May-Thurner Syndrome

Tuesday, 03/08/11 | 112274 reads
Author(s): 

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.

Presentation

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.

Diagnosis

The diagnosis of May-Thurner syndrome is based on the clinical presentation of left lower extremity swelling and pain in association with radiologic evidence of compression. This being said, diagnosis of May-Thurner syndrome may not always be straightforward. Doppler ultrasound will detect if a DVT is present in the iliac vessels, but is unable to visualize iliac vein compression and spurs. Other diagnostic modalities include helical abdominal computed tomography (CT), CT venography, magnetic resonance venography (MRV), intravenous ultrasound (IVUS) and conventional venography. Kibbe et al11 used abdominal helical CT scanning to determine the incidence of left common iliac vein compression in an asymptomatic population (Figure 2). They found that two-thirds of all patients studied had at least 25% compression of the left iliac vein. The authors concluded that compression of the left iliac vein may be a normal anatomic finding, and that abdominal CT scanning is accurate in determining if left iliac vein compression is present. There are, however, limitations to the use of abdominal CT scanning in determining if iliac vein compression is present. The CT scans were obtained during the arterial phase of the intravenous bolus, which limits the type of vessel reconstruction and analysis that can be performed. CT venography may be used as an effective adjunctive modality when there is a known DVT. Chung et al12 found that CT venography was just as specific and highly sensitive in the diagnosis of DVT compared with ultrasound and accurately delineated venous anatomy and the extent of thrombus present. A limitation of CT venography involves the inability to control for the volume status of the patient, which could lead to overemphasis of the degree of compression of the left iliac vein in a dehydrated patient. The traditional “gold standard” for diagnosis of May-Thurner syndrome is conventional venography, which can be diagnostic and therapeutic when endovascular therapy is used (Figure 3.). Non-invasive imaging methods are being used increasingly to diagnose DVT and iliac compression. The aforementioned imaging modalities may help in planning catheter-directed thrombosis without the initial need for conventional venography. These non-invasive imaging modalities are simple, efficient and cost-effective in diagnosing DVT associated with iliac compression.3

Treatment Methods

May-Thurner syndrome patients are commonly asymptomatic, and it is therefore unrecognized until symptoms develop. Treatment of symptomatic May-Thurner syndrome has evolved over the years from traditional open repair to less invasive endovascular repair. Treatment is aimed at clearing the thrombus present to prevent post-thrombotic syndrome and to correct the underlying compression of the left iliac vein. Untreated, a significant majority of adults with May-Thurner syndrome and thrombosis develop debilitating post-thrombotic syndrome.13 Historically, several surgical procedures have been used to ameliorate symptoms and correct the underlying compression such as venovenous bypass with autologous vein, creation of a tissue sling to elevate the overriding right iliac artery, retropositioning of the iliac artery and excision of the intraluminal spur with patch venoplasty. Traditional open repair has yielded variable results, and with the advent of endovascular technology and technique, mainstay therapy now includes a combination of surgical and endovascular approaches.

The first known report of treatment of May-Thurner syndrome solely by endovascular means was by Berger14 et al in 1995, who successfully placed a venous stent to relieve iliac compression. Several subsequent studies have demonstrated efficacy in the treatment of iliac vein compression with thrombectomy and endovascular stenting.15,16 The initial treatment of patients with documented iliofemoral thrombosis in the setting of iliac vein compression is to decrease the clot burden by use of thrombectomy. Traditionally, surgical thrombectomy alone was used. However, if a stent was not placed subsequently, reocclusion occurred in approximately 70% of patients treated.17 Catheter-directed thrombolysis with urokinase or t-PA is very effective in reducing clot burden by dissolving the thrombus present (Figure 4). Localized thrombolytic therapy is commonly performed to decrease the risk of major bleeding that can be seen with the use of systemic thrombolytic therapy. Alternatively, mechanical thrombolysis has been used to reduce lytic infusion time and complications. Following thrombectomy, angioplasty with stent placement is used to correct the venous obstruction. Stent implantation versus angioplasty alone is more effective in relieving venous obstruction.18 Recanalization of the involved segment involves passing a wire through the occlusion and in general predilating the vessel. Self-expandable stents are used in the venous system as they can cover long distances, are easy to re-sheath and have adequate durability. Balloon-expandable stents may be used if needed (insufficient response to predilatation/self-expandable stent). Extending the stent into the inferior vena cava (IVC) may be done without increasing the risk of contralateral iliac vein occlusion.19 However, some studies have found that extending the iliac stent below the inguinal ligament in the common femoral vein to ensure venous inflow could increase the risk of in-stent restenosis.20,21 These results, though, have been controversial and there is to date no consensus on the risk of venous stenting below the inguinal ligament. Long-term 5-year patency rates for patients undergoing stent implantation range from 74–80%.5,21 Patency can be affected by the amount of occlusion in the iliac vein. Patients who have chronic complete occlusion (as in patients with May-Thurner) have lower patency rates when compared to those with just stenotic obstructions.20 This has led to an increase in combined surgical and endovascular approaches for patients with complete venous occlusions in the late 1990s and early 2000. Surgical intervention typically involved common femoral venectomy, complete thrombus removal with stent placement. The results shown by Kolbel et al5 and Wahlgren et al22 have shown that now similar results can be accomplished with endovascular stenting alone. Several complications occur with endovascular stenting including stent migration, stent fracture, retroperitoneal hemorrhage and early in-stent thrombosis. Patients are routinely anticoagulated following thrombectomy and venous stent placement for up to 6 months to minimize in-stent restenosis. There are several factors associated with in-stent restenosis, despite the use of anticoagulation, which include recent trauma, thrombotic disease, thrombophilia and stenting below the inguinal ligament.23

Conclusion

May-Thurner syndrome continues to challenge medical practitioners to this day. It can have debilitating sequelae resulting from post-thrombotic syndrome. More and more, helical CT scanning is becoming the standard for diagnosis of iliofemoral vein thrombosis. Management of May-Thurner syndrome has evolved over the past few decades favoring endovascular management as the primary treatment. With early recognition and aggressive management, May-Thurner syndrome can be a well-managed disease.

References

1. May R, Thurner J. The cause of the predominately sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957;8:419–427.
2. Kasirajan K, Gray B, Ouriel K. Percutaneous angiojet thrombectomy in the management of extensive deep vein thrombosis. J Vasc Interv Radiol 2001;12:179–185.
3. Oguzkurt L, Ozkan U, Tercan F, Koc Z. Ultrasonographic diagnosis of iliac vein compression (May-Thurner) syndrome. Diag Interv Radiol 2007;13:152–155.
4. Baron HC, Sharms J, Wayne M. Iliac vein compression syndrome: A new method of treatment. Am Surg 2000;66:653–655.
5. Kolbel T et al. Chronic iliac vein occlusion: Midterm results of endovascular recanalization. J Endovasc Ther 2009;16:483–491.
6. Dheer S, Joseph AE, Drooz A. Retroperitoneal hematoma caused by a ruptured pelvic varix in a patient with iliac vein compression syndrome. J Vasc Interv Radiol 2003;14:387–390.
7. Molloy S, Jacob S, Buckenham T, et al. Arterial compression of the right common iliac vein: An unusual anatomic variant. Cardiovasc Surg 2002;10:291–292.
8. Fretz V, Binkert A. Compression of the Inferior vena cava by the right iliac artery: A rare variant of May-Thurner syndrome. Cardiovasc Intervent Radiol 2010;33:1060–1063.
9. Burke RM, Rayan SS, Kasirajan K, et al. Unusual case of right-sided May-Thurner syndrome and review of its management. Vascular 2006;14:47–50.
10. Kim D, Orron DE, Porter DH. Venographic anatomy, technique and interpretation. In: Kim D, Orron DE (eds.) Peripheral Vascular Imaging and Intervention. St Louis (Missouri); Mosby-Year Book; 1992, pp 269–349.
11. Kibbe MR, Ujiki M, Goodwin A, et al. Iliac vein compression in an asymptomaticpatient population. J Vasc Surg 2004;937–943.
12. Chung JW, Yoon CJ, Jung SI, et al. Acute iliofemoral deep vein thrombosis: Evaluation of underlying anatomic abdnormalities by spiral CT venography. J Vasc Interv Radiol 2004;15:249–256.
13. Raffini L, Raybagkar D, Cahill AM, et al. May-Thurner syndrome (iliac vein compression) and thrombosis in adolescents. Pediatr Blood Cancer 2006;47:834–838.
14. Berger A, Jaffe JW, York TN. Iliac compression syndrome treated with stent placement. J Vasc Surg 1995;21:510–514.
15. O’Sullivan GJ, Semba CP, Bittner CA, et al. Endovascular management of iliac veincompression (May-Thurner) syndrome. J Vasc Intervent Radiol 2000;11:823–836.
16. Schwarzbach MH, Schumacher H, Böckler D, et al. Surgical thrombectomy followed by intraoperative endovascular reconstruction for symptomatic ilio-femoral venous thrombosis. Eur J Vasc Endovasc Surg 2005;29:58–66.
17. Mickley V, Schwagierek R, Rilinger N, et al. Left iliac venous thrombosis caused by venous spur: Treatment with thrombectomy and stent implantation. J Vasc Surg 1998;28:492–497.
18. Whittemore AD, Donaldson MC, Polak JF, Mannick JA. Limitations of balloon angioplasty for vein graft stenosis. J Vasc Surg 1991;14:340–345.
19. Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous in chronic venous disease: Long-term stent-related outcome, clinical and hemodynamic result. J Vasc Surg 2007;46:979–990.
20. Neglen P, Tackett TP, Raju S. Venous stenting across the inguinal ligament. J Vasc Surg 2008;48:1255–1261.
21. Hood DB, Alexander JQ. Endovascular management of iliofemoral venous occlusive disease. Surg Clin North Am 2004;84:1381–1396.
22. Wahlgren CM, Wahlberg E, Olofsson P. Endovascular treatment in postthrombotic syndrome. Vasc and Endovasc Surg 2010;44:356–360.
23. Knipp et al. Factors associated with outcome after interventional treatment of symptomatic iliac vein compression syndrome. J Vasc Surg 2007;46:743–748.

___________________________________________________________________

Omar Al-Nouri, DO, MS* and Ross Milner, MD§

From the *Department of Surgery and the §Department of Vascular and Endovascular Surgery, Loyola University Medical Center, Maywood, Illinois.

The authors report no conflicts of interest regarding the content herein.

Address for correspondence: Al-Nouri, DO, MS, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153.

Clinical Review

Comments

I am a desperate person after living with these ulcers on my left leg and recently found that I have the May-Thurner syndrome. Through the websites I have learned more about treatments of the ilac artery which has been blocked for some time. I had DVT 1996 after extended stay in the hospital and another in 2002. After stacis ulcers occurred intermittently in the past five years, I have found a vascular specialist who should be able to help me correct some of the blood flow.

I am most interested in the research and treatment of May-Thurner. Your information in this article is most helpful to me and gives me some hope to a better and healthier life.

Carole Smith
Bear Creek, NC
5/16/2011

I am a 18 year old female and have been living with May-Thurner syndrome since i was 6 years old. I am currently hospitalized and am dealing with trying to get the swelling in my left leg taken care of. I am really interested in know your story about how you have been dealing with it and all your treatments. Hope to hear some stories

8/2/2011

Hi,
I am 37 years old and just this year spent a month in the hospital for treatment of a 9in clot in my left leg caused by May-Thurner Syndrome. I never knew I had this condition until after 3 days of back pain it had become so excruciating that I could not walk and my entire leg from groin to ankle was swollen, hard and blue. I was admitted to ICU and had 3 stents and an IVC filter placed because I developed a Pulmonary Embolism. One of stents was placed in the bottom left iliac vein where it was being compressed by the right iliac artery. This was done to prevent compression so the blood could flow through more easily. I am also on 9-10mg of Coumadin to keep my INR between 2-3 and I will be on this for life. I have not had any ulcers or sores. Since my discharge from the hospital they have found another DVT in my armpit and was just sent today to a Coagulation Specialist because the Hematologist did every blood test and they were all fine. There was a blood work up of about 17 vials testing for everything but unfortunately I do not know the names of them. I know one is the X5 factor if you are from European decent. If you have any questions you can call or text me at (57zero) 79three-808three. I didn't include my email because my entire name is my email address. I would also very much appreciate hearing how you found out at 6 years old that you had this condition. My daughter is 8 and although it is not hereditary, it is genetic and I have a concern for her as well. Best of luck to you.
Kim

My 16 year old daughter whom has had varicose veins in her left leg since 12, recently was diagnosed with May-Thurner. I did some research and discovered this is rare condition in young adults but there are solutions. A balloon procedure was performed and her swelling went down and her once painful legs seem to of found some relief. Hopefully this procedure will continue to be beneficial. Thank you to good medicine.

Hello, Im a 24 years old female . I was diagnosed with May Thurner a year ago..after having an ovarain cyst removed I got a DVT my left leg was purple..and numb. I was admitted to Sokie NorthShore Hospital upon arrival to the ER. I was then transferred the next morning to Evanston Hospital. I received ctheter-directed thrombolytic therapy, angioplasting and stenting. Also
Anticoagulation therapy 10 months after treatment...( lovenox 60 mg twice daily). I got pregnant a month after i was released from the hospital...so I had to stay on Lovenox my entire pregnancy. I had my son is about 7 months old.am not on any blood thinners..my left leg/pelvic area have some pain from time to time..also i cant stand for long periods of times because my leg gets tingly...and feels heavy. Please contact me if you have anymore questions.

My sister has one of the worst cases in the US right now and when they have their annual conferences they are showing pics of her abdomen and the on-going damage this has done. After reading your post Nicole, I have to say, it seems really odd to me that you're not on any anti-coag treatments. This disease constantly produces blood clots when untreated, my sister wasn't diagnosed properly after having her first child 15 years ago, her left leg was twice the size as her right and has really never shrunk back down to the proper size. I'd get a 2nd opinion to be safe, also do you have your blood checked regularly? Trying to be a friend and honestly not trying to pry. Thank you for your time.

Have you had a follow-up CT venography to see if the stent is patent or a renarrowing has developed? Also, ask about SFJ incompetence. You should see a physician with phlebology experience and even better if he/she is board certified in phlebology. You can find one in your area on the web side of the ACPh.

I was diagnosed with May Thurner in October 2012. After suffering with spts for at least five years. I had complications after two vein ligations and the physician did not go any further with test. I did find a Dr. That diagnosed it had two stents put in three weeks ago. I really don't feel totally better and also have venous insufficient in left popliteal vein. I have also found that I am having left hip pain and lumbar pain and pressure. Has anyone experienced these secondary problems?

Have a stent in my left illiec region for a history of DVT(blood clot). My left leg still swells,and has bad circulation. I also have microscopic moderate amounts of blood in my urine. I am wondering if May Thurner Syndrome has anything to do with this unexplained blood in my lab work. Dr told me it looks like I have May Thurner Syndrome. I am looking for a specialist who knows about May Thurner Syndrome.It could be in any state. I just need someone who knows what the MTS is and will treat me. I used to exercise 5 times a week before the DVT. Now I can't because of pain,swelling,and feeling like my blood isn't circulating thru my legs. Then I get light headed. It has been misery for 6 years,now gaining 50 pounds without being to vigerously exercise. I have had complete testing to rule out other things. However,I am anemic now. Is there a doctor out there who can help with MTS and the after effects of DVT,and procedures to irradicate the blood clot with a radioactive procedure that tried to zap out the blood clot,by a vascular surgeon and a radiologist in my procedure 6 years ago? It didnt fully work. Then they put a stent in me and treated me with blood thinners for 6 months. I think the procedure they tried was a thrombolectomy. Please help. Thanks.

Hi everyone!
I was 21 with my first DVT and years later I was diagnosed with Factor V Leiden, May Thurner Syndrome, Post-trombotic syndrome and Lipoedema. I have had bypass-surgeries that didn't worked...It's clotted and the doctor is saying stenting isn't a possibility for me. It is about an area from belly button to below the knee. I'm from the Netherlands and I was wondering if there are more treatments possible in America than in the Netherlands? Here they don't know what to do anymore because hey have never seen this problem in this severe degree.
I am now 34 years old.
Kind regards Tanja

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May-Thurner Syndrome

Tuesday, 03/08/11 | 112274 reads
Author(s): 

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.

Presentation

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.

Diagnosis

The diagnosis of May-Thurner syndrome is based on the clinical presentation of left lower extremity swelling and pain in association with radiologic evidence of compression. This being said, diagnosis of May-Thurner syndrome may not always be straightforward. Doppler ultrasound will detect if a DVT is present in the iliac vessels, but is unable to visualize iliac vein compression and spurs. Other diagnostic modalities include helical abdominal computed tomography (CT), CT venography, magnetic resonance venography (MRV), intravenous ultrasound (IVUS) and conventional venography. Kibbe et al11 used abdominal helical CT scanning to determine the incidence of left common iliac vein compression in an asymptomatic population (Figure 2). They found that two-thirds of all patients studied had at least 25% compression of the left iliac vein. The authors concluded that compression of the left iliac vein may be a normal anatomic finding, and that abdominal CT scanning is accurate in determining if left iliac vein compression is present. There are, however, limitations to the use of abdominal CT scanning in determining if iliac vein compression is present. The CT scans were obtained during the arterial phase of the intravenous bolus, which limits the type of vessel reconstruction and analysis that can be performed. CT venography may be used as an effective adjunctive modality when there is a known DVT. Chung et al12 found that CT venography was just as specific and highly sensitive in the diagnosis of DVT compared with ultrasound and accurately delineated venous anatomy and the extent of thrombus present. A limitation of CT venography involves the inability to control for the volume status of the patient, which could lead to overemphasis of the degree of compression of the left iliac vein in a dehydrated patient. The traditional “gold standard” for diagnosis of May-Thurner syndrome is conventional venography, which can be diagnostic and therapeutic when endovascular therapy is used (Figure 3.). Non-invasive imaging methods are being used increasingly to diagnose DVT and iliac compression. The aforementioned imaging modalities may help in planning catheter-directed thrombosis without the initial need for conventional venography. These non-invasive imaging modalities are simple, efficient and cost-effective in diagnosing DVT associated with iliac compression.3

Treatment Methods

May-Thurner syndrome patients are commonly asymptomatic, and it is therefore unrecognized until symptoms develop. Treatment of symptomatic May-Thurner syndrome has evolved over the years from traditional open repair to less invasive endovascular repair. Treatment is aimed at clearing the thrombus present to prevent post-thrombotic syndrome and to correct the underlying compression of the left iliac vein. Untreated, a significant majority of adults with May-Thurner syndrome and thrombosis develop debilitating post-thrombotic syndrome.13 Historically, several surgical procedures have been used to ameliorate symptoms and correct the underlying compression such as venovenous bypass with autologous vein, creation of a tissue sling to elevate the overriding right iliac artery, retropositioning of the iliac artery and excision of the intraluminal spur with patch venoplasty. Traditional open repair has yielded variable results, and with the advent of endovascular technology and technique, mainstay therapy now includes a combination of surgical and endovascular approaches.

The first known report of treatment of May-Thurner syndrome solely by endovascular means was by Berger14 et al in 1995, who successfully placed a venous stent to relieve iliac compression. Several subsequent studies have demonstrated efficacy in the treatment of iliac vein compression with thrombectomy and endovascular stenting.15,16 The initial treatment of patients with documented iliofemoral thrombosis in the setting of iliac vein compression is to decrease the clot burden by use of thrombectomy. Traditionally, surgical thrombectomy alone was used. However, if a stent was not placed subsequently, reocclusion occurred in approximately 70% of patients treated.17 Catheter-directed thrombolysis with urokinase or t-PA is very effective in reducing clot burden by dissolving the thrombus present (Figure 4). Localized thrombolytic therapy is commonly performed to decrease the risk of major bleeding that can be seen with the use of systemic thrombolytic therapy. Alternatively, mechanical thrombolysis has been used to reduce lytic infusion time and complications. Following thrombectomy, angioplasty with stent placement is used to correct the venous obstruction. Stent implantation versus angioplasty alone is more effective in relieving venous obstruction.18 Recanalization of the involved segment involves passing a wire through the occlusion and in general predilating the vessel. Self-expandable stents are used in the venous system as they can cover long distances, are easy to re-sheath and have adequate durability. Balloon-expandable stents may be used if needed (insufficient response to predilatation/self-expandable stent). Extending the stent into the inferior vena cava (IVC) may be done without increasing the risk of contralateral iliac vein occlusion.19 However, some studies have found that extending the iliac stent below the inguinal ligament in the common femoral vein to ensure venous inflow could increase the risk of in-stent restenosis.20,21 These results, though, have been controversial and there is to date no consensus on the risk of venous stenting below the inguinal ligament. Long-term 5-year patency rates for patients undergoing stent implantation range from 74–80%.5,21 Patency can be affected by the amount of occlusion in the iliac vein. Patients who have chronic complete occlusion (as in patients with May-Thurner) have lower patency rates when compared to those with just stenotic obstructions.20 This has led to an increase in combined surgical and endovascular approaches for patients with complete venous occlusions in the late 1990s and early 2000. Surgical intervention typically involved common femoral venectomy, complete thrombus removal with stent placement. The results shown by Kolbel et al5 and Wahlgren et al22 have shown that now similar results can be accomplished with endovascular stenting alone. Several complications occur with endovascular stenting including stent migration, stent fracture, retroperitoneal hemorrhage and early in-stent thrombosis. Patients are routinely anticoagulated following thrombectomy and venous stent placement for up to 6 months to minimize in-stent restenosis. There are several factors associated with in-stent restenosis, despite the use of anticoagulation, which include recent trauma, thrombotic disease, thrombophilia and stenting below the inguinal ligament.23

Conclusion

May-Thurner syndrome continues to challenge medical practitioners to this day. It can have debilitating sequelae resulting from post-thrombotic syndrome. More and more, helical CT scanning is becoming the standard for diagnosis of iliofemoral vein thrombosis. Management of May-Thurner syndrome has evolved over the past few decades favoring endovascular management as the primary treatment. With early recognition and aggressive management, May-Thurner syndrome can be a well-managed disease.

References

1. May R, Thurner J. The cause of the predominately sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957;8:419–427.
2. Kasirajan K, Gray B, Ouriel K. Percutaneous angiojet thrombectomy in the management of extensive deep vein thrombosis. J Vasc Interv Radiol 2001;12:179–185.
3. Oguzkurt L, Ozkan U, Tercan F, Koc Z. Ultrasonographic diagnosis of iliac vein compression (May-Thurner) syndrome. Diag Interv Radiol 2007;13:152–155.
4. Baron HC, Sharms J, Wayne M. Iliac vein compression syndrome: A new method of treatment. Am Surg 2000;66:653–655.
5. Kolbel T et al. Chronic iliac vein occlusion: Midterm results of endovascular recanalization. J Endovasc Ther 2009;16:483–491.
6. Dheer S, Joseph AE, Drooz A. Retroperitoneal hematoma caused by a ruptured pelvic varix in a patient with iliac vein compression syndrome. J Vasc Interv Radiol 2003;14:387–390.
7. Molloy S, Jacob S, Buckenham T, et al. Arterial compression of the right common iliac vein: An unusual anatomic variant. Cardiovasc Surg 2002;10:291–292.
8. Fretz V, Binkert A. Compression of the Inferior vena cava by the right iliac artery: A rare variant of May-Thurner syndrome. Cardiovasc Intervent Radiol 2010;33:1060–1063.
9. Burke RM, Rayan SS, Kasirajan K, et al. Unusual case of right-sided May-Thurner syndrome and review of its management. Vascular 2006;14:47–50.
10. Kim D, Orron DE, Porter DH. Venographic anatomy, technique and interpretation. In: Kim D, Orron DE (eds.) Peripheral Vascular Imaging and Intervention. St Louis (Missouri); Mosby-Year Book; 1992, pp 269–349.
11. Kibbe MR, Ujiki M, Goodwin A, et al. Iliac vein compression in an asymptomaticpatient population. J Vasc Surg 2004;937–943.
12. Chung JW, Yoon CJ, Jung SI, et al. Acute iliofemoral deep vein thrombosis: Evaluation of underlying anatomic abdnormalities by spiral CT venography. J Vasc Interv Radiol 2004;15:249–256.
13. Raffini L, Raybagkar D, Cahill AM, et al. May-Thurner syndrome (iliac vein compression) and thrombosis in adolescents. Pediatr Blood Cancer 2006;47:834–838.
14. Berger A, Jaffe JW, York TN. Iliac compression syndrome treated with stent placement. J Vasc Surg 1995;21:510–514.
15. O’Sullivan GJ, Semba CP, Bittner CA, et al. Endovascular management of iliac veincompression (May-Thurner) syndrome. J Vasc Intervent Radiol 2000;11:823–836.
16. Schwarzbach MH, Schumacher H, Böckler D, et al. Surgical thrombectomy followed by intraoperative endovascular reconstruction for symptomatic ilio-femoral venous thrombosis. Eur J Vasc Endovasc Surg 2005;29:58–66.
17. Mickley V, Schwagierek R, Rilinger N, et al. Left iliac venous thrombosis caused by venous spur: Treatment with thrombectomy and stent implantation. J Vasc Surg 1998;28:492–497.
18. Whittemore AD, Donaldson MC, Polak JF, Mannick JA. Limitations of balloon angioplasty for vein graft stenosis. J Vasc Surg 1991;14:340–345.
19. Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous in chronic venous disease: Long-term stent-related outcome, clinical and hemodynamic result. J Vasc Surg 2007;46:979–990.
20. Neglen P, Tackett TP, Raju S. Venous stenting across the inguinal ligament. J Vasc Surg 2008;48:1255–1261.
21. Hood DB, Alexander JQ. Endovascular management of iliofemoral venous occlusive disease. Surg Clin North Am 2004;84:1381–1396.
22. Wahlgren CM, Wahlberg E, Olofsson P. Endovascular treatment in postthrombotic syndrome. Vasc and Endovasc Surg 2010;44:356–360.
23. Knipp et al. Factors associated with outcome after interventional treatment of symptomatic iliac vein compression syndrome. J Vasc Surg 2007;46:743–748.

___________________________________________________________________

Omar Al-Nouri, DO, MS* and Ross Milner, MD§

From the *Department of Surgery and the §Department of Vascular and Endovascular Surgery, Loyola University Medical Center, Maywood, Illinois.

The authors report no conflicts of interest regarding the content herein.

Address for correspondence: Al-Nouri, DO, MS, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153.

Clinical Review

Comments

I am a desperate person after living with these ulcers on my left leg and recently found that I have the May-Thurner syndrome. Through the websites I have learned more about treatments of the ilac artery which has been blocked for some time. I had DVT 1996 after extended stay in the hospital and another in 2002. After stacis ulcers occurred intermittently in the past five years, I have found a vascular specialist who should be able to help me correct some of the blood flow.

I am most interested in the research and treatment of May-Thurner. Your information in this article is most helpful to me and gives me some hope to a better and healthier life.

Carole Smith
Bear Creek, NC
5/16/2011

I am a 18 year old female and have been living with May-Thurner syndrome since i was 6 years old. I am currently hospitalized and am dealing with trying to get the swelling in my left leg taken care of. I am really interested in know your story about how you have been dealing with it and all your treatments. Hope to hear some stories

8/2/2011

Hi,
I am 37 years old and just this year spent a month in the hospital for treatment of a 9in clot in my left leg caused by May-Thurner Syndrome. I never knew I had this condition until after 3 days of back pain it had become so excruciating that I could not walk and my entire leg from groin to ankle was swollen, hard and blue. I was admitted to ICU and had 3 stents and an IVC filter placed because I developed a Pulmonary Embolism. One of stents was placed in the bottom left iliac vein where it was being compressed by the right iliac artery. This was done to prevent compression so the blood could flow through more easily. I am also on 9-10mg of Coumadin to keep my INR between 2-3 and I will be on this for life. I have not had any ulcers or sores. Since my discharge from the hospital they have found another DVT in my armpit and was just sent today to a Coagulation Specialist because the Hematologist did every blood test and they were all fine. There was a blood work up of about 17 vials testing for everything but unfortunately I do not know the names of them. I know one is the X5 factor if you are from European decent. If you have any questions you can call or text me at (57zero) 79three-808three. I didn't include my email because my entire name is my email address. I would also very much appreciate hearing how you found out at 6 years old that you had this condition. My daughter is 8 and although it is not hereditary, it is genetic and I have a concern for her as well. Best of luck to you.
Kim

My 16 year old daughter whom has had varicose veins in her left leg since 12, recently was diagnosed with May-Thurner. I did some research and discovered this is rare condition in young adults but there are solutions. A balloon procedure was performed and her swelling went down and her once painful legs seem to of found some relief. Hopefully this procedure will continue to be beneficial. Thank you to good medicine.

Hello, Im a 24 years old female . I was diagnosed with May Thurner a year ago..after having an ovarain cyst removed I got a DVT my left leg was purple..and numb. I was admitted to Sokie NorthShore Hospital upon arrival to the ER. I was then transferred the next morning to Evanston Hospital. I received ctheter-directed thrombolytic therapy, angioplasting and stenting. Also
Anticoagulation therapy 10 months after treatment...( lovenox 60 mg twice daily). I got pregnant a month after i was released from the hospital...so I had to stay on Lovenox my entire pregnancy. I had my son is about 7 months old.am not on any blood thinners..my left leg/pelvic area have some pain from time to time..also i cant stand for long periods of times because my leg gets tingly...and feels heavy. Please contact me if you have anymore questions.

My sister has one of the worst cases in the US right now and when they have their annual conferences they are showing pics of her abdomen and the on-going damage this has done. After reading your post Nicole, I have to say, it seems really odd to me that you're not on any anti-coag treatments. This disease constantly produces blood clots when untreated, my sister wasn't diagnosed properly after having her first child 15 years ago, her left leg was twice the size as her right and has really never shrunk back down to the proper size. I'd get a 2nd opinion to be safe, also do you have your blood checked regularly? Trying to be a friend and honestly not trying to pry. Thank you for your time.

Have you had a follow-up CT venography to see if the stent is patent or a renarrowing has developed? Also, ask about SFJ incompetence. You should see a physician with phlebology experience and even better if he/she is board certified in phlebology. You can find one in your area on the web side of the ACPh.

I was diagnosed with May Thurner in October 2012. After suffering with spts for at least five years. I had complications after two vein ligations and the physician did not go any further with test. I did find a Dr. That diagnosed it had two stents put in three weeks ago. I really don't feel totally better and also have venous insufficient in left popliteal vein. I have also found that I am having left hip pain and lumbar pain and pressure. Has anyone experienced these secondary problems?

Have a stent in my left illiec region for a history of DVT(blood clot). My left leg still swells,and has bad circulation. I also have microscopic moderate amounts of blood in my urine. I am wondering if May Thurner Syndrome has anything to do with this unexplained blood in my lab work. Dr told me it looks like I have May Thurner Syndrome. I am looking for a specialist who knows about May Thurner Syndrome.It could be in any state. I just need someone who knows what the MTS is and will treat me. I used to exercise 5 times a week before the DVT. Now I can't because of pain,swelling,and feeling like my blood isn't circulating thru my legs. Then I get light headed. It has been misery for 6 years,now gaining 50 pounds without being to vigerously exercise. I have had complete testing to rule out other things. However,I am anemic now. Is there a doctor out there who can help with MTS and the after effects of DVT,and procedures to irradicate the blood clot with a radioactive procedure that tried to zap out the blood clot,by a vascular surgeon and a radiologist in my procedure 6 years ago? It didnt fully work. Then they put a stent in me and treated me with blood thinners for 6 months. I think the procedure they tried was a thrombolectomy. Please help. Thanks.

Hi everyone!
I was 21 with my first DVT and years later I was diagnosed with Factor V Leiden, May Thurner Syndrome, Post-trombotic syndrome and Lipoedema. I have had bypass-surgeries that didn't worked...It's clotted and the doctor is saying stenting isn't a possibility for me. It is about an area from belly button to below the knee. I'm from the Netherlands and I was wondering if there are more treatments possible in America than in the Netherlands? Here they don't know what to do anymore because hey have never seen this problem in this severe degree.
I am now 34 years old.
Kind regards Tanja

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