Abstract
May-Thurner syndrome (MTS) is defined as extrinsic venous compression by the arteries of the iliocaval system. The most common manifestation of MTS is compression of the left common iliac vein by the right common iliac artery.May-Thurner syndrome is pathologically seen in 2%-5% of patients presenting with symptomatic deep vein thrombosis (DVT). As an anatomic variant, the prevalence is predicted to be much higher as most patients with MTS anatomy are asymptomatic and do not seek evaluation. Symptomatic clinical presentations can include left lower extremity pain, swelling, skin discoloration, ulceration, and venous claudication. Here we present a patient with symptomatic MTS.A 64-year-old female with no pertinent past medical history presented with complaint of worsening left lower extremity swelling and pain. Clinical picture was concerning for phlegmasia cerulea dolens and ultrasound was bypassed in favor of a CT scan of the lower extremities bilaterally.The CT showed occlusion of the deep veins of the left leg secondary to stenosis of the left common iliac vein just posterior to the right common iliac artery; a finding consistent with MTS. Interventional radiology performed a catheter-directed thrombolysis with stenting of the left common iliac and external iliac veins. The patient clinically improved and was discharged with anticoagulative therapy. May-Thurner syndrome is a condition that typically manifests due to external anatomic compression of the left common iliac vein. It is our belief that patients (with the appropriate risk factors) presenting with signs and symptoms consistent with proximal lower extremity DVT would benefit from further radiographic studies to fully evaluate for iliocaval venous stenosis and subsequent catheter-directed thrombolysis with endovascular stenting.
Highlights
May-Thurner syndrome (MTS) is a pathologically variable condition characterized by extrinsic venous compression of the iliocaval vessels, leading to a varying degree of venous outflow obstruction
While anatomic variants have been discovered, the most common manifestation of MTS is compression of the left common iliac vein between the right common iliac artery and the fifth lumbar vertebrae [1]. It has been known since the mid-1800s that deep vein thrombosis (DVT) was about five times more likely to occur in the left lower extremity than the right lower extremity but the etiology behind this was never properly elucidated
While many patients are asymptomatic due to the variable degree of extrinsic compression, those with symptoms often exhibit signs of venous hypertension secondary to venous outflow obstruction. Those with MTS are at higher risk for venous ulcers, claudication, swelling, pain, skin discoloration, acute DVT, and reduced quality of life
Summary
May-Thurner syndrome (MTS) is a pathologically variable condition characterized by extrinsic venous compression of the iliocaval vessels, leading to a varying degree of venous outflow obstruction. While anatomic variants have been discovered, the most common manifestation of MTS is compression of the left common iliac vein between the right common iliac artery and the fifth lumbar vertebrae [1]. The patient underwent a third venogram the day that revealed dissolution of the thrombus but severe stenosis of the left common iliac vein and left external iliac vein (Figure 5). Post-stent venogram revealed markedly improved blood flow through the left common iliac vein into the inferior vena cava (Figure 6). The patient relayed improvement in her left lower extremity pain and swelling post-procedure. She was subsequently transferred out of the ICU and deemed stable for discharge on eliquis 5 mg twice a day for six months
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