Abstract
We report a case of a 31-year-oldman who presented to the hospital with extensive deep vein thrombosis (DVT) complicated by pulmonary embolism (PE) after a recent trauma and prolonged immobilization. He underwent contrast venography that revealed features of May-Thurner syndrome (MTS). He was managed with therapeutic anticoagulation, inferior vena cava filter placement, mechanical clot aspiration, catheter-directed thrombolytic therapy, and left common iliac vein stenting.MTS is a vascular condition caused by the compression of the left common iliac vein by an overlying right common iliac artery against a vertebral body. This results in indolent endothelial changes secondary to the pulsating nearby artery as well as the compression increasing the susceptibility to venous thrombosis. Females are thought to be more prone to the condition due to the nature of their pelvic anatomy. Most patients are asymptomatic or present with unspecific symptoms, rendering the condition underdiagnosed. The gold standard diagnostic modality is contrast venography that reveals collaterals and a pressure gradient greater than 2 mmHg at rest across the stenotic region. Treatment is revolved around the removal of the thrombus along with the correction of the anatomical defect through interventional or surgical treatment to prevent a recurrence.Untreated MTS complicated with DVT carries a risk of potentially life-threatening complications, such as PE, iliac vein rupture, retroperitoneal hematoma, or refractory DVT that is difficult to treat. Due to the chronicity of this syndrome, its management plan differs from that of other causes of DVT. Proper identification of MTS carries a positive outcome in treating DVT secondary to MTS. Here we are going to discuss a case diagnosed with MTS complicated by saddle PE outlying the possible pathophysiology, clinical manifestation, diagnostic tools, and management of complicated MTS.
Highlights
Deep vein thrombosis (DVT) is a common complication in many individuals who have the propensity for thrombosis
In the middle of the 19th century, Cocket and Thomas conducted the first study in living subjects presented with acute left-sided lower limb DVT and they investigated in detail the causes using venography, where they first described the nature of the obstruction as induration and ulceration that did not respond to a surgical mobilization of the nearby blood vessels, which suggested further intraluminal pathology rather than solely mechanical obstruction due to compression
May-Thurner syndrome (MTS) is a rare cause of venous thromboembolism caused by compression of the left common iliac vein by the right common iliac artery against the nearby vertebral bodies
Summary
Deep vein thrombosis (DVT) is a common complication in many individuals who have the propensity for thrombosis. Due to left lower limb swelling, a venous Doppler ultrasound was done, which highlighted extensive acute thrombus in the left external iliac vein to saphenofemoral vein, common femoral vein, popliteal vein, major leg veins to involve the saphenofemoral junction, and the greater saphenous vein. He was started on therapeutic subcutaneous heparin injection. The patient was left for a couple of hours to be called back again for a repeat venogram This time there was a significant resolution of the clot; there was still chronic thrombus and stenosis of the left common iliac vein (Figure 5). He was discharged on anticoagulation therapy over six months with rivaroxaban, with a follow-up appointment for IVC filter retrieval
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