Compression Of Left Common Iliac Vein Research Articles

Technical Feasibility and Clinical Efficacy of Iliac Vein Stent Placement in Adolescents and Young Adults with May-Thurner Syndrome.

To report technical feasibility and clinical efficacy of iliac vein stent placement in adolescent patients with May-Thurner Syndrome (MTS). Single-institution retrospective review of the medical record between 2014 and 2021 found 63 symptomatic patients (F = 40/63; mean age 16.1years, 12-20years) who underwent left common iliac vein (LCIV) stent placement for treatment of LCIV compression from an overriding right common iliac artery, or equivalent (n = 1, left IVC). 32/63 (50.7%) patients presented with non-thrombotic iliac vein lesions (NIVL). 31/63 (49.2%) patients presented with deep vein thrombosis of the lower extremity and required catheter-directed thrombolysis after stent placement (tMTS). Outcomes include technically successful stent placement with resolution of anatomic compression and symptom improvement. Stent patency was monitored with Kaplan-Meier analysis at 3, 6, 12, 24, and 36months. Anticoagulation and antiplatelet (AC/AP) regimens were reported. Technical success rate was 98.4%. 74 bare-metal self-expanding stents were placed in 63 patients. Primary patency at 12, and 24-months was 93.5%, and 88.9% for the NIVL group and 84.4% and 84.4% for the tMTS group for the same period. Overall patency for the same time intervals was 100%, and 95.4% for the NIVL group and 96.9%, and 96.9% for the tMTS group. Procedural complication rate was 3.2% (2/63) with no thrombolysis-related bleeding complications. Clinical success was achieved in 30/32 (93.8%) and 29/31 (93.5%) patients with tMTS and NIVL groups, respectively. CIV stent placement in the setting of tMTS and NIVL is technically feasible and clinically efficacious in young patients with excellent patency rates and a favorable safety profile.

Prevalence and predictors of radiological left common iliac vein compression in asymptomatic patients

ObjectiveThe aim of this study was to investigate the prevalence of radiological left common iliac vein (LCIV) compression among the asymptomatic population and identify possible predictors. MethodsContrast-enhanced abdominal and/or pelvic computed tomography scans of eligible asymptomatic patients were examined. The LCIV diameter was measured from different horizontal planes in the venous phase using PACSView. Degree of LCIV compression (Dc) was calculated by a predefined formula and graded as insignificant (Dc < 25%), mild (≥25% Dc < 50%), moderate (≥50% Dc <75%), and severe (Dc ≥ 75%). Venous stenosis was defined as a Dc of ≥50%. Comparison of variables, including gender, age, body mass index (BMI), and comorbidities was performed between the different grades of LCIV compression. ResultsBetween November 2019 and July 2022, 1698 eligible asymptomatic patients (53.1% females; mean age, 39.3 ± 11.8 years; mean BMI, 22.9 ± 3.6 kg/m2) were reviewed. The mean Dc was 46.2% (range, 0.29%-90.4%). Insignificant, mild, moderate, and severe compression were distributed in 14.5%, 38.0%, 42.2%, and 5.2% of the cohort population, respectively. Prevalence of venous stenosis was higher in females than males (58.1% vs 42.2%; χ2 = 15.52; P < .001). Females aged ≥25 and <35 years accounted for the highest proportion of venous stenosis than other age groups and was a significant predictor (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.74-7.79; P < .001). In the Asian BMI classification group, being underweight is associated with venous stenosis (OR, 4.69; 95% CI, 2.70-8.14; P < .001) and obesity may be a protective factor (OR, 0.38; 95% CI, 0.23-0.64; P < .001). There is an inverse relationship between Dc and age and BMI. ConclusionsThe prevalence of radiological LCIV compression on computed tomography scans was high, but all patients were asymptomatic. Female gender, especially those aged ≥25 and <35 years, and underweight were possible predictors for venous stenosis.

PD18-09 THE INCIDENCE OF LEFT COMMON ILIAC VEIN COMPRESSION IN MEN WITH A VARICOCELE. IMPLICATIONS FOR ETIOLOGY AND MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023PD18-09 THE INCIDENCE OF LEFT COMMON ILIAC VEIN COMPRESSION IN MEN WITH A VARICOCELE. IMPLICATIONS FOR ETIOLOGY AND MANAGEMENT Peter Chin and Laurencia Villalba Peter ChinPeter Chin More articles by this author and Laurencia VillalbaLaurencia Villalba More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003273.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The etiology of varicocele is thought to be related to incompetence of the gonadal vein. Epidemiological studies have shown that Left Common Iliac Vein Compression (LCIVC) ≥25% occurs in 22-35% of the general population. The objective of this study was to compare the incidence and severity of LCIVC in men with a varicocele with the published incidence in asymptomatic men, document the incidence of left gonadal incompetence and provide a possible explanation for varicocele treatment failure. METHODS: Men presenting at our practice with a varicocele were enrolled into this study. Ethics approval was obtained. All participants underwent a Duplex Ultrasound of the pelvic veins. The degree of LCIVC was grouped into ≥25% (significant compression) and ≥50% (severe compression). The results were compared to a vascular epidemiological study of 272 asymptomatic men (Cheng et al 2017), by Chi-squared analyses. Degree of compression was analyzed for association with Grade of varicocele by Kruskal-Wallis ANOVA test. RESULTS: 80 men with varicoceles completed the investigations. Mean age of the cohort was 39.5 years. In our study group, 91.2% men had a LCIVC ≥25% (73/80) compared to the expected incidence in asymptomatic men of 29.4% (80/272) [χ2=96.2; p<0.001]. The study also showed that 67.5%% (54/80) had LCIVC ≥50% (severe) compared to the expected incidence in asymptomatic men of 6.9% (19/272) [χ2=137; p<0.0001]. Only 23% of men had incompetent gonadal veins (19/80). 16% of men with varicoceles had retrograde flow through the left internal iliac vein. 8.8% (7/80) men presented with recurrent varicocele and all had severe LCIV compression ≥50%. There was no significant correlation between WHO varicocele grade and degree of compression (Kruskal-Wallis one-way ANOVA H=3.26, p=0.196). CONCLUSIONS: This is the largest study to show that men with varicoceles have a significantly higher incidence of LCIVC ≥25% (significant) and LCIVC ≥50% (severe) than asymptomatic men. Increased pelvic venous pressure from LCIVC can lead to retrograde flow through the left internal iliac vein (16%). The high incidence of LCIVC in men with a varicocele suggests that a varicocele is an “escape” vessel for increased pelvic venous pressure. The majority of men in our cohort did not have a demonstrable incompetent gonadal vein (23%). This would make embolization difficult, and ligation unlikely to provide long term benefit if there was a separate pelvic feeding vessel. Severe LCIV compression (≥50%) is associated with DVT and pelvic venous congestion. Men with varicoceles should be further investigated with a pelvic duplex ultrasound. All of the men presenting with recurrent varicocele after embolization had severe LCIV compression. Although these results are significant, larger studies are needed to confirm these findings. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e506 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter Chin More articles by this author Laurencia Villalba More articles by this author Expand All Advertisement PDF downloadLoading ...

Lumbar overlordosis — towards the better understanding of the May-Thurner syndrome pathogenesis

Introduction: May-Thurner Syndrome (MTS) is a condition in which the left common iliac vein is compressed by the right common iliac artery, which together with intraluminal vein changes can lead to clinically symptomatic venous outflow obstruction. Patients having such pathology may suffer from symptoms of venous hypertension as well as lower leg deep venous thrombosis. In most of the MTS cases, static and continuous compression is observed which can also lead to the intraluminal spur formation. According to the literature, among the factors which can influence the severity of iliac vein compression, lumbar spinal degeneration can also be mentioned. Considering the aortic bifurcation anatomical conditions, also other, non — degenerative changes of the lumbar vertebral column segment can be taken into consideration. Aim: This study aimed to reveal the prevalence of the left common iliac vein compression in young healthy individuals as well as to assess the severity of the left iliac vein compression provoked by lumbar hyperlordosis. Material and methods: The study was performed on a group of 207 volunteers of both sexes, aged 21–27 yrs. using ultrasound examination to measure the diameter of the right common iliac vein as well as the diameter of the left common iliac vein in the area of the possible compression by the right iliac artery. In all the patients the measurements were performed in the supine position as well as in the provoked lumbar hyperlordosis position. In all the individuals the presence of the symptoms and signs of the lower leg chronic venous disease were investigated. Results: The mean anterior-posterior diameter of the right common iliac vein in the standard supine position in the whole study group was 5.71 mm (± 0.6 mm). The mean diameter of the left common iliac vein in a normal horizontal position was 4.87 mm (± 0.6 mm) with a range from 3.8 mm to 6.2 mm. In most of the cases, the difference between the left and iliac common vein diameter (when measured in the place of the right iliac artery crossing) did not exceed 20%. In 15.9% of the study subjects, the right and left iliac vein diameter difference ranges between 20–30% and in 2.41% only, the diameter difference over 30% was noticed (in none of the cases the stenosis exceeding 40% of the vein diameter was found). Looking for the effect of the overlordosis on the proclivity to decrease left iliac vein diameter, in the provoked hyperlordosis position the changes of the iliac vein diameter in the range of 21–30% were observed in 15.9% and over 30% in 2.4% of the study subjects. Hyperlordosis presence was also responsible for the shift towards lower left iliac vein diameter — in 36.2% of the patients, the left iliac vein diameter below 4 mm was noticed including 1.9% of individuals with a diameter not exceeding 3 mm. In the analysis, there was no statistically significant correlation between the presence of the reported CVD symptoms in the left leg and the reported diameter reduction between the right and left iliac veins in the population of the studied young individuals. Conclusions: Left common iliac vein compression may be anatomically conditioned at least in some of the young population individuals. Lumbar hyperlordosis influence on the left common iliac vein diameter suggests that also in healthily individuals, an incorrect spinal position can promote the occurrence of the left iliac vein compression. Further studies are needed to assess the haemodynamic influence of these findings on the lower leg venous outflow.

The association between iliac vein compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis.

This study aimed to investigate the association between the left common iliac vein (CIV) compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis (DVT). This was a single-center retrospective observational study. Between January 2015 and June 2022, first diagnosed left lower extremity DVT patients with enhanced computed tomography of lower extremities were included. Patient demographics, comorbidities, risk factors, DVT characteristics, and CIV compression degree were collected and analyzed. Logistic regressions were performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI) of iliofemoral or mixed DVT vs. compression percentage. The association between compression percentage and iliofemoral or mixed DVT was evaluated on a continuous scale with restricted cubic splines (RCS). The association between compression percentage and thrombus burden was evaluated using the Spearman test. A total of 196 (mean age, 61.8 ± 16.1 years; 86 males) patients were included. The median CIV compression percentage in iliofemoral or mixed DVT patients was significantly greater than in non-iliofemoral or non-mixed DVT, respectively (64.4 vs. 46.6%, p < 0.001; 67.8 vs. 54.8%, p = 0.004). CIV compression >50% was associated with significantly increased morbidity of iliofemoral DVT (adjusted OR, 2.96; 95% CI, 1.58-5.52; p = 0.001) or mixed DVT (adjusted OR, 2.39; 95% CI, 1.19-4.81; p = 0.014). RCS showed that a greater compression percentage was associated with a continuously increased OR of iliofemoral DVT (overall p = 0.003, non-linear p = 0.577) or mixed DVT (overall p = 0.020, non-linear p = 0.771). CIV compression percentage had a positive correlation with thrombus burden (rs = 0.284, p < 0.001). A greater left CIV compression percentage may be associated with increasing likelihood of more proximal location and severe clot extent in first diagnosed left lower extremity DVT.

MAY-THURNER SYNDROME: UNCOMMONLY COMMON

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: May-Thurner syndrome is a venous compression syndrome characterized by common iliac vein compression between the left lumbar spine and the common iliac artery. The most common pattern is left common iliac vein compression by the right common iliac artery. Clinical presentation can vary from asymptomatic to signs and symptoms of venous stasis. This can include lower extremity swelling, edema, pain, and ulceration. More advanced stenosis results in deep vein thrombosis (DVT). The exact incidence and prevalence of MTS are unknown; however, it is felt to be underdiagnosed. MTS can be attributed to 2-5% of all venous thromboembolism (VTE). We present a case of DVT and pulmonary embolism (PE) in a patient who was found to have MTS. CASE PRESENTATION: The patient was an 83-year-old male with diabetes mellitus and hypertension who presented to the emergency department (ED) for evaluation of dyspnea on exertion. In the ED he was noted to be in respiratory distress, but otherwise hemodynamically stable. He was hypoxic, requiring supplemental oxygen via nasal cannula. Serum studies and chest radiographs were unremarkable. Computed tomography angiography of the chest revealed saddle pulmonary embolism extending into bilateral upper lobar arteries. After a thorough history, it was felt the VTE was unprovoked. The patient was admitted to the ICU and underwent emergent catheter-directed pulmonary artery thrombectomy. Anticoagulation was initiated with unfractionated heparin infusion. An echocardiogram revealed normal left ventricular function and a moderately dilated right ventricle. Lower extremity ultrasound revealed extensive clot burden in the left femoral, popliteal, and tibial veins. Lower extremity angiography revealed compression of the left common iliac vein. He subsequently underwent venous thrombectomy and common iliac vein stenting. He tolerated the procedures and hospitalization well and was ultimately discharged in stable condition DISCUSSION: MTS is characterized by compression of the left common iliac vein by the right common iliac artery, with resultant stenosis and venous stasis. It is estimated to cause 2-5% of all VTE although the prevalence may be higher (1). Diagnosis requires a high clinical suspicion, as MTS does not present specific findings in the setting of VTE. Initial presentation could range from lower extremity swelling to pain, venous stasis, or ulcerations – all of which could be attributed to the DVT (2). Making the diagnosis is important, however, as it presents a chance for therapeutic endovascular intervention. CONCLUSIONS: Our case highlights first that MTS may be very underdiagnosed. Secondly, it is a cause of provoked venous thromboembolism. It may therefore present a therapeutic endovascular option and may alter the duration of anticoagulation. For these reasons, the clinician should consider MTS in the differential for all VTE, and especially for recurrent VTE Reference #1: 1. Sigua-Arce P, Mando R, Spencer L, Halalau A. Treatment of May–Thurner's syndrome and associated complications: A multicenter experience. Int J Gen Med. 2021;14:4705–10. Reference #2: 2. Knuttinen MG, Naidu S, Oklu R, Kriegshauser S, Eversman W, Rotellini L, et al. May-Thurner: Diagnosis and endovascular management. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S159–64. DISCLOSURES: No relevant relationships by Wajahat Khan No relevant relationships by Nelson Okoh

Prevalence of left iliac vein compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis: A multicenter cross-sectional study in southern China.

Population-based epidemiological data on left common iliac vein (LCIV) compression is scarce. This study aimed to investigate the prevalence of LCIV compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis (IF-DVT). Nonprobability sampling method was used in this multicenter cross-sectional study. The minimum diameter of LCIV and right common iliac vein minimum were measured. The percentage of LCIV compression (LCIV-CP) was calculated. Compression severity (CS) was classified as mild (CP ≤ 50%), moderate (50% < CP ≤ 70%), and severe (CP > 70%). In all, 896 subjects constituted the asymptomatic population and 93 patients constituted the IF-DVT population. In the asymptomatic population, LCIV-CP ranged from 1.1% to 89.9% (mean 44.0%), and people with mild, moderate, and severe CS accounted for 62.3%, 28.2%, and 9.5%, respectively. In the IF-DVT population, the mean LCIV-CP was 71.1% (range 42.2%-95.2%), and patients with severe CS accounted for 75.3%. Gender and age differences in LCIV-CP and CS distribution were observed in the asymptomatic population. Females, the young- and middle-aged group had higher LCIV-CPs. In the population with moderate-severe CS, the middle-aged group accounted for a larger proportion. Middle-aged females comprised the highest percentage of patients with moderate or severe CS. Sex and age affected the LCIV-CP and CS distribution. No gender and age differences were observed in the IF-DVT population. LCIV compression is common in population. Middle-aged females are the predominant population with moderate-severe compression. Overlapping of LCIV-CP in the asymptomatic and IF-DVT population is significant and other risk factors should be integrated into the consideration when assessing the risk of IF-DVT secondary to LCIV compression.

Acute left iliofemoral vein thrombosis: Comparison between simple and bony May-Thurner syndrome in CT venography.

To explore the etiology of May-Thurner syndrome (MTS) with acute iliofemoral deep vein thrombosis (DVT) regarding imaging findings and clinical features. We retrospectively analyzed 57 patients with acute left iliofemoral DVT from 2015 to 2020. The diameter of left common iliac vein (LCIV) at the maximal compression site and its percent compression regarding the average diameter of the uncompressed iliac vein were recorded in central and distal portions of the LCIV according to the location in the quadrant of lumbar vertebral body. Compression was categorized into simple and bony MTS; Simple MTS as LCIV compressed by the right common iliac artery (RCIA) versus Bony MTS as LCIV by lower lumbar degenerative changes regardless of RCIA compression. Initial computed tomographic venography (CTV) regarding chronic change of LCIV such as fibrotic atrophy or cordlike obliteration, extent of thrombus, and lumbar degenerative changes were evaluated. Therapeutic effect after initial therapy was assessed in follow-up CTVs after 3-6months. All patients showed LCIV compression with 19 simple MTS (mean age, 42.8 ± 14.1years [23-67years]; 12 females; symptom for 4.4 ± 5.5days) and 38 bony MTS (mean age, 73.0 ± 10.2years [49-85years]; 26 females; symptom for 5.5 ± 4.8days). There was significant difference in age (p < .001) and no significant difference in sex or symptom duration between two groups (p = .691 and 0.415, respectively). All simple MTS showed compression only in the central LCIV and half of bony MTS showed compression in both central and distal LCIV (p < .001). Among the lumbar degenerative changes, symmetric anterolateral osteophyte (p < .001) and asymmetric osteophyte (p < .001) were significantly associated with bony MTS, but not scoliosis (p = .799), compared to simple MTS. Although there was no significant difference in chronic change of LCIV, thrombosis extent, and therapeutic effect between two groups (p > .05), chronic change of LCIV showed significant difference between single and dual compression (23.7% vs. 57.9%, p = .024) and residual thrombus after initial therapy was occurred in 21.1% of single compression and 47.4% in dual compression with non-significant trend (p = .082). Bony MTS related to lumbar degenerative changes with acute iliofemoral DVT occurs in older patients, presenting more than one stenosis at LCIV, inducing more chronic change with possibly weaker therapeutic effect than simple MTS.

Abstract No. 394 May-Thurner iliac venous compression and clinical presentation with evaluated with 4D Flow MRI

May-Thurner Syndrome (MTS) is caused by compression of the left common iliac vein (LCIV). While imaging findings and clinical manifestations may be associated, these relationships are complex. We aimed to determine whether hemodynamic significance of LCIV compression and related clinical manifestations could be assessed by measuring the relative blood flow in the proximal LCIV and proximal right common iliac vein (RCIV). 4D Flow MRI quantified LCIV and RCIV blood flow and LCIV/RCIV flow ratio was calculated in patients with LCIV compression compared with control patients with no vascular abnormalities (NVA).

Left lower limb deep venous thrombosis, May-Thurner syndrome and endovascular management.

Objectives:To determine the prevalence of May-Thurner syndrome (MTS) in left lower limb deep venous thrombosis (DVT) cases and to analyze the outcome of endovascular intervention in these patients.Methods:A record-based descriptive study was carried out in Radiology Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia, including patients who underwent lower limb duplex ultrasounds between January 2015-2021. Patients with bilateral DVTs, known pelvic masses, and pelvic surgeries were excluded. All patients positive for DVTs were identified and further imaging was reviewed. Left common iliac vein compression of 50% or more on computed tomography (CT) was considered positive for MTS. Endovascular interventions (venoplasty alone or with stenting) were evaluated and success recorded by observing patency of vein on follow-up imaging or improvement of symptoms on follow-up visits.Results:Of 182 patients with left lower limb duplex studies, 51 patients were positive for DVTs. A total of 37 patients had CTs and 21 patients had MTS (17 females, 3 males). A total of 15 patients underwent endovascular interventions, 2 patients had venoplasties alone (one successful) and 13 patients had venoplasties with stenting (10 successful).Conclusion:Patients with MTS as cause of DVT may benefit from early endovascular intervention.

Common iliac vein stenting for May-Thurner syndrome and subsequent pregnancy

BackgroundFor women with left common iliac vein compression (ie, May-Thurner syndrome) who undergo venous stenting and subsequently become pregnant, concerns have been raised regarding a possible compromise of stent patency due to compression from the gravid uterus and the hypercoagulability induced by pregnancy. Only a small body of literature exists on this subject, and limited management guidelines are available. The present study was designed to evaluate the safety of iliac vein stenting for May-Thurner syndrome (MTS) with subsequent pregnancy. MethodsFemale patients who had undergone common iliac vein stenting at our center who were aged 18 to 45 years and had subsequently become pregnant were identified. A retrospective medical record review of eight eligible patients was conducted, recording the demographics, procedural characteristics, and anticoagulation strategies. The primary outcome evaluated was stent patency. ResultsAll eight patients had undergone left common iliac vein stenting for MTS. A total of eight stents were placed, and all demonstrated duplex ultrasound patency throughout pregnancy and postpartum. Seven patients delivered healthy pregnancies, and one experienced a stillbirth. The clinical CEAP (clinical, etiologic, anatomic, pathophysiologic) class remained unchanged or improved from pregnancy to postpartum for all patients. The average age at stent placement was 31 ± 5 years, and the average interval from stent placement to pregnancy was 28 ± 19 months. One patient developed nonobstructive deep vein thrombosis (DVT) of the left femoral vein during pregnancy and was treated with therapeutic enoxaparin. The nonobstructive DVT did not compromise the iliac vein stent. Two patients received low-dose aspirin and prophylactic doses of enoxaparin, one for a history of DVT and factor V Leiden and one for a recent history of fertility treatment. The five remaining patients received no anticoagulation, three received low-dose aspirin, and two received no antiplatelet therapy. ConclusionsCommon iliac vein stent patency was not compromised by subsequent pregnancy in our eight patients with MTS. Furthermore, the stents remained patent throughout pregnancy in patients receiving a wide range of anticoagulation and antiplatelet treatments, suggesting that no uniform therapeutic threshold exists and treatment should be individualized. For most patients, low-dose aspirin alone or no treatment was adequate. This could have implications for counseling women who require intervention for MTS and are of child-bearing age.

Atypical iliac vein compression in patients with symptomatic May-Thurner syndrome.

We aimed to investigate the incidence, etiology, treatment, and clinical course of atypical iliac vein compressions (AIVCs) among patients with May-Thurner syndrome (MTS). A total of 173 patients who presented with MTS were retrospectively analyzed at a single center. Computed tomographic venography (CTV) was used to diagnose MTS. An AIVC was defined as the compression of the left common iliac vein (LCIV) by structures other than the right common iliac artery (RCIA) or the compression of other venous structures in the pelvic cavity instead of the LCIV. The patients with AIVC were categorized into the LCIV compression group (category A) and non-LCIV compression group (category B). Ten patients with AIVC were identified (5.8%; male/female, 5/5), five in category A and five in category B. The median age of patients was 76 years (range, 51-94 years), and the median follow-up duration was 388 days (range, 12-4694 days). In category A, the LCIVs were compressed by the left common iliac artery (LCIA) (n=2), uterine leiomyoma (n=1), LCIA aneurysm (n=1), and RCIA aneurysm (n=1). In category B, the right common iliac veins were compressed by the RCIA (n=4) and L5 osteophyte (n=1). Endovascular treatment, including balloon angioplasty and stent placement, was performed in six patients, three from each group. Three patients underwent conservative treatment due to their advanced age and comorbidities. Endovascular aneurysm repair was performed in one patient with RCIA aneurysm. Follow-up images were available for six patients, and all of them had patent venous flow. The AIVC had an incidence of 5.8% (10/173) among symptomatic MTS patients and wide spectrum of etiologies. Pathogenesis-tailored endovascular treatments are safe and effective.

May\u2013Thurner syndrome, a diagnosis to consider in young males with no risk factors: a case report and review of the literature

BackgroundMay–Thurner syndrome is an anatomical condition characterized by compression of the left common iliac vein by the right common iliac artery, causing venous outflow obstruction. It is an uncommon cause of deep vein thrombosis and is more prevalent among women. This paper highlights the importance of considering May–Thurner syndrome in young males without risk factors presenting with left lower limb pain, as endovascular treatment may be required.Case presentationA 23 year-old Caucasian male presented with a 1-week history of left lower limb pain, edema, and pallor. He was found to have an unprovoked deep vein thrombosis on Doppler ultrasound involving the left fibular, soleus, gastrocnemius, popliteal, femoral, common femoral, and external iliac veins. A heparin infusion was commenced as the initial treatment for deep vein thrombosis. Further investigation with computer tomography pulmonary angiogram and computer tomography venography of the abdomen and pelvis showed bilateral pulmonary emboli and left common iliac vein compression with left common, internal, and external iliac vein thrombosis. He was diagnosed with May–Thurner syndrome despite having no risk factors. A retrievable Cook Celect Platinum inferior vena cava filter was placed, and thrombus of the left common femoral, external, and common iliac veins was treated successfully with AngioJet thrombectomy, thrombolysis using 200,000 units of urokinase, angioplasty and stenting using two Cook Zilver Vena venous self-expanding stents. Therapeutic enoxaparin was commenced on discharge. His filter was removed after 10 weeks. Hematological follow-up 4 months later showed an overall negative thrombophilia screen, and anticoagulation was switched to apixaban. He has had no recurrent thrombosis.ConclusionsClinicians should have a low threshold to investigate for May-Thurner syndrome in patients with left lower limb venous thrombotic events regardless of risk factors, as endovascular treatment may be required to minimize the long-term sequelae of deep vein thrombosis. Duplex ultrasound can be used initially for diagnosis, and computer tomography venography used subsequently if the common iliac vein is not visualized on ultrasound. Endovascular treatment is preferred over anticoagulation alone, especially in otherwise fit patients presenting early, the aim being to reduce the chances of chronic venous hypertension in the lower limb.

Left common iliac vein compression in patients with may-thurner syndrome: A 10-year retrospective study in an australian cohort

Left common iliac vein compression in patients with may-thurner syndrome: A 10-year retrospective study in an australian cohort

Imaging findings of pelvic venous insufficiency in patients with postural orthostatic tachycardia syndrome.

Some patients with postural orthostatic tachycardia syndrome (POTS) demonstrate improved dysautonomic symptoms following treatment for pelvic venous insufficiency (PVI). This study assessed the prevalence of significant left common iliac vein (LCIV) compression in POTS patients. Radiologists retrospectively reviewed CT images of pelvic veins for 216 women (191 with POTS and 25 age-comparable controls).Quantitative vascular analysis identified percent-diameter compression of the LCIV by the right common iliac artery. Significant LCIV compression was defined as >50%. Significant LCIV compression was found in 69% (131/191) of females with POTS versus 40% (10/25) in controls. The hypothesis that venous compression and presence of POTS are independent was rejected (p = .005). Significant LCIV compression was noted in a majority of female POTS patients, suggesting that incidence of iliac venous obstruction may be higher than the general population. Patients with POTS and symptoms of PVI may benefit from assessment for venous outflow obstruction.

Lower limb deep venous thrombosis due to vertebral osteophyte: a May-Thurner-like syndrome

Lower extremity venous thrombosis is a risky condition that may cause crucial complications including pulmonary embolism and post-thrombotic syndrome. May-Thurner syndrome is a venous compression syndrome resulting in compression of the left common iliac vein by the overriding right iliac artery. In this case, left common iliac vein compression arises from the vertebral osteophyte.

May-Thurner Syndrome and Recurrent DVT: A Case Report

May-Thurner syndrome/Cockets syndrome/ileocaval syndrome is a rarely diagnosed, anatomical and pathologically variable condition, causing venous flow obstruction in iliocaval territory. We report a case of 64 year old male patient who presented with unprovoked proximal deep venous thrombosis (DVT) of left lower limb. Evaluated for hypercoagulable state, which was negative, the patient underwent catheter guided thrombolysis and anticoagulation for 6 months. Two years later, he developed left lower limb swelling, and venous doppler revealed acute DVT; CT venogram was consistent with left common iliac vein compression by right common iliac artery suggestive of May-Thurner syndrome. Catheter-guided thrombolysis was done, and percutaneous transluminal peripheral angioplasty/stent was placed from inferior vena cava to left common iliac vein. This case highlights the importance of high index of suspicion in managing patients with DVT for possible ileocaval syndrome wherein anticoagulation alone is insufficient and needs more aggressive and definitive treatment to relieve the obstruction and to prevent recurrence.

Case of Deep Venous Thrombosis Secondary to May-Thurner Syndrome

May-Thurner syndrome (MTS) remains an underdiagnosed cause of venous thromboembolism (VTE) because most individuals with MTS anatomy are asymptomatic. The most common variant of MTS is due to compression of the left iliac vein between the overlying right common iliac artery and the fifth lumbar vertebrae. Clinical features include chronic venous hypertension that usually presents as lower extremity pain and swelling. Acute VTE almost exclusively affects the left lower extremity. In cases of acute VTE of an unknown etiology, MTS should be considered when other more common pathologies have been ruled out. A 65-year-old African American gentleman with past medical history of hypertension and coronary artery disease presented with left lower extremity pain and swelling of the leg for five days. He had no history of leg trauma, recent surgery, bed rest, travel, malignancy, previous clotting episodes or family history of hypercoagulable disorders. Patient regularly ambulates. He is a lifetime non-smoker and does not take any medication. His left lower extremity was swollen from the calf down to the ankle and foot, tense, erythematous and tender to palpation. Dorsalis pedis and posterior tibial pulses were weakly palpable. Homan’s sign was appreciated while the rest of the physical exam was unremarkable. Duplex ultrasound of the left lower extremity showed thrombi in the left popliteal, posterior tibial and peroneal veins. CT abdomen and pelvis with IV contrast demonstrated significant compression of the left common iliac vein as it crosses posterior to the left internal iliac artery, consistent with MTS. Spiral chest CT was significant for subsegmental emboli in the bilateral lobe pulmonary arteries. Patient was started on anticoagulation, then he was referred to an advanced vascular center to consider the need for angioplasty and stenting and for possible thrombolysis. MTS was first described in 1908 by Virchow, who observed that iliofemoral vein thrombosis was five times more likely to occur in the left leg than in the right leg. May and Thurner discovered an anatomical variant where the right iliac artery compressed the left iliac vein against the fifth lumbar vertebra. Clinicians should have a high index of suspicion for MTS in the presence of unprovoked DVT in the left lower extremity, and/or signs of chronic venous hypertension. Angioplasty and stenting of the affected lesion is the definitive treatment for MTS, while anticoagulation management is similar to patients with provoked VTE. Therefore, it can be argued that in patients with an unexplained cause of VTE, investigation for MTS if clinically suspected can impact management decisions.

Role of trans-abdominal and trans-perineal venous duplex ultrasound in cases of pelvic congestion syndrome

BackgroundFor evaluation the role of trans-abdominal and trans-perineal venous duplex ultrasound in cases of pelvic congestion syndrome, fifty patients with pelvic congestion syndrome were included in the current research. All were evaluated by trans-abdominal and trans-perineal venous duplex.ResultsAn incompetent left gonadal vein was detected in all cases with a mean diameter (± SD) = 7.9 ± 1.1 mm. The right gonadal vein was incompetent in 4 cases (8%) with a mean diameter (± SD) 5.9 ± 0.4 mm.A refluxing proximal internal iliac vein was detected in 3cases (6%). Left renal vein nutcracker was present in 41cases (82%) while the left common iliac vein compression was present in 3 cases (6%).Vulvoperineal varicosities were seen in all cases {right side = (36%, n = 18), left side = (30%, n = 15), and bilateral = (34%, n = 17)}.Thigh extension of the vulvoperineal varicosities was present in (74%, n = 37).Round ligament varicosities were present in (6%, n = 3).ConclusionsTrans-abdominal and trans-perineal venous duplex offer a simple, noninvasive, and quick technique that can help in an accurate evaluation of the ovarian vein reflux, diameters as well as the presence of vulvoperineal, and round ligament varicosities, Moreover, it is useful in the assessment of the left renal and iliac veins compression.

Recurrent Varicocele Associated With Congestion Pelvic Syndrome

Left Renal Vein compression, entitled as Nutcracker Syndrome, usually is described as cause of Pelvic Congestion once the difficult of drainage of the left kidney deviate vein flow to Gonadal vein developing Pelvic varices in women, and Varicocele in men. Recurrence of Varicocele is described to be between 1 to 35%, dependent on the surgical technique used to repair it. Among the cause of recurrent varicocele, include surgical technique failure, low Body Mass Index, venous plexus variation (persistence of branched spermatic veins), and venous compression. In this study, the authors present 2 cases of recurrent varicocele in young men caused by pelvic congestion due to the Left Renal Vein (LRV) and Left Common Iliac Vein (LCIV) compression, treated by endovascular techniques with good results. In the Literature there are few papers relating the association of both syndromes. Authors discuss of the association of recurrent varicocele and pelvic congestion, and also suggest a routine investigation of it in this recurrence.