Thurner Syndrome Research Articles

May Thurner Syndrome

A 54-year-old man with an unremarkable past medical history presented with a four-hour history of severe left lower extremity pain and swelling. He arrived earlier in the same day after a 15-hour transpacific flight. On physical exam, his left leg was edematous and demonstrated palpable pulses. His sensation, strength, and range of motion were preserved, but his left lower extremity was markedly tender. Duplex ultrasound evaluation demonstrated a nonocclusive thrombus in the superficial femoral vein extending to the common femoral vein. Given the severity of the patient’s symptoms, he was evaluated by interventional radiology for ultrasound-assisted thrombolysis. Venography revealed occlusion of the left common iliac vein with numerous small collaterals consistent with May Thurner syndrome (Figure 1). Balloon venoplasty yielded improved flow, and the high grade stenosis of the left common iliac vein demonstrated prompt wide open forward flow to the IVC following stenting (Figure 2). The patient tolerated the procedure well and his symptoms resolved subsequently. May Thurner syndrome, also known as iliac vein compression syndrome, is an underdiagnosed venous disease caused by the compression of the left iliac vein by the right iliac artery, which predisposes to venous insufficiency and thrombosis. Treatment with systemic anticoagulation alone is often inadequate, and clot lysis followed by stent placement is usually necessary to correct the underlying anatomic cause. This entity should be particularly considered in the differential diagnosis of young patients with recurrent DVT.

May Thurner Syndrome: An Important Differential Diagnosis for DVT

May Thurner Syndrome (MTS) is an anatomical variant in which the left common iliac vein is compressed against the fifth lumbar vertebra by the right common iliac artery resulting in lower extremity venous outflow obstruction. It is estimated to be present in about 20% of the population and predominantly seen in young females. It can present as acute or chronic DVT with symptoms of unilateral leg pain, edema, and / or varicosities. MTS related deep venous thrombosis (DVT) accounts for 2%-3% of all lower limb DVTs. In addition to standard anticoagulation, endovascular thrombolysis with angioplasty and stent placement is recommended as part of treatment.We present a case of a 43 year old female who presented with an unprovoked left DVT and diagnosis of MTS was made on CT scan.

Endovascular Stent Placement for May–Thurner Syndrome in the Absence of Acute Deep Vein Thrombosis

PurposeTo assess the clinical utility of iliac vein stent placement for patients with chronic limb edema or pelvic congestion presenting with nonocclusive May–Thurner physiology. Materials and MethodsAll patients (N = 45) undergoing stent placement for May–Thurner syndrome (MTS) without an associated acute thrombotic event between 2007 and 2014 were retrospectively reviewed; 11 were excluded for poor follow-up. A total of 34 patients (28 female) were studied (mean age, 44 y; range, 19–80 y). Average follow-up time was 649 days (median, 488 d; range, 8–2,499 d). ResultsThe technical success rate was 100% (34 of 34). No major and two minor (5%) complications occurred, and 68% of patients (23 of 34) had clinical success with relief of presenting symptoms on follow-up visits. Technical parameters including stent size and number, stent type, concurrent angioplasty, access site, and resolution of collateral iliolumbar vessels were not found to be statistically related to clinical success (P > .05). Similarly, no significant relation to clinical success was seen for clinical factors such as the type of symptoms, presence of chronic deep vein thrombosis (DVT), or concurrent coagulopathy (P > .05). Female sex was found to correlate with clinical success (82% vs 18%; P = .04). ConclusionsIliac stent placement in patients presenting with chronic limb or pelvic symptoms from MTS without acute DVT is associated with clinical success in the majority of patients.

Phlegmasia Cerulea Dolens and May–Thurner Syndrome in the first trimester of Pregnancy

Background Venous thromboembolism in pregnancy remains one of the leading causes of morbidity and mortality. Case A young, gravid patient presented with a cyanotic, edematous left lower extremity with no distal pulses palpable. She was emergently taken to the operating room and was found to have extensive iliofemoral thrombosis requiring femoral angioplasty and embolectomy with 43.7-rad intraoperative radiation exposure. Phlegmasia cerulea dolens and May–Thurner syndrome were diagnosed. Conclusion Timely diagnosis and prompt surgical management are necessary due to the limb-threatening nature of this condition. Despite maternal radiation exposure, the nature and extent of fetal effects depends upon radiation dose and gestational age.

May Thurner Syndrome: A case based review

May Thurner Syndrome: A case based review

Recanalization of the Left Common Iliac Vein for May–Thurner Syndrome Associated with Arteriovenous Fistula

Introduction Cases of May–Thurner syndrome associated with pelvic arteriovenous fistula (AVF) are uncommon. All the treatments reported are embolizations. The efficacy of recanalization of the left common iliac vein (CIV) in treatment of such cases is reported. Report The case of a 78 year old man with co-existing May–Thurner syndrome and pelvic AVF confirmed by computed tomography angiography and arteriography is reported. Treatment by recanalization of the left CIV followed by a bare stent was selected instead of embolizing the AVF; a good result was obtained. Discussion Recanalization of the left CIV by an endovascular technique can be an effective treatment for May–Thurner syndrome associated with AVF.

A case report of May–Thurner Syndrome associated with a large intra abdominal cyst

Introduction: May–Thurner Syndrome (MTS) usually presents with signs and symptoms of deep vein thrombosis or chronic venous insufficiency. We report the first case of MTS in a previously healthy adolescent female associated with a large intra-abdominal cyst arising from the right ovary. Case Report: The patient presented with signs and symptoms suggestive of deep vein thrombosis. Imaging confirmed extensive deep vein thromboses extending into the common iliac vein. Further imaging successfully diagnosed MTS and also identified a cyst arising from the right ovary. Catheter-directed thrombolysis followed by removal of the cyst and the right ovary was performed. Following re-thromboses few days later, the patient underwent further management with surgical thrombectomy with left common iliac vein stenting and IVC filter placement. Conclusion: The present case identifies an unusual presentation of a previously undiagnosed MTS in an adolescent female. In this case, anticoagulation alone was found to be ineffective and required the assistance of endovascular intervention.

A Content Analysis of Cognitive and Affective Uses of Patient Support Groups for Rare and Uncommon Vascular Diseases: Comparisons of May Thurner, Thoracic Outlet, and Superior Mesenteric Artery Syndrome

Rare disease patients are the predominant group of patients who are now connecting online to patient support groups, yet research on their uses of support groups has received little attention. This is a content analysis of three vascular diseases of differing degrees of rarity. Wall posts from Facebook patient support groups for May Thurner syndrome, thoracic outlet syndrome, and superior mesenteric artery syndrome were analyzed over a period of two years. Using Uses and Gratifications as the theoretical framework, the study purpose was to assess how variations in health condition and rarity of condition affect online support group user needs. Results indicated common main cognitive and affective uses across conditions, indicating a consistent pattern of needs communicated by all patients. However, there were nuanced differences in subcategories of cognitive and affective uses between the most and least rare disorders, which inform areas for tailored support mechanisms. Additionally, these vascular patients used their respective support groups primarily for cognitive reasons, especially for the rarest conditions, which informs of basic medical informational needs these patients face related to tests, treatment, surgery, and diagnoses.

How should we treat May–Thurner syndrome and other causes of iliac vein obstruction? Examining the evidence

May–Thurner syndrome most commonly refers to left-sided iliofemoral vein obstruction caused by compression of the left common iliac vein between the right common iliac artery and lumbar vertebrae. However, other forms of May–Thurner syndrome have been described, and May–Thurner syndrome is part of a larger spectrum of venous disease, iliac vein obstruction. May–Thurner syndrome and other forms of iliac vein obstruction can present with acute iliofemoral deep vein thrombosis or chronic venous symptoms of pain, swelling, skin changes and ulceration. The treatment of May–Thurner syndrome and other forms of iliac vein obstruction has evolved with the advancements of endovascular surgery.

Case Series of Isolated Primary Persistent Sciatic Vein

Our study aimed to present a short series on the persistent sciatic vein, a rare venous variation, without Klippel-Trenaunay-Weber syndrome and to review the anatomical consideration of deep venous systems. Four cases of lower-type persistent sciatic vein were found. A combination of May-Thurner syndrome and persistent sciatic vein was found in 2 cases. Non-hypoplastic femoral veins, normal and duplicated, were found in 3 cases. This study concluded that in this persistent sciatic vein, the associated non-hypoplastic femoral vein is not uncommon, and care must be taken about this condition during ultrasonographic examination. Unusual causes of chronic venous insufficiency and other venous anomalies should not be overlooked.

Iliac vein stenting as a durable option for residual stenosis after catheter-directed thrombolysis and angioplasty of iliofemoral deep vein thrombosis secondary to May–Thurner syndrome

This study aims to evaluate the primary patency and clinical outcomes after stenting for residual iliac venous stenosis during catheter-directed thrombolysis treatment of acute iliofemoral deep vein thrombosis arising from May-Thurner syndome. A retrospective study was done for the all patients who underwent iliac vein stenting after catheter-directed thrombolysis treatment of acute iliofemoral deep vein thrombosis due to May-Thurner syndrome from January 2005 to April 2011 in Inha University Hospital. Patient information was assembled from the electronic medical records, imaging and interview. The patency of iliac vein stent was evaluated with serial computed tomography. Fifty-one patients were enrolled. The median age was 70 years (range 44-86). There were 37 females (72.5%). The duration of symptoms of acute deep vein thrombosis before catheter-directed thrombolysis treatment was 6 days (median, range 1-33). Self-expanding stent was used for iliac vein stenting. Initial technical success rate was 94.1%. There were two complications (3.9%): an arteriovenous fistula formation in left popliteal area and a right inguinal hematoma. Mean follow-up was 15.6 months (range 6 days-80.8 months). Primary patency rate after iliac vein stenting was 95.8% at 6 months, 87.5% at 12 months and 84.3% at 24 months. Four patients had recurrent thrombotic occlusion (7.8%) during the follow-up. Iliac vein stenting showed good primary patency rate with few complications. Iliac vein stenting is a durable option for residual stenosis after catheter-directed thrombolysis treatment of acute deep vein thrombosis in May-Thurner syndrome.

Successful treatment of a spontaneous rupture of the left external iliac vein in a man

Spontaneous rupture of the external iliac vein associated with a May-Thurner syndrome is infrequent, particularly in men. We report a case of previously healthy 73-year-old man with a left iliac vein thrombosis, who presented a large lower left abdominal hematoma of sudden-unset. Emergent laparotomy revealed a 3-cm longitudinal tear in the left external iliac vein, which was repaired primarily. Patient's recovery was uneventful. Possible etiological factors have been identified as venous hypertension due to iliac vein thrombosis associated with Cockett syndrome, as well as inflammatory venous wall. Some other estrogenic factors could explain female preponderance of the event.

Abstract No. 361 - Treatment of deep venous thrombosis (DVT) in children with mechanical and catheter directed thrombolysis

Purpose The mainstay of treatment of acute DVT is anticoagulation therapy, which only prevents further clot propagation but does not directly lead to clot lysis. Long term complications of DVT include extremity edema, hyperpigmentation, pain and ulceration collectively called post thrombotic syndrome (PTS). The most important prognostic factor in preventing development of PTS was patency and competency of extremity veins. This study examines the use of minimally invasive approach, including pharmacologic thrombolysis and mechanical thrombectomy, to treat deep venous thrombosis in the pediatric population and the subsequent clinical outcome at Cincinnati Children’s Hospital Medical Center over the last 4 years. Materials and Methods A retrospective chart review was performed in concert with clinical evaluation by hematologists during the follow up period. The Villalta score for severity of PTS was calculated on these patients. Results PTS scores were available on twenty-one patients, age ranging from 1 - 21 years (mean 14.7), over the 4 year period. A total of 47 procedures were performed. Angiojet Thrombectomy System (MedRad, Warrendale, PA) was used in 31 procedures in 19 of the patients. The Trellis System was used in 5 procedures in 4 patients. Catheter directed therapy by using infusion catheter was used in 19 patients. Stents were placed in three patients with May Thurner Syndrome. The mean follow up duration was 19.6 months (ranging 4 - 44 months). During this time, 11 patients did not develop any signs or symptoms of post thrombotic syndrome. Nine patients developed minor symptoms in the affected limb but were not classified as having post thrombotic syndrome by Villalta score ( Conclusion The limited results of this study demonstrate the ability to safely perform catheter directed thrombolysis in a pediatric population. Over the study period the rate of developing post thrombotic syndrome was very low (5%).

Delayed diagnosis of May–Thurner syndrome following staging surgery for ovarian cancer

Delayed diagnosis of May–Thurner syndrome following staging surgery for ovarian cancer

Uterine artery pseudoaneurysms secondary to tubal surgery

pia au to riz ad a p or CD R typically starts within the first 12 months [2]. In the present case, the left limb was affected 4 years after surgery. May–Thurner syndrome commonly affects the left lower limb. The right common iliac artery crosses over the left iliac vein and compresses it against the lumbar vertebral body and results in progressive fibrosis [3]. There is no literature describing how ovarian cancer surgery can affect compression or the fibrosis, but it appears to be a possible factor in the present case. Systemic anticoagulation alone is not suitable for treatment of May–Thurner syndrome if additional complications exist. If there are complications such as deep vein thrombosis, it should be treated aggressively with thrombolysis and angioplasty with stent placement. In the present case, 1 year after the diagnosis, no additional complications have occurred. Conflict of interest

An unusual presentation of May–Thurner Syndrome in a pediatric patient with a pelvic kidney

We report a case of an adolescent who presented with a deep vein thrombosis (DVT) and clinical findings consistent with May–Thurner Syndrome. Specific imaging demonstrated direct compression of the left common iliac vein by an overlying pelvic kidney. The patient's history and clinical presentation is detailed. The discussion focuses on the potential implications for care and management of a patient with an ectopic left pelvic kidney.

Incapacitating Pelvic Congestion Syndrome in a Patient With a History of May–Thurner Syndrome and Left Ovarian Vein Embolization

The aim of this article is to report a rare case of unresolved incapacitating pelvic congestion syndrome (PCS) in a patient with a history of May-Thurner syndrome previously treated with stenting and left ovarian vein embolization. Additionally, this article highlights the role of pelvic venography in patients with PCS and reviews the coexistence. A 32-year-old woman was referred to us for the evaluation of recurrent pelvic pain and dyspareunia requiring analgesics. Initially, she developed left lower-extremity deep vein thrombosis a few months after her first pregnancy. On further workup, she was diagnosed with May-Thurner syndrome and underwent left common iliac and left external iliac vein stenting. Furthermore, left ovarian vein coil embolization was performed for symptoms suggesting PCS at the same outside facility. The patient was referred to us for persistent pelvic pain approximately 1 year after she underwent left ovarian vein coil embolization. A diagnosis of incompletely resolved PCS was considered. Iliocaval venogram demonstrated patent left common iliac and external iliac venous stents in situ. Subsequent right ovarian venogram revealed a patent, but grossly dilated, right ovarian vein with retrograde flow and cross-pelvic collaterals confirming grade III PCS. Right ovarian vein coil embolization was performed, with excellent patient outcome. In the setting of a combined diagnosis of PCS and May-Thurner syndrome, persistent incapacitating PCS after initial iliac stenting should be followed with a complete pelvic venous evaluation including ovarian and left renal venography to rule out residual pelvic congestion secondary to any coexisting ovarian vein incompetencies or nutcracker syndrome.

Endovascular Management of May-Thurner Syndrome

May-Thurner syndrome or iliac vein compression syndrome is associated with deep vein thrombosis (DVT) resulting from chronic compression of the left iliac vein against lumbar vertebrae by the overlying right common iliac artery. Historically, May-Thurner syndrome has been treated with anticoagulation therapy. However, this therapy can be problematic when given alone, because it prevents the propagation of the thrombus without eliminating the existing clot. Furthermore, it does not treat the underlying mechanical compression. Consequently, syndrome who was managed by anticoagulation therapy alone, there is a significant chance that the patient will develop recurrent deep vein thrombosis or post thrombotic syndrome or both. Recently, both retrospective and prospective studies have suggested that endovascular management should be front-line treatment; endovascular management actively treats both the mechanical compression with stent placement and the thrombus burden with chemical dissolution. We report our case of 53 years old male patient with May Thurner syndrome who managed by endovascular treatment.

Long-Term Outcomes of Endovascular Intervention for May-Thurner Syndrome

Endovascular interventions for May Thurner Syndrome (MTS) have become first line therapy, often performed in a young patient population despite the lack of robust supportive data. This paper reports on long term outcomes from a large series of patients treated for de-novo or posthrombotic presentation.

Pharmacomechanical Thrombolysis for Phlegmasia Cerulea Dolens

Phlegmasia cerulea dolens (PCD) is limb-threatening. Traditional treatments are very morbid. We examine the efficacy of percutaneous treatment of PCD. Between May 2005 and September 2008, we treated 21 limbs in 20 patients with lower extremity PCD who were candidates for thrombolysis. Diagnosis was by clinical examination and duplex ultrasound. Catheter access to the deep venous system was obtained through a popliteal vein. Therapy used pulse spray thrombolysis with tissue plasminogen activator (tPA). Infusion catheters and adjunctive percutaneous techniques were used as indicated. Postoperatively, patients were treated with systemic anticoagulation, compression hose, and interval follow-up. Limbs were graded according to the CEAP classification. Twenty patients (13 male) were treated with a mean age of 55.8 years. Nine patients had hypercoagulable states, four May Thurner syndrome, three a history of cancer, one postcolon resection, one acute myocardial infarction, and one postfemoral vein puncture. All patients had resolution of PCD without the need for open surgery. The initial tPA dose was 19.5 mg with pulse spray thrombolysis. Infusion catheters were required in 18 patients and used for 16.1 hours (range, 8 to 36 hours) until complete thrombolysis. Venous angioplasty was necessary in 14 patients with nine of these requiring venous stents. One patient required above-knee amputation despite successful treatment of her PCD. Mean follow-up was 10.7 months (range, 1 to 39 months). All patients demonstrated no or minimal residual thrombus and intact valvular function and a mean clinical CEAP score of 2.4. Percutaneous treatment of PCD produced excellent results with minimal morbidity.