Pediatric May-Thurner Syndrome-Systematic review and individual patient data meta-analysis

Current Diagnostic and Therapeutic Approaches in May-Thurner Syndrome in Children, Adolescents, and Young Adults: A Survey among Thrombosis Experts of the German Society of Thrombosis and Haemostasis

May-Thurner syndrome (MTS) is a pelvic venous disorder involving compression of the left common iliac vein by the right common iliac artery, which results in predisposition for deep vein thrombosis. Although MTS is increasingly recognized in young patients, specific guidelines on diagnosis and management for children, adolescents, and young adults do not exist so far. The aim of this study was to assess current diagnostic and therapeutic practice in Germany, Austria, and Switzerland in children and young adults with thrombosis and MTS.We designed an online survey with 11 questions, which we sent via a mailing list to all members of the German, Austrian, and Swiss Society of Thrombosis and Haemostasis Research. Between July and October 2022, 33 specialists answered the questionnaire. Most participating specialists worked at pediatric hospitals (61%). Numbers of annually treated thromboses ranged from <5 (26%) to >30 (13%). Most specialists used venous ultrasound to diagnose deep vein thrombosis, 53% magnetic resonance imaging. Only 25% of specialists systematically screened for MTS in deep vein thrombosis. MTS was managed with anticoagulation (65%), iliac vein stent placement (32%), or balloon angioplasty (13%). In total, 31% of specialists reported to use more than one therapeutic method. Diagnostic and therapeutic approaches for MTS differed between specialists. Lack of standardization resulted in individualized and highly diverse management. Prospective observational clinical studies investigating the outcome of different management strategies including long-term follow-up on outcome and incidence of postthrombotic syndrome will help in defining patient groups who benefit most from revascularizing interventional strategies and developing standardized guidelines.

Familiar Disposition of May-Thurner Syndrome-A Case Series

May-Thurner syndrome is a venous compression syndrome of the pelvic vessels that represents a relevant risk factor for thrombus formation. The standard procedure to secure a diagnosis is venography, followed by endovascular therapy as the preferred treatment choice if the patient is symptomatic. In our case series, there are three related patients with May-Thurner syndrome. A 16-year-old female was admitted with pulmonary embolism, dyspnoea and hip pain. The compression syndrome was diagnosed with interventional venography, and the patient received venous stent implantation. Due to her family history, we also suspected her mother to be affected by the syndrome and elucidated the diagnosis shortly afterwards by invasive venography. Subsequently, we examined the patient's 19-year-old brother, and magnetic resonance imaging confirmed May-Thurner syndrome. A similar case series has not been published before. In this case, the family relation indicates a possible hereditary aspect of May-Thurner syndrome. This hypothesis should be the subject of further research. In conclusion, it is essential to assess family history thoroughly when treating patients with May-Thurner syndrome.

Pulmonary Embolism in an Adolescent With May-Thurner Syndrome: A Case Report

May-Thurner syndrome (MTS) is a pathological variant where the left iliac vein is compressed by the right iliac artery. Usually common in females between the third and fourth decades of life, this case report is about MTS in an adolescent girl. The patient was overweight and had a sedentary lifestyle. She developed a sudden onset of unilateral left leg deep venous thrombosis (DVT), leading to low-risk pulmonary embolism (PE) within a week of the symptoms starting. The patient received a heparin infusion for one week, after which she was switched to subcutaneous low-molecular-weight heparin. Apart from the initial high D-dimer, the rest of the thrombophilia workup was unremarkable. The whole exome sequencing (WES) study was negative. An inferior vena cava (IVC) filter was not advised for her due to the small size of the clot and her age. The patient responded well to heparin alone and was discharged home on enoxaparin.

Society of Interventional Radiology Position Statement on the Management of Chronic Iliofemoral Venous Obstruction with Endovascular Placement of Metallic Stents

PURPOSE

To state the position of the Society of Interventional Radiology (SIR) on the endovascular management of chronic iliofemoral venous obstruction with metallic stents.

MATERIALS AND METHODS

A multidisciplinary writing group with expertise in treating venous disease was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 41 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified. The expert writing group developed 15 recommendations on the use of endovascular stent placement.

CONCLUSIONS

SIR considers the use of endovascular stent placement for chronic iliofemoral venous obstruction to be likely to help selected patients, but the risks and benefits have not been fully quantified in well-designed randomized studies. SIR recommends urgent completion of such studies. In the meantime, careful patient selection and optimization of conservative therapy are recommended prior to stent placement, with attention to appropriate stent sizing and quality procedural technique. The use of multiplanar venography with intravascular ultrasound is suggested in diagnosing and characterizing obstructive iliac vein lesions and in guiding stent therapy. After stent placement, SIR recommends close patient follow-up to ensure optimal antithrombotic therapy, durable symptom response, and early identification of adverse events.

Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis

PURPOSE

To establish the updated position of the Society of Interventional Radiology (SIR) on the endovascular management of acute iliofemoral deep vein thrombosis (DVT).

MATERIALS AND METHODS

A multidisciplinary writing group with expertise in treating venous diseases was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 84 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified and included in the review. The expert writing group developed 17 recommendations that pertain to the care of patients with acute iliofemoral DVT with the use of endovascular venous interventions.

CONCLUSIONS

SIR considers endovascular thrombus removal to be an acceptable treatment option in selected patients with acute iliofemoral DVT. Careful individualized risk assessment, high-quality general DVT care, and close monitoring during and after procedures should be provided.

Evidence-Based Nursing Model in Interventional Thrombolysis for Acute Lower Extremity Arterial Embolism

Acute lower extremity arterial embolism (AE) is a serious clinical emergency, and, if not treated in time, it can easily lead to limb ischemia and necrosis and eventually facing amputation, which seriously damages patients' physical and mental health. In the past, the conventional drug thrombolytic therapy had slow and limited efficacy, and the best time for treatment is easily delayed, while arterial dissection and thrombectomy treatment, although fast, is traumatic and has many complications, which is not easily accepted by patients. The aim of this study was to investigate the value of evidence-based care model in the application of interventional thrombolysis for acute lower limb arterial embolism. Seventy-two patients with acute lower limb arterial embolism who underwent interventional thrombolysis treatment received by the Department of Vascular Surgery of our hospital from July 2016 to December 2021 were randomly divided into a control group (given conventional nursing services) and a quality group (given full quality nursing services) to compare the effect of nursing services in the two groups. The results showed that the postoperative psychological status of patients in the quality group was significantly better than that of patients in the control group (P < 0.05). The total incidence of postoperative adverse events and the total treatment efficiency of the quality group were better than those of the control group (P < 0.05). The efficacy of quality nursing care in patients with acute lower extremity arterial embolism is more desirable than conventional nursing care and is recommended. The site of vascular occlusion after bypass surgery can be clarified when angiography is performed after thrombolytic therapy, which can help secondary surgical intervention to prolong the time to patency. The efficacy of quality nursing care in patients with acute lower extremity arterial embolism is more desirable than that of conventional nursing care and is recommended.

Combined high-resolution 3D CUBE T1-weighted imaging and non-contrast-enhanced magnetic resonance venography for evaluation of vein stenosis in May-Thurner syndrome

PURPOSE

To explore the feasibility of high-resolution MRI 3-dimensional (3D) CUBE T1-weighted magnetic resonance imaging (MRI) in combination with non-contrast-enhanced (NCE) magnetic resonance venography (MRV) for the assessment of lumen stenosis in May-Thurner syndrome.

METHODS

Twenty-nine patients underwent computed tomography venography (CTV) and high-resolution MRI-CUBE T1, and NCE MRV acquisitions. ANOVA and LSD tests were used to compare the stenosis rate and narrowest and distal diameters of the vessel lumen.

RESULTS

There were no significant differences in the estimated stenosis rate between CTV, CUBE T1, and NCE MRV (p = 0.768). However, there were significant differences in the measured stenosis diameters of the left common iliac vein (LCIV), with CTV giving the largest mean diameter and CUBE had the smallest mean diameter (p < 0.05). The measured normal LCIV diameters did not significantly differ between MRV and CUBE (p = 0.075) but were significantly larger on CTV than on MRV and CUBE (p < 0.05).

CONCLUSIONS

Compared with CTV, a combination of CUBE and MRV could provide an improved assessment of the degree of lumen stenosis in May-Thurner syndrome and demonstrate acute thrombosis. MRI underestimates the diameter of the vessel in comparison with CTV. MRI can be a substitute tool for Duplex ultrasound and CTV.

Case Report: Rare Iliac Vein Compression (May-Thurner) Syndrome in a Pediatric Patient

Iliac vein compression syndrome (IVCS) or May-Thurner syndrome occurs predominantly in young to middle-aged women. Here we reported a case of IVCS in a 5-year-old boy. The child was admitted to our vasculocardiology department with left lower extremity that had been swollen for 1 month. Blood tests revealed coagulation routine and platelets in the normal ranges. Computer tomography angiography (CTA) and magnetic resonance imaging (MRI) showed the left common iliac vein had become narrow before it entered the right common iliac vein. To further clarify, we performed angiography, which clearly showed the stenosis and the blood return of the left common iliac vein. So IVCS was diagnosed. What is more, we found the aorta descended to the right of the spine, and this may be the reason for the apparent compression of the left common iliac vein. Given the young age and mild symptoms of the child, the treatment was conservative mainly including elevation of the affected limb, wearing medical elastic socks, and short-term oral aspirin for anticoagulation. Meanwhile, the boy is being followed up closely. If the swelling of the left lower extremity significantly increases, stent placement may need to be considered in the future.