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Kidane MY, Mideksa AG, Adem MB, Gebrehiwot FG, Adem RY, Ahmed MM, Aderu AK, Berta MT. Case Report; Concomitant Left Nutcracker Syndrome and Right Ureteropelvic Junction Obstruction. Res Rep Urol 2024; 16:131-135. [PMID: 38883265 PMCID: PMC11178079 DOI: 10.2147/rru.s446710] [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: 11/30/2023] [Accepted: 06/02/2024] [Indexed: 06/18/2024] Open
Abstract
We report rare case of concomitant left nutcracker syndrome and right ureteropelvic junction obstruction (UPJO) on adult female patient diagnosed by CT urogram after she presented with intermittent bilateral flank pain. For this we did Anderson-Hynes pyeloplasty for right ureteropelvic obstruction, it was laparoscopic initially but due to difficulty of stenting it is changed to open. She had smooth post-op course then discharged on 3rd post-op day. Symptoms of nutcracker syndrome are not that much bothersome for the patient so we planned to follow her conservatively.
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Affiliation(s)
- Mintesnot Yitagesu Kidane
- Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, Ethiopia
| | - Adugna Getachew Mideksa
- Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, Ethiopia
| | - Mubarek Bargicho Adem
- Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Ramzi Yessuf Adem
- Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, Ethiopia
| | - Mensur Mohammed Ahmed
- Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, Ethiopia
| | - Abebe Ketema Aderu
- Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, Ethiopia
| | - Mintesnot Tadesse Berta
- Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, Ethiopia
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2
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Talboom A, Van Dessel E. Single Anastomosis Sleeve Jejunal Bypass in Acute Mesenteric Artery Syndrome: A Case Report. Cureus 2024; 16:e60971. [PMID: 38910630 PMCID: PMC11193876 DOI: 10.7759/cureus.60971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Superior mesenteric artery syndrome is a rare vascular compression syndrome in which the duodenum is compressed between the aorta and the overlying superior mesenteric artery. This condition is often chronic and secondary to cachexia. It can trigger further weight loss due to the subsequent proximal intestinal obstruction, causing a positive feedback loop. We report a case of acute presentation of superior mesenteric artery syndrome, complicated by gastric necrosis and treated surgically using the principles of a novel bariatric procedure.
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Affiliation(s)
- Arno Talboom
- General Surgery, University of Antwerp, Antwerp, BEL
| | - Els Van Dessel
- Abdominal Surgery, Gasthuiszusters Antwerpen, Antwerp, BEL
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3
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M Koshy R, Chee RKW, Wilson MP, Singh R, Mathew RP, Tu W, Low G. Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review. Abdom Radiol (NY) 2024; 49:1747-1761. [PMID: 38683215 DOI: 10.1007/s00261-024-04315-7] [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: 02/26/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 05/01/2024]
Abstract
Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed. Salient imaging features of each entity are illustrated through imaging examples using multiple modalities including ultrasound, fluoroscopy, CT, and MRI.
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Affiliation(s)
- Reshma M Koshy
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada.
| | - Ryan K W Chee
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Mitchell P Wilson
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Ranjit Singh
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Rishi P Mathew
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Wendy Tu
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Gavin Low
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
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4
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Selva Raj SR, Han GH, Karupiah M, Nagendram SV, Kang WH. COVID-19 infection with severe hypocalcaemia and superior mesenteric artery syndrome-a case report. AME Case Rep 2024; 8:54. [PMID: 38711895 PMCID: PMC11071014 DOI: 10.21037/acr-23-106] [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: 07/24/2023] [Accepted: 02/02/2024] [Indexed: 05/08/2024]
Abstract
Background Coronavirus disease 2019 (COVID-19) infection has been associated with various endocrinopathies. Few literatures have reported cases of transient hypoparathyroidism in acute COVID-19 infections, or even exacerbation of hypocalcaemia in previously known hypoparathyroidism patients. The mechanism of hypocalcaemia in COVID-19 infection remains unclear. Case Description Our patient is a young gentleman who was incidentally diagnosed with superior mesenteric artery (SMA) syndrome and symptomatic primary hypoparathyroidism while presenting with an acute COVID-19 infection. He initially presented with high-grade fever, followed by multiple episodes of vomiting and abdominal pain and subsequently hypocalcaemic symptoms such as tonic-clonic seizures and carpopedal spasms. A computed tomographic scan of his abdomen revealed a SMA syndrome while his blood investigation showed a parathyroid hormone (PTH)-dependent hypocalcaemia. His SMA syndrome was a result of severe malnourishment and improved with refeeding, but his primary hypoparathyroidism persisted despite having recovered for 6 months from the initial COVID-19 infection. There was no evidence to suggest a congenital cause of hypoparathyroidism. Conclusions To the best of our knowledge this is the first case report that describe this unique case of persistent primary hypoparathyroidism related to COVID-19 infection. Parathyroid gland involvement in a COVID-19 infection is rare but not impossible. Further studies are needed to determine the mechanism and extent of damage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to the parathyroid glands.
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Affiliation(s)
| | - Guan Hoe Han
- Department of Radiology, Hospital Ampang, Ampang, Malaysia
| | | | | | - Waye Hann Kang
- Department of Medicine, M. Kandiah Faculty of Medicine & Health Sciences, Universiti Tunku Abdul Rahman, Kajang, Malaysia
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Costa M, Ferreira G, Gomes D, Oliveira C, Domingues N. May-Thurner Syndrome: The Worst-Case Scenario. Cureus 2024; 16:e55742. [PMID: 38586812 PMCID: PMC10998721 DOI: 10.7759/cureus.55742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
May-Thurner syndrome (MTS) is caused by compression of the left common iliac vein by the right common iliac artery against the spinal column. It can range from asymptomatic or present with subtle and unspecific signs and symptoms and rarely exhibit severe complications such as pulmonary embolism (PE). The diagnosis is confirmed by typical imaging findings. Treatment may include conservative measures, anticoagulation, endovascular or even surgical options. We report the case of a 20-year-old female who presented with cardiac arrest caused by an acute massive PE. Further study showed partial thrombosis of the internal iliac veins resulting from MTS. She continued anticoagulation therapy with low-molecular-weight heparin and then switched to edoxaban with a good clinical outcome. She was also referred to Vascular Surgery to discuss the possibility of iliac vein stenting. Abdominopelvic vascular compression syndromes include a large spectrum of conditions, and they are rarely considered as an etiology for venous thromboembolism. The clinical presentation of PE varies with several triggering factors and atypical presentation is more common in nonmalignant causes. The combination of noninvasive and invasive imaging modalities might be beneficial to establish a definitive diagnosis. Nevertheless, invasive procedures are often restricted to doubtful cases or to guide endovascular procedures which is the current treatment of choice. There is little evidence using nonvitamin K oral anticoagulants, but there are some case reports detailing their successful use. This case aims to point out the need for a profound understanding of different causes of deep vein and pulmonary thromboembolism; common entities in our practice but with a variety of clinical presentations and potentially caused by rare underlying conditions. MTS can be the origin of serious and deadly complications, hence the importance of early recognition and treatment.
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Affiliation(s)
- Marta Costa
- Department of Internal Medicine, Unidade Local de Saúde Viseu Dão-Lafões, Viseu, PRT
| | - Gonçalo Ferreira
- Department of Cardiology, Unidade Local de Saúde Viseu Dão-Lafões, Viseu, PRT
| | - Dora Gomes
- Department of Internal Medicine, Unidade Local de Saúde Viseu Dão-Lafões, Viseu, PRT
| | - Catarina Oliveira
- Department of Internal Medicine, Unidade Local de Saúde Viseu Dão-Lafões, Viseu, PRT
| | - Nelson Domingues
- Department of Internal Medicine, Unidade Local de Saúde Viseu Dão-Lafões, viseu, PRT
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6
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Lim C, Roh YH, Kim DW, Nam KW. Is the May-Thurner Syndrome a Major Risk Factor for Deep Vein Thrombosis in Total Hip Arthroplasty? Clin Orthop Surg 2024; 16:34-40. [PMID: 38304205 PMCID: PMC10825252 DOI: 10.4055/cios23128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 02/03/2024] Open
Abstract
Background May-Thurner syndrome (MTS) is iliac vein compression syndrome associated with postoperative deep vein thrombosis (DVT) resulting from chronic compression of the left iliac vein against lumbar vertebrae by the overlying right or left common iliac artery. MTS is not well known as a risk factor for DVT after total hip arthroplasty (THA). We evaluated the incidence of DVT after THA and analyzed if the MTS is a risk factor for DVT after THA. We hypothesized that MTS would be associated with an increased risk of developing DVT after THA. Methods All patients > 65 years of age who underwent THA between January 1, 2009, and January 12, 2017, were identified. Among them, the patients who presented for postoperative DVT of the lower extremity were reviewed with medical record data. MTS was diagnosed with computed tomography (CT) angiography of the lower extremity. We analyzed the demographic data, symptoms, diagnoses, and treatment of MTS patients. Results A total of 492 consecutive patients aged > 65 years who underwent operation for THA were enrolled. Among them, 5 patients (1.0%) presented for postoperative DVT of the lower extremity. After reviewing the CT angiography of the lower extremity, 4 out of 5 DVT patients (80%) were identified as having MTS. All MTS patients were female and presented with pain and swelling of the left leg. All MTS patients were treated with systemic anticoagulation, aspiration thrombectomy, and percutaneous transluminal angioplasty. Complete resolution of thrombus was observed in all patients. Conclusions If the diagnosis of MTS is delayed, the morbidity and mortality rates are significantly increased. Orthopedic surgeons should be aware of MTS as a risk factor for DVT after THA. Moreover, preoperative evaluation with duplex sonography or CT angiography to confirm MTS should be considered. In this regard, this study is considered to have sufficient clinical value for early diagnosis and appropriate treatment of MTS after THA.
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Affiliation(s)
- Chaemoon Lim
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Young Ho Roh
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Dae Whan Kim
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Kwang Woo Nam
- Department of Orthopaedic Surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Korea
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Liu Y, Zheng H, Wang X, Wang Z, Zhu Q, Wen C, Tong Y. Ultrasound characteristics of abdominal vascular compression syndromes. Front Cardiovasc Med 2023; 10:1282597. [PMID: 38173818 PMCID: PMC10764025 DOI: 10.3389/fcvm.2023.1282597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024] Open
Abstract
Abdominal vascular compression syndrome (AVCS) is caused by the compression of abdominal blood vessels by adjacent structures or the compression of abdominal organs by neighboring blood vessels. Such compressions can result in a variety of clinical symptoms. They are not commonly seen in ultrasound practices, and their presence may have been underrecognized and underdiagnosed. This article reviews the clinical features, ultrasound characteristics, and diagnostic criteria of four types of AVCS, namely, celiac artery compression syndrome, renal vein compression syndrome, iliac vein compression syndrome, and superior mesenteric artery syndrome to increase awareness of these conditions among ultrasound practitioners. The ultrasound criteria for AVCS are primarily based on studies with small sample sizes, and therefore, it is important to exercise caution if these criteria are used.
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Affiliation(s)
- Yan Liu
- Department of Ultrasound, Peking University International Hospital, Beijing, China
| | - Haining Zheng
- Department of Ultrasound, Peking University International Hospital, Beijing, China
| | - Xiaoqing Wang
- Department of Ultrasound, Peking University International Hospital, Beijing, China
| | - Zi Wang
- Department of Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qiang Zhu
- Department of Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chaoyang Wen
- Department of Ultrasound, Peking University International Hospital, Beijing, China
| | - Yisha Tong
- Department of Vascular Surgery, Austin Hospital, University of Melbourne, Melbourne, VIC, Australia
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8
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Donnelly L, Turner B, Davies AH. Atypical case of coexistent vascular compression syndromes: median arcuate ligament syndrome and nutcracker syndrome. BMJ Case Rep 2023; 16:e257754. [PMID: 37989330 PMCID: PMC10668132 DOI: 10.1136/bcr-2023-257754] [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] [Indexed: 11/23/2023] Open
Abstract
Vascular compression syndromes, including median arcuate ligament syndrome (MALS) and nutcracker syndrome (NCS), are poorly understood and frequently delayed diagnoses. This case describes a young adult female presenting with chronic vomiting, abdominal pain and weight loss, with dependence on nasogastric feeding. Subsequent to her gastrointestinal symptoms, she developed haematuria and orthostatic intolerance. Investigations confirmed NCS and possible MALS, with superadded gastroparesis and bradygastria. Under the joint care of general and vascular surgeons, she underwent a gastrojejunostomy and panelled renocaval bypass which led to partial resolution of her symptoms. It is hypothesised that gastroparesis may have been caused by MALS via a neurogenic mechanism, or coexistent compression of the duodenum by the superior mesenteric artery. This case highlights the difficulty in diagnosis of vascular compression syndromes, the overlap between the conditions and the potential for multiple coexistent conditions which complicate diagnosis and lead to increased lead-time and morbidity for patients.
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Affiliation(s)
- Liam Donnelly
- London North West University Healthcare NHS Trust, London, UK
| | | | - Alun H Davies
- Academic Section of Vascular Surgery, Imperial College London, London, UK
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Cassim N, Diljohn J, Rampersad FS, Chan A. Superior Mesenteric Artery Thrombosis in a Patient With Median Arcuate Ligament Syndrome. Cureus 2023; 15:e39351. [PMID: 37351226 PMCID: PMC10284597 DOI: 10.7759/cureus.39351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/24/2023] Open
Abstract
Median arcuate ligament syndrome (MALS) is a rare and controversial vascular compression syndrome. In this condition, the median arcuate ligament compresses the celiac artery, resulting in symptoms such as postprandial abdominal pain, vomiting, and weight loss. Its diagnosis is based on clinical findings in conjunction with supporting radiological features such as elevated flow velocities on Doppler ultrasound and focal indentation of the proximal celiac artery with the typical 'hooked' or 'J'-shaped appearance on conventional angiography or computed tomography angiography (CTA). Herein is the case of a 44-year-old female who presented with early satiety, postprandial abdominal pain, vomiting, and weight loss. A computed tomography mesenteric angiogram (CTMA) showed thickening of the median arcuate ligament with a hooked appearance of the celiac artery and thrombosis of the mid to distal superior mesenteric artery with associated ischemia of a short segment of the jejunum. Subsequent Doppler ultrasound demonstrated elevated peak systolic velocities within the celiac artery over the compressed segment, which varied with respiration (end-inspiration: 234.3 cm/s and end-expiration: 373.5 cm/s).
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Affiliation(s)
| | - Jason Diljohn
- Radiology, University of the West Indies, St. Augustine, TTO
| | | | - Adrian Chan
- Radiology, University of the West Indies, St. Augustine, TTO
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10
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Chan SM, Weininger G, Kozhimala M, Sumpio BJ, Levine LJ, Harris S, Zheng S, Ochoa Chaar CI, Guzman RJ, Sumpio BE. Utility of Hook Sign in the Diagnosis of Median Arcuate Ligament Syndrome. Ann Vasc Surg 2023:S0890-5096(23)00186-3. [PMID: 37023920 DOI: 10.1016/j.avsg.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/18/2023] [Accepted: 03/19/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE Median arcuate ligament syndrome (MALS) is a clinical syndrome caused by compression of the celiac artery by the median arcuate ligament (MAL) that often manifests with non-specific abdominal pain. Identification of this syndrome is often dependent on imaging of compression and upward bending of the celiac artery by lateral CTA, the so-called "hook sign." The purpose of this study was to assess the relationship of radiologic characteristicss of the celiac artery to clinically relevant MALS. DESIGN Single-center retrospective study METHODS: An IRB-approved retrospective chart review from 2000-2021 of 293 patients at a tertiary academic center diagnosed with celiac artery compression (CAC) was performed. Patient demographics and symptoms of 69 patients who were diagnosed with symptomatic MALS were compared to 224 patients without MALS (but with CAC) per electronic medical record review. CTA images were reviewed and the fold angle (FA) was measured. The presence of a hook sign (defined as a visual fold angle < 135 degrees) was recorded as well as stenosis (defined as >50% of luminal narrowing on imaging). Wilcoxon rank sum test and Chi-squared were utilized for comparative analysis. Logistic model was run to relate the presence of MALS with comorbidities and radiographic findings. RESULTS Imaging was available in 59 patients (25 males, 34 females) and 157 patients (60 males, 97 females) with and without MALS respectively. Patients with MALS were more likely to have a more severe FA (120.7 ± 33.6 vs. 134.8 ± 27.9, P = 0.002). Males with MALS were also more likely to have a more severe FA compared with males without MALS (111.1 ± 33.7 vs. 130.4 ± 30.4, P = 0.015). In patients with BMI > 25, MALS patients also had narrower FA compared with patients without MALS (112.6 ± 30.5 vs. 131.7 ± 30.3, P = 0.001). The FA was negatively correlated with BMI in patients with CAC . The hook sign and stenosis were associated with diagnosis of MALS (59.3% vs. 28.7%, P < 0.001, and 75.7% vs. 45.2%, P < 0.001, respectively). In logistic regression, pain, stenosis and a narrow FA were statistically significant predictors of the presence of MALS. CONCLUSIONS The upward deflection of the celiac artery in patients with MALS is more severe compared with patients without MALS. Consistent with prior literature, this bending of the celiac artery is negatively correlated with BMI in patients with and without MALS. When demographic variables and comorbidities are considered, a narrow FA is a statistically significant predictor of MALS. Regardless of MALS diagnosis, a hook sign was associated with narrower FA. While demographics and imaging findings may inform MALS diagnosis, clinicians should not rely on a visual assessment of a hook sign but should quantitatively measure the anatomic bending angle of the celiac artery to assist with the diagnosis and understand the outcomes.
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Affiliation(s)
- Shin Mei Chan
- Yale University School of Medicine, New Haven, CT, 06511
| | - Gabe Weininger
- Yale University School of Medicine, New Haven, CT, 06511
| | - Meagan Kozhimala
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Brandon J Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, 02114
| | - Louis J Levine
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06511
| | - Sean Harris
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Sijin Zheng
- Yale University School of Medicine, New Haven, CT, 06511
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Bauer E Sumpio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511.
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Abstract
Pelvic venous disorders (PeVD) also known as Pelvic Congestion Syndrome (PCS) affect a great number of women worldwide and often remain undiagnosed. Gynecological symptoms caused by vascular background demand a holistic approach for appropriate diagnosis. This is a relevant cause of chronic pelvic pain and atypical varicose veins. The diagnosis is based on imaging studies and their correlation with clinical presentation. Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation. The following paper describes an in-depth overview of anatomy, pathophysiology, symptoms, diagnosis and treatment of PCS. In recent years, minimally invasive interventions have become the method of first choice for the treatment of this condition. The efficacy of a percutaneous approach is high and it is rarely associated with serious complications.Key MessagesPelvic venous disorders demand a holistic approach for appropriate diagnosis.This article takes an in-depth look at existing therapies of Pelvic Congestion Syndrome and pathophysiology of this condition.Embolisation is an effective and safe treatment option.
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Affiliation(s)
- Kamil Bałabuszek
- Department of Radiography, Medical University of Lublin, Lublin, Poland
| | - Michał Toborek
- Department of Radiography, Medical University of Lublin, Lublin, Poland
| | - Radosław Pietura
- Department of Radiography, Medical University of Lublin, Lublin, Poland
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12
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Hadi SS, Kareem TF, Kamal AM. Normal values of angle and distance between the superior mesenteric artery and aorta in Iraqi population: A single centre study. J Med Radiat Sci 2022; 69:191-197. [PMID: 34898028 PMCID: PMC9163471 DOI: 10.1002/jmrs.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The diagnosis of the superior mesenteric syndrome depends on measuring the distance and angle between the superior mesenteric artery (SMA) and aorta on CT scan in the presence of duodenal compression. Studies examining the normal range of these measurements are scarce and none of them was conducted on the Iraqi population. The aim of this study was to assess the values of aorto-SMA angle (AMA) and aorto-SMA distance (AMD) in asymptomatic patients to define the normal range in the Iraqi population and to compare it with the normal published range and different demographical values and body mass index (BMI). METHODS A total of 333 patients referred to arterial phase CT examinations for reasons unrelated to gastrointestinal tract were recruited. On axial and reformatted sagittal-oblique images, the angle and the distance between SMA and aorta were measured at the location where the duodenum crosses. RESULTS Both AMA and AMD had a wider range 10-147° and 4-44 mm, respectively, compared to the literature reported range. There was a significant reduction in AMA and AMD values in underweight participants (AMA, P < 0.001; and AMD, P = 0.014) and in female patients (AMA and AMD, P < 0.0001) and those who were younger than 20 (AMA, P = 0.014; and AMD, P = 0.001). A moderate correlation (r = 0.507, P < 0.0001) was found between AMA and AMD values. The correlation of BMI with AMD values was moderate (r = 0.46), and with AMA was weak (r = 0.23) (P < 0.0001). CONCLUSION Very low values of AMA and AMD can occur in normal asymptomatic patients without compressing the duodenum, which warrants further follow-up studies. Evaluating normal values of AMA and AMD in the Iraqi population can help in providing a reference for CT-based diagnosis of SMA syndrome.
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Malli F, Dimeas IE, Sinis SI, Karetsi E, Nana P, Kouvelos G, Gourgoulianis KI. Bilateral Deep Vein Thrombosis and Pulmonary Embolism Due to Right Common Iliac Artery Aneurysm with a Contained Rupture. Medicina (B Aires) 2022; 58:medicina58030421. [PMID: 35334597 PMCID: PMC8953859 DOI: 10.3390/medicina58030421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (comprising deep venous thrombosis and/or pulmonary embolism) is a common disease, often of multifactorial cause. Focal iliac artery aneurysms are relatively rare, and only a few reports exist in the literature describing patients with venous thromboembolism resulting from venous floe disruption due to iliac artery aneurysm. Thus, we report a case of a 65-year-old male presenting with pulmonary embolism and bilateral deep vein thrombosis associated with a contained rupture of the right common iliac artery aneurysm.
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Affiliation(s)
- Foteini Malli
- Respiratory Medicine Department, School of Medicine, University of Thessaly, Biopolis (Mezourlo), 41110 Larissa, Greece; (I.E.D.); (S.I.S.); (E.K.); (K.I.G.)
- Respiratory Disorders Lab., Faculty of Nursing, University of Thessaly, 41500 Larissa, Greece
- Correspondence: ; Tel.: +30-241-068-4612; Fax: +30-241-350-1563
| | - Ilias E. Dimeas
- Respiratory Medicine Department, School of Medicine, University of Thessaly, Biopolis (Mezourlo), 41110 Larissa, Greece; (I.E.D.); (S.I.S.); (E.K.); (K.I.G.)
| | - Sotirios I. Sinis
- Respiratory Medicine Department, School of Medicine, University of Thessaly, Biopolis (Mezourlo), 41110 Larissa, Greece; (I.E.D.); (S.I.S.); (E.K.); (K.I.G.)
| | - Eleni Karetsi
- Respiratory Medicine Department, School of Medicine, University of Thessaly, Biopolis (Mezourlo), 41110 Larissa, Greece; (I.E.D.); (S.I.S.); (E.K.); (K.I.G.)
| | - Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, School of Medicine, University of Thessaly, 41110 Larissa, Greece; (P.N.); (G.K.)
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, School of Medicine, University of Thessaly, 41110 Larissa, Greece; (P.N.); (G.K.)
| | - Konstantinos I. Gourgoulianis
- Respiratory Medicine Department, School of Medicine, University of Thessaly, Biopolis (Mezourlo), 41110 Larissa, Greece; (I.E.D.); (S.I.S.); (E.K.); (K.I.G.)
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Superior mesenteric artery syndrome (Wilkie Syndrome) with unusual clinical onset: Description of a rare case. Radiol Case Rep 2021; 16:2998-3002. [PMID: 34401041 PMCID: PMC8358285 DOI: 10.1016/j.radcr.2021.07.004] [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: 06/17/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022] Open
Abstract
Wilkie's Syndrome is a very rare disease caused by reduction of aorto-mesenteric space with consequent duodenum compression. It can combine with left renal vein stenosis which, when symptomatic, is known as "Nutcracker Syndrome". We describe a clinical onset case with epigastric pain without vomiting in a normal weight patient. 28-year-old woman who came to our observation for intense epigastric pain after a weight loss of 14 kg in 4 months. Multidetector Computed Tomography and Ultrasound revealed gastric and duodenal overdistension with hydro-air levels, severe duodenum stenosis, and left renal vein compression. Wilkie's Syndrome is common in anorexic individuals suffering from recurrent postprandial vomiting, onset with severe epigastric pain, without vomiting, is quite unusual. High-calorie diet must be first therapeutic approach, in case of failure treatment of first choice should be endovascular stenting and, only in selected cases, surgical treatment should be used because it is very invasive and burdened with numerous complications. Failure to diagnose this disease can expose patients to serious health risks.
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Farina R, Gozzo C, Foti PV, Conti A, Vasile T, Pennisi I, Venturini M, Basile A. A man with the rare simultaneous combination of three abdominal vascular compression syndromes: median arcuate ligament syndrome, superior mesenteric artery syndrome, and nutcracker syndrome. Radiol Case Rep 2021; 16:1264-1270. [PMID: 33854661 PMCID: PMC8026914 DOI: 10.1016/j.radcr.2021.02.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 01/27/2023] Open
Abstract
Median arcuate ligament syndrome and superior mesenteric artery syndrome are well-known abdominal compression syndromes, the coexistence of which is rarely described in literature. In addition, due to the common pathogenesis, anterior nutcracker syndrome may occur simultaneously to superior mesenteric artery syndrome. To our knowledge, this is the first case reporting combination of these 3 syndromes detected with ultrasound, Computed Tomography and upper gastrointestinal fluoroscopic exam. A 69-year-old man came to our attention for rapid weight loss, postprandial epigastric pain and recurrent vomiting for at least 6 months. Doppler ultrasound showed both celiac artery and left renal vein stenosis with simultaneous left varicocele. Computed tomography showed a reduction of aortomesenteric space causing both left renal vein and duodenal stenosis, this latter confirmed by upper gastrointestinal fluoroscopic exam. The diagnosis of these three vascular compression syndromes (MALS, SMAS, and anterior NCS) has been formulated, based on clinical and imaging findings. We assumed that the postprandial crises caused by median arcuate ligament syndrome may induce a reduction of meals consumption and progressive weight loss which can be a cause of anterior nutcracker syndrome and superior mesenteric artery syndrome onset. Doppler ultrasound, in expert hands, allows to accurately diagnosing these syndromes which are often underestimated. Failure to recognize it and inadequate treatment could have serious consequences for patients' health.
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Affiliation(s)
- Renato Farina
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, Radiodiagnostic and Radiotherapy Unit, Catania, Italy
| | - Cecilia Gozzo
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, Radiodiagnostic and Radiotherapy Unit, Catania, Italy
| | - Pietro Valerio Foti
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, Radiodiagnostic and Radiotherapy Unit, Catania, Italy
| | - Andrea Conti
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, Radiodiagnostic and Radiotherapy Unit, Catania, Italy
| | - Tiziana Vasile
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, Radiodiagnostic and Radiotherapy Unit, Catania, Italy
| | - Isabella Pennisi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, Radiodiagnostic and Radiotherapy Unit, Catania, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Department, Circolo Hospital, Insumbria University, Varese, Italy
| | - Antonio Basile
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, Radiodiagnostic and Radiotherapy Unit, Catania, Italy
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16
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Gozzo C, Farina R, Coppolino P, Cancemi G, Foti PV, Palmucci S, Venturini M, Basile A. Double May-Thurner syndrome causing chronic deep vein thrombosis and natural venous femoro-femoral bypass: a description of rare case. Radiol Case Rep 2021; 16:1608-1612. [PMID: 33995751 PMCID: PMC8105594 DOI: 10.1016/j.radcr.2021.04.020] [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: 03/28/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 11/24/2022] Open
Abstract
May-Thurner syndrome (MTS) belongs to a group of uncommon vascular syndromes. It consists in left common iliac vein (LCIV) compression between the right common iliac artery (RCIA) anteriorly and the lumbar spine posteriorly. A compression of LCIV by the left common iliac artery (LCIA) or by both iliac arteries were described. We present a rare case of "double MTS" which consist in double stenosis of LCIV by both RCIA and LCIA. Double MTS can cause acute or chronic DVT; this latter could be clinical manifest or well compensated. A 58-year-old woman with chronic mild pelvic pain underwent Doppler Ultrasound (US) of the pelvis and lower extremity vessels which showed thrombosis of both LCIV and ipsilateral common femoral vein caused by the extrinsic compression by both common iliac arteries against the spine. CT angiography confirmed the US data and ruled out other causes of compression. CT scan also showed the development of a natural venous femoro-femoral bypass which allowed to counteract the venous stasis and compensate venous drainage. Therefore, we decide for a long-term prophylaxis with anticoagulant drugs and doppler US follow-up at 6 months. In conclusion, doppler US is a non-invasive, low-cost, repeatable and sensitive method which allows to diagnose MTS and associated DVT. It may be considered the first level exam which allows to easily detect pelvic vascular compression syndrome.
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Affiliation(s)
- Cecilia Gozzo
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Radio diagnostic and Radiotherapy Unit, Catania, Italy
| | - Renato Farina
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Radio diagnostic and Radiotherapy Unit, Catania, Italy
| | - Pietro Coppolino
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Radio diagnostic and Radiotherapy Unit, Catania, Italy
| | - Giovanna Cancemi
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Radio diagnostic and Radiotherapy Unit, Catania, Italy
| | - Pietro Valerio Foti
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Radio diagnostic and Radiotherapy Unit, Catania, Italy
| | - Stefano Palmucci
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Radio diagnostic and Radiotherapy Unit, Catania, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Department, Circolo Hospital, Insubria University, Varese, Italy
| | - Antonio Basile
- Diagnostic and Interventional Radiology Department, Circolo Hospital, Insubria University, Varese, Italy
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17
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Lakhani DA, Balar AB, Tarabishy AR. Atypical cause of episodic abdominal pain and unintentional weight loss. Eur J Intern Med 2021; 87:92-93. [PMID: 33762141 PMCID: PMC8371992 DOI: 10.1016/j.ejim.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Dhairya A Lakhani
- Department of Radiology, West Virginia University, Morgantown, WV 26506, United States.
| | - Aneri B Balar
- Department of Radiology, West Virginia University, Morgantown, WV 26506, United States
| | - Abdul R Tarabishy
- Department of Radiology, West Virginia University, Morgantown, WV 26506, United States; Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, WV 26506, United States
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18
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Esmat HA, Najah DM. Superior mesenteric artery syndrome caused by acute weight loss in a 16-year-old polytrauma patient: A rare case report and review of the literature. Ann Med Surg (Lond) 2021; 65:102284. [PMID: 33912344 PMCID: PMC8066379 DOI: 10.1016/j.amsu.2021.102284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/04/2021] [Accepted: 04/04/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction Superior mesenteric artery syndrome is a rare entity, caused by compression of the duodenum between the superior mesenteric artery and the aorta. Case presentation A 16-year-old male in the inpatient service of our hospital complained of vomiting for two weeks. The patient had a long hospital stay in our center for the management of trauma-related complications, which resulted in significant weight loss despite the parenteral nutrition as he was unable for taking the enteral nutrition due to severe facial traumatic injury. In oral contrast study, the proximal duodenal segments were dilated. The contrast media could not reach the duodenojejunal junction in the supine position, though a small amount of the contras passed the distal duodenal part on repositioning the patient to prone. On abdominal CT images, the angle and distance between the superior mesenteric artery and the abdominal aorta were decreased to 20. 80, and 7.3 mm respectively. The findings were consistent with the superior mesenteric artery compression syndrome. He underwent a mini-laparotomy for the placement of a jejunostomy feeding tube aiming to promote weight gain and mesenteric fat restoration for preventing the SMA compression effects on the duodenum. Discussion The decrease in retroperitoneal fat owing to weight loss may result in aortomesenteric angle reduction and duodenal compression. Prompt nutritional support and timely diagnosis may preclude the need for more invasive surgical intervention. Conclusion Superior mesenteric artery syndrome is a rare condition, often resulting in small bowel obstruction. The clinical symptoms of this syndrome are nonspecific, which may underestimate the diagnosis. However, clinical suspicion supported by imaging study may help the accurate diagnosis. Superior mesenteric artery syndrome should be considered in all polytrauma and longstanding immobile patients present with rapid weight loss and vomiting. Superior mesenteric artery syndrome is a rare condition, often resulting in small bowel obstruction. The clinical symptoms of this syndrome are nonspecific, which may underestimate the diagnosis. Clinical suspicion supported by imaging study may help the accurate diagnosis. Prompt nutritional support and timely diagnosis may preclude the need for surgical intervention.
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Affiliation(s)
- Habib Ahmad Esmat
- Corresponding author. Fellow of radiology at EGE University Hospital, Izmir, Turkey.
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19
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Farina R, Foti PV, Iannace FA, Conti A, Pennisi I, Coppolino P, Vasile T, Gozzo C, Failla G, Basile A. May-Thurner Syndrome with Double Compression of the Iliac Vein: Lessons Based on a Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e928957. [PMID: 33895771 PMCID: PMC8083791 DOI: 10.12659/ajcr.928957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patient: Female, 73-year-old Final Diagnosis: May-Thurner syndrome with double stenosis of the left common iliac vein Symptoms: Acute onset of worsening dyspnea, with lymphedema of the left lower limb Medication: — Clinical Procedure: — Specialty: Diagnostics, Laboratory • Radiology
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Affiliation(s)
- Renato Farina
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Francesco Aldo Iannace
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Andrea Conti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Isabella Pennisi
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Pietro Coppolino
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Tiziana Vasile
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Cecilia Gozzo
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Giovanni Failla
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Antonio Basile
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
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20
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Sun Y, Song S. Nonnegligible causes of symptoms of acute lower extremities--3 cases of May-Thurner syndrome with deep vein thrombosis. Thromb J 2021; 19:25. [PMID: 33874947 PMCID: PMC8054378 DOI: 10.1186/s12959-021-00278-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/05/2021] [Indexed: 01/16/2023] Open
Abstract
Background May-Thurner syndrome is a kind of disease caused by the compression of the left common iliac vein. It is one of the causes of incomplete venous valves and superficial varicose veins in lower limbs, and is also a potential factor of acute deep vein thrombosis (DVT). Method Here 3 cases are diagnosed as May-Thurner syndrome at different ages. Case presentations 1. A 35-year-old female patient was hospitalized with swelling of the left lower limb for 1 week. Computed tomography (CT) showed compression of the left common iliac vein with thrombosis. May-Thurner syndrome was diagnosed and catheter-directed thrombolysis was performed. 2. A 37-year-old male patient came to our hospital due to sudden swelling of the right lower extremity and pain for 3 days. Computed tomography showed compression of the left common iliac vein and deep venous thrombosis (DVT) of the right iliac vein. May-Thurner syndrome was diagnosed. The patient was performed with inferior vena cava (IVC) filter implantation, catheter-directed thrombolysis and balloon angioplasty for right iliac vein. And the patient recovered well; 3. A 55-year-old female patient came to our hospital with swelling and discomfort in the left lower extremity for 3 days. Computed tomography showed stenosis of the left common iliac vein with deep vein thrombosis. May-Thurner syndrome was diagnosed, balloon dilation and stent implantation were performed. During 3 years of follow-up, there was no swelling or new thrombosis in her lower limbs. Conclusion When encountering unexplained deep vein thrombosis, iliac vein compression syndrome should be considered and treated in time to prevent the recurrence of thrombosis. Catheter-directed thrombolysis can relieve symptoms and stenting placement is the optimal way to relieve stenosis, supplemented by long-term anticoagulation therapy and graduated compression stockings.
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Affiliation(s)
- Yi Sun
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Shenghan Song
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
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21
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García-García A, Oblitas CM, Galeano-Valle F, Olmos-Nieto A, Ortega-Soudant A, Demelo-Rodríguez P. May-Thurner syndrome and deep vein thrombosis: A series of 8 patients. Med Clin (Barc) 2021; 156:622-624. [PMID: 33810871 DOI: 10.1016/j.medcli.2020.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To analyze the prevalence of May-Thurner syndrome (MTS) among patients with deep vein thrombosis (DVT) of left lower limb (LLL), and outcomes after long-term follow-up. METHOD Retrospective observational study that included patients older than 18 diagnosed with acute DVT and MTS. RESULTS Among 760 patients diagnosed with DVT in the LLL, 8 patients were diagnosed with MTS (1.05%), with a mean age of 39 years. All patients received long-term anticoagulation, with a mean of 31.9 (±25.2) months. Invasive treatment with pharmaco-mechanical thrombectomy was performed in 5 patients (62.5%). During follow-up (mean of 32.4 months), 25% of patients suffered DVT recurrence. Only 1 case presented major bleeding, and no deaths were registered. CONCLUSIONS May-Thurner syndrome constitutes a permanent and underdiagnosed risk factor for the development of DVT of LLL. Our findings suggest that long-term anticoagulation therapy might be considered in selected cases.
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Affiliation(s)
- Alejandra García-García
- Venous Thromboembolism Unit, Internal Medicine. Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Crhistian-Mario Oblitas
- Venous Thromboembolism Unit, Internal Medicine. Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Galeano-Valle
- Venous Thromboembolism Unit, Internal Medicine. Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain.
| | - Andrea Olmos-Nieto
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana Ortega-Soudant
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Pablo Demelo-Rodríguez
- Venous Thromboembolism Unit, Internal Medicine. Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain
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22
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Gozzo C, Farina R, Foti PV, Iannace FA, Conti A, Pennisi I, Santonocito S, Palmucci S, Basile A. Posterior nutcracker syndrome: a case report. J Med Case Rep 2021; 15:42. [PMID: 33522968 PMCID: PMC7849074 DOI: 10.1186/s13256-020-02617-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Posterior nutcracker syndrome is defined by the compression of the left renal vein between the abdominal aorta and a lumbar vertebral body. It can be clinically manifest with intermittent hematuria, gonadal or spermatic reflux resulting in varicocele. Ultrasound is the first-line imaging which require more accurate study with contrast-enhanced computed tomography. Management can be conservative in younger patients with mild hematuria due to the high spontaneous remission rate and invasive with open surgical and endovascular interventions. We describe a very rare case with compression of the left renal vein due to an osteophyte of the spine. Case presentation A 62-year-old Caucasic male came to our radiology department for chronic hepatitis B virus (HBV)-related liver disease follow-up and mild scrotal pain. The ultrasound examination revealed a compression of the left retro-aortic renal vein in the aorto-vertebral space caused by an osteophyte. Duplex Doppler ultrasound revealed flow congestion in the left renal vein and renal failure; power Doppler ultrasound showed left varicocele. Conclusions Doppler ultrasound is the first-line imaging and allows the detection of all the typical signs of posterior nutcracker: left renal vein stenosis, flow congestion and renal failure. Nutcracker syndrome should be suspected in older patients with left varicocele associated with hematuria. Failure to diagnose and treat these patients could have serious consequences for their health.
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Affiliation(s)
- Cecilia Gozzo
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy.
| | - Renato Farina
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Francesco Aldo Iannace
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Andrea Conti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Isabella Pennisi
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Serafino Santonocito
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Stefano Palmucci
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Basile
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
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23
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Abstract
Online supplemental material is available for this article.
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Affiliation(s)
- Furkan Ufuk
- From the Department of Radiology, University of Pamukkale, Denizli 20100, Turkey
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24
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Farina R, Foti PV, Iannace FA, Fanzone L, Pennisi I, Conti A, Santonocito S, Basile A. May Thurner syndrome: description of a case with unusual clinical onset. J Ultrasound 2020; 25:309-313. [PMID: 32577934 DOI: 10.1007/s40477-020-00497-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/12/2020] [Indexed: 12/18/2022] Open
Abstract
May-Thurner syndrome (MTS) is a congenital vascular alteration that is part of a restricted category of very rare vascular syndromes that have in common the compression of an arterial or venous vessel. MTS, first described in 1957, is due to compression of the left common iliac vein against the lumbar spine by the adjacent common iliac artery. It can cause chronic thrombosis of the left lower limb and can give edema, pain, claudication, thrombophlebitis, and, in severe cases, pulmonary embolism. Color Doppler and duplex Doppler ultrasound allow us to easily locate the deep vein thrombosis, to measure its extension, and to highlight the vascular changes typical of MTS: compression and consequent hypertension of the left common iliac vein. The therapy depends on the degree of venous stasis and on the presence of venous thrombosis; generally, it consists of the administration of short- or long-term anticoagulant and thrombolytic drugs. In cases of severe stenosis of the left common iliac vein, the first-choice treatment consists of positioning a vascular stent, which resolves compression and significantly reduces chronic thrombotic episodes. We describe a case of MTS with an unusual clinical onset with pulmonary embolism.
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Affiliation(s)
- Renato Farina
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy.
| | - Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Francesco Aldo Iannace
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Luigi Fanzone
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Isabella Pennisi
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Andrea Conti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Serafino Santonocito
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Basile
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
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