An Underconsidered Cause of Central Venous Occlusion

Abstract

Classic iliocaval venous compression also known as May Thurner or Cockett’s syndrome is defined as extrinsic arterial compression of the left iliac vein. We present a retrospective case review. A 68-year-old man who was treated for 6 months with rivaroxaban for an unprovoked left lower extremity deep vein thrombosis (DVT) developed recurrent DVT 2 weeks after cessation. He was evaluated at an outside hospital and anticoagulation was restarted. Thrombophilic workup was negative with the exception of a mildly elevated homocysteine. Adjuncts including prostate-specific antigen, chest radiograph, and colonoscopy were all unremarkable. His symptoms progressed to severe swelling, pain, limited ambulation, and numbness. He presented to another institution where a computed tomography venography revealed a thrombosed iliac artery aneurysm causing extrinsic venous compression. He had a prior aortobifemoral bypass for occlusive disease. He underwent mechanical thrombolysis with the reconstitution of collateral blood flow. Two days after his procedure, his venous claudication resolved. Central venous occlusions can present with a multitude of symptoms including edema, pain, claudication, thrombosis, and chronic venous insufficiency. Central venous occlusion needs to be included in the differential diagnosis of all patients who present with these symptoms. Arterial aneurysm development is just one etiology of extrinsic compression. Treatment can usually be achieved through endovascular approaches.