years, it is currently a recognized pathology in the vascular surgery community; but not long ago due to several factors, it was underdiagnosed and sub-optimally treated. In the last 20 years, with renewed interest in venous pathology, technical imaging advances and the recent interventional procedures, it has become a better known disease. On the other hand, nowadays the easiness in diagnosis and treatment of the syndrome has lead to overtreatment of such patients. In this article, we do a historical review and describe the significant advances and current management of May-Thurner syndrome.

May-Thurner syndrome: History of understanding and need for defining population prevalence

Patients with May-Thurner syndrome (MTS) are at elevated risk of developing an extensive left iliofemoral deep vein thrombosis (DVT; localized blood clot) due to an anatomical variant where the right common iliac artery compresses the left common iliac vein against the lumbar spine. While MTS was initially presumed to be rare when it was first anatomically defined in 1957, case reports of this syndrome have recently become more frequent, perhaps due to improved imaging techniques allowing for enhanced visualization of the iliac veins. Still, the population burden of this condition is unknown, and there is speculation it may be higher than generally perceived. In the present review, we (a) review history of how MTS became recognized, (b) describe practical challenges of studying MTS in population-based settings due to the specialized imaging required for diagnosis, (c) discuss why the contribution of MTS to DVT may be underestimated, (d) describe uncertainty regarding the degree of venous compression which leads to DVT, and (e) outline future research needs. Our goal is to raise awareness of MTS and spark additional research into the epidemiology of this condition, which may be an underappreciated causative venous thromboembolism risk factor.

May-Thurner syndrome: an uncommon and incidental finding in a postpartum female

May-Thurner syndrome or Cockett syndrome is a pathological condition that arises due to extrinsic compression on iliocaval venous territory, leading to venous outflow obstruction. Here, author presents an incidental finding of left common iliac vein extrinsic compression by right common iliac artery with collateral vessels in the pelvis in a postpartum female.

May-Thurner syndrome - Are we aware enough?

Iliac vein compression syndrome (May-Thurner syndrome - MTS) is an anatomically variable clinical condition in which the left common iliac vein is compressed between the right common iliac artery and the underlying spine. This anatomic variant results in an increased incidence of left iliac or iliofemoral vein thrombosis. It predominantly affects young women in the second or third decades of life with preponderance during pregnancy or oral contraceptive use. Although MTS is rare, its true prevalence is underestimated but it can be a life-threatening condition due to development of pulmonary embolism (PE). In this case based review the authors present three cases of MTS. All patients had been previously confirmed with PE, but despite they were admitted to hospital, diagnosed and correctly treated for PE and investigated for thrombophilia, the iliac vein compression syndrome was not suspected or investigated. With this presentation the authors would like to emphasize that MTS is mostly underdiagnosed, and it needs to be ruled out in left iliofemoral vein thrombosis in young individuals.

Left iliac vein compression is not associated with infrainguinal deep venous thrombosis but is associated with iliac vein involvement

OBJECTIVE

The purpose of this study was to investigate whether left iliac vein (LIV) compression had similar correlation with the risk of left iliac deep venous thrombosis (DVT; iliac vein involvement) and infrainguinal DVT (without iliac vein involvement).

METHODS

A retrospective analysis of records and enhanced computed tomography images was conducted of 278 patients with left-sided DVT (iliac DVT, 228 patients; infrainguinal DVT, 50 patients) and 232 control patients without DVT on either side. The influences of LIV compression on the risk of left iliac DVT and infrainguinal DVT were investigated using logistic regression analysis.

RESULTS

Mean percentage compression of the LIV in left iliac DVT (74.64% ± 0.99%) patients was significantly higher than in non-DVT patients (53.42% ± 1.49%; P < .01). However, mean percentage compression of the LIV in left infrainguinal DVT patients (45.37% ± 2.71%) was significantly lower than in non-DVT patients (53.42% ± 1.49%; P < .01). LIV compression was associated with increased odds of left iliac DVT (odds ratio, 1.88; 95% confidence interval, 1.64-2.15; P < .01) for each 10% increase in percentage compression of the LIV. However, LIV compression was not associated with increased odds of infrainguinal DVT (odds ratio, 0.89; 95% confidence interval, 0.76-1.03; P = .126).

CONCLUSIONS

Left iliac DVT patients had more severe LIV compression than left infrainguinal DVT patients did. LIV compression was not associated with development of left infrainguinal DVT, but it did correlate with the presence of left-sided DVT with iliac vein involvement.

Left lower limb may be a forbidden region for indwelling needle during operation

INTRODUCTION

Information about the incidence and risk factors of venous thromboembolism (VTE) after thyroid operation is limited. This study aimed to analyze the incidence and risk factors of postoperative VTE in patients who had undergone thyroid surgery.

MATERIALS AND METHODS

A prospective, multi-center cohort study was performed from June 2013 to June 2015 in 3 hospitals throughout South Central China. We analyzed 5029 patients who had undergone thyroid operation and received no VTE prophylaxis postoperatively. For the diagnosis of deep vein thrombosis (DVT), bilateral whole-leg ultrasound was conducted in patients with a high pretest probability of DVT. Lung ventilation/perfusion scintigraphy, pulmonary angiography, or helical computed tomography was implemented in patients suspected to have pulmonary embolism (PE).

RESULTS

DVT was diagnosed in 18 patients (0.36%). No patient was diagnosed with PE. Binomial logistic regression analysis revealed that age and left lower limb intraoperative venous access (IVA) were significant risk factors for DVT. The incidence of DVT increased as the number of risk factors increased.

CONCLUSIONS

VTE is uncommon in patients who have undergone thyroid surgery. The left lower limb was not an appropriate insertion site IVA. Pharmacologic thromboprophylaxis was not mandatory, particularly in those patients without risk factors.

Compression of the right iliac vein in asymptomatic subjects and patients with iliofemoral deep vein thrombosis

OBJECTIVE

To evaluate right iliac vein and left iliac vein compression in asymptomatic subjects, right-sided and left-sided iliofemoral deep vein thrombosis patients.

METHODS

A retrospective analysis of records and computed tomography images was conducted in 200 asymptomatic subjects (male:female, 100:100). A prospective analysis was conducted in 79 consecutive deep vein thrombosis patients (left:right deep vein thrombosis, 47:32) who had undergone contrast-enhanced computed tomography examination. The minor diameter and percentage compression of the iliac vein were evaluated.

RESULTS

In asymptomatic subjects, 13.5% had right iliac vein compression >50%, 2.0% had right iliac vein compression >70%, mean compression was 23.48%; 45.0% had left iliac vein compression >50% and 17.0% had left iliac vein compression >70%, mean compression was 47.58%. Right iliac vein sandwiched between the right external iliac artery and the right internal iliac artery was the most common compression pattern (59.26%). Males had higher right iliac vein compression than the females (male:female, 26.29%:20.68%, P < 0.001). Mean percentage compression of the right iliac vein was higher in right deep vein thrombosis patients than in left deep vein thrombosis patients (right:left deep vein thrombosis, 48.54%:22.29%, P < 0.001).

CONCLUSION

Similar to left iliac vein compression, right iliac vein compression was a frequent imaging finding in CT and represented a normal anatomic pattern. Right deep vein thrombosis patients had more serious right iliac vein compression than left deep vein thrombosis patients, and further research is required on the association of right iliac vein compression with right iliofemoral deep vein thrombosis.

Incidence and clinical significance of iliac vein compression

Objectives

To determine the frequency of left common iliac vein (CIV) compression by the right common iliac artery (CIA) based on CT scan images.

Methods

CT scan images were reviewed and the diameter of CIV was measured at the area of minimal diameter and compared to the distal adjacent segment and the contralateral CIV at the same level. Medical records were reviewed for symptoms, deep vein thrombosis (DVT) and risk factors that might be associated with DVT. Data were analyzed with SPSS program using both Chi square and t test. A p < 0.05 was considered statistically significant. Linear regression (R2) was used to evaluate correlation.

Results

A total of 300 complete records were reviewed. The mean age was 51.89 years, with 126 (42%) males. Comparison between the two groups (>70% vs <70%) showed similar clinical factors such as history of DVT, surgery, immobilization, malignancy, limb trauma, pregnancy, obesity, CHF, and smoking. There were more females with CIV compression of 70% or more than males (19.5% vs 11.1% P < .049).

Conclusion

Diameter stenosis more than 70% was present in 30.6% of cases with higher incidence in females. The presence of stenosis was not associated with the presence of clinical symptoms.

Diagnosis and management of iliac vein thrombosis in pregnancy resulting from May-Thurner Syndrome

One of the least recognized risks for the development of deep venous thrombosis (DVT) is iliac vein compression or the May-Thurner Syndrome (MTS), in which most often, the right common iliac artery compresses the subjacent left common iliac vein. We present three patients with MTS complicated by massive left lower extremity DVT managed with percutaneous pharmacomechanical thrombectomy during pregnancy. Although often not considered in obstetrics, percutaneous therapies to resolve extensive thrombosis should be considered in pregnant women, as they have the potential to improve symptoms and mitigate the risk of developing post-thrombotic syndrome.

Differences in limb, age and sex of Chinese deep vein thrombosis patients

OBJECTIVE

Recently, the differences in age or sex of deep vein thrombosis (DVT) patients have been widely debated. However, close analyses of the differences in limb, age and sex of Chinese DVT patients have been scarcely reported. The purpose of this research is to study the differences in limb, age and sex of DVT patients.

METHODS

A total of 783 consecutive DVT patients were retrospectively reviewed. Patients with an acute presentation of DVT were diagnosed by means of compression ultrasonography or venography. Clinical characteristics and provoked risk factors were analyzed.

RESULTS

There were three frequency peaks including two smaller peaks at age 20-24 and 70-74 years, and the largest peak at age 45-59 years. The most significant risk factors affecting different age groups were as follows: pregnancy/puerperium for age ≤ 39; fracture and hysterectomy for age 40-64; fracture and malignancy for age ≥ 65. DVT frequency rate provoked by malignancy was higher in right DVT than left DVT (15.8% vs. 4.6%; p < 0.001). Left DVT was more common than right DVT (582 vs. 158). Left DVT tended to occur in females (male:female, 40.5%:59.5%), and right DVT in males (male:female, 74.7%:25.3%). DVT provoked by pregnancy/puerperium (56/63, 88.9%) or hysterectomy (27/30, 90.0%) was mostly located in left limb.

CONCLUSION

It is necessary to pay more attention to thromboprophylaxis for patients with the risk factors of pregnancy/puerperium, hysterectomy, fracture and malignancy, especially those over the age of 65. And further research into the cause of limb, age and sex differences in DVT occurrence is needed.