- Volume 8 - Issue 3 - March 2011
- Posted on: 3/8/11
- 14 Comments
- 92203 reads
Omar Al-Nouri, DO, MS and Ross Milner, MD
May-Thurner syndrome — also called iliocaval compression syndrome, Cockett syndrome or iliac vein compression syndrome — occurs secondary to compression of the left iliac vein by the overriding right iliac artery. Virchow was the first author to be credited with describing iliac vein compression. It was not until 1957 that May and Thurner brought much attention to the anatomic variant thought responsible for Virchow’s observation. They found that the right iliac artery compressed the left iliac vein against the fifth lumbar vertebra in 22–32% of 430 cadavers.1 These terms may be used interchangeably, but they all describe the phenomenon of left-sided vein compression by the right iliac artery causing left iliofemoral deep venous thrombosis (DVT).
Etiology and Incidence
The incidence of May-Thurner syndrome is unknown and ranges from 18–49% among patients with left-sided lower extremity DVT.2 Close to 600,000 hospitalizations occur in the United States each year due to DVT. DVT is more common in the left lower extremity than the right, and May-Thurner syndrome is considered to be a risk factor for patients with left-sided iliofemoral DVT. May and Thurner postulated that the chronic pulsations of the overriding right iliac artery led to the development of a “spur” in the vein wall, and that this spur would result in partial venous obstruction (Figure 1). Chronic trauma to the inner side of the vein wall due to adjacent arterial pulsations leads to the accumulation of elastin and collagen, contributing to spur formation.3 In addition to the chronic arterial pulsations, mechanic compression of the iliac vein by the thick-walled overriding iliac artery leads to extensive local intimal proliferation, impaired venous return and venous thrombosis.4 In addition to the mechanical alterations to the vessel wall, hypercoaguable states, when tested, are found in the majority of patients. Kolbel et al5 found underlying hypercoaguable disorders in 67% of patients screened prior to treatment of chronic iliac vein occlusion. Left iliac vein compression is the most common variant seen in May-Thurner syndrome; however, several other variants have been described in the literature. Compression of the left common iliac vein by the left internal iliac artery,6 compression of the right common iliac vein by the right internal iliac artery,7 compression of the inferior vena cava by the right common iliac artery8 and right-sided May-Thurner syndrome in a patient with a left-sided inferior vena cava9 have all been described.
Patients with May-Thurner syndrome typically present with unilateral (left) lower extremity edema and pain. A propensity for this disorder is seen in young women in their second to fourth decade of life, after prolonged immobilization or pregnancy. Because of the chronic nature of the disease process, patients may also present with stigmata associated with post-thrombotic syndrome such as pigmentation changes, varicose veins, chronic leg pain, phlebitis and recurrent skin ulcers.4 The clinical stages of iliac vein compression were described by Kim et al,10 and include: Stage I, asymptomatic iliac vein compression; Stage II, development of a venous spur; Stage III, development of left iliac vein DVT.