May-Thurner Syndrome

doi:10.1016/j.amjms.2017.09.011

The American Journal of the Medical Sciences

Volume 355, Issue 5, May 2018, Pages 510-514

https://doi.org/10.1016/j.amjms.2017.09.011 Get rights and content

Abstract

This single-center, retrospective review identified 6 patients (n = 6, 100% female) treated by endovascular therapy for May-Thurner syndrome from June 2013 to September 2015. Patients consisted of 3 African American, 2 Caucasian and 1 Asian; mean age was 53.50 ± 8.31 years, range: 39-63 years. Clinical presentations consisted of left lower extremity deep vein thrombosis in 4, left lower extremity deep vein thrombosis with pulmonary embolism in 1 and pulmonary embolism with left common iliac vein thrombosis in 1 patient. All 6 patients were treated with catheter‐directed thrombolysis and venous stenting to correct the underlying anatomical defect. Hypercoagulability work up revealed antiphospholipid antibody syndrome in 1 patient. No major periprocedural complications were observed. Median follow-up period was 22 ± 5.5 months (range: 13-30 months). One patient with pre-exiting antiphospholipid antibody syndrome developed stent thrombosis with secondary loss of patency. Endovascular therapy for May-Thurner syndrome in our adult cohort seemed safe and effective. One patient with pre-existing thrombophilia developed secondary loss of stent patency, suggesting need for further investigation in this subgroup.

Introduction

May-Thurner syndrome (MTS) is an anatomical defect described as an external compression of left common iliac vein (CIV) by right common iliac artery (CIA) against the pelvic brim and the fifth lumbar vertebra¹ leading to symptoms of impaired venous outflow from the left lower extremity (LLE). Long-standing compression by a pulsatile artery causes intimal fibrosis leading to venous spur formation. This results in mechanical obstruction to venous flow, which causes increased risk of LLE deep vein thrombosis (DVT), chronic venous stasis and venous hypertension. It is not uncommon to find left CIV compression by right CIA on imaging in asymptomatic patients.² Radiologic studies have reported up to 24% prevalence of greater than 50% compression of left CIV by right CIA.² This anatomical abnormality has a reported prevalence of 20-34% in cadaveric studies.¹ The occurrence of the LLE DVT³ is 5 times more common and is believed to be related to this anatomic defect; however, only 2-3% of LLE DVTs are reported as related to MTS.1, 2 Such under diagnosis is probably because workup is generally stopped once the diagnosis of DVT is confirmed. In this case series, we describe 6 cases of MTS presenting with LLE DVT and pulmonary embolism (PE). All 6 cases were treated with thrombolysis, anticoagulation and correction of anatomical defect by angioplasty.

Section snippets

Cases

Formal, informed consent was obtained from each individual patient per institutional policy and approval from the institutional review board was obtained. A retrospective review of the picture archiving and communication system radiology database was done using May-Thurner syndrome as the keyword. We identified 6 patients above the age of 18 who underwent endovascular therapy for MTS from June 2013 to September 2015. Patients who had endovascular intervention or stent placement in the lower

Discussion

Rudolf Virchow described the famous Virchow’s triad of thrombosis in the setting of iliofemoral DVT and venous stasis in 1851. He noted DVTs occurring 5 times more commonly in the LLE compared to the right.³ May and Thurner¹ explained the anatomical basis for this left-sided propensity as MTS. MTS is described as the compression of the left CIV by the right CIA against the spine and pelvic brim.¹ The syndrome is reportedly seen in approximately 18-49% of patients with left-sided lower extremity

Conclusions

Left CIV compression by right CIA is a relatively under-diagnosed clinical entity. It should be considered as a possible cause of unexplained left-leg DVT and unexplained swelling and pain of the left leg, given its reported prevalence in cadaveric and radiological studies. Failure to recognize underlying MTS may increase the risk of recurrent venous thromboembolism, attributing to increased risk of morbidity and mortality. It is noted that all patients in our female cohort were multiparous.

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Cited by (11)

May-Thurner syndrome and deep vein thrombosis: A series of 8 patients
2021, Medicina Clinica
To analyze the prevalence of May-Thurner syndrome (MTS) among patients with deep vein thrombosis (DVT) of left lower limb (LLL), and outcomes after long-term follow-up.
Retrospective observational study that included patients older than 18 diagnosed with acute DVT and MTS.
Among 760 patients diagnosed with DVT in the LLL, 8 patients were diagnosed with MTS (1.05%), with a mean age of 39 years. All patients received long-term anticoagulation, with a mean of 31.9 (±25.2) months. Invasive treatment with pharmaco-mechanical thrombectomy was performed in 5 patients (62.5%). During follow-up (mean of 32.4 months), 25% of patients suffered DVT recurrence. Only 1 case presented major bleeding, and no deaths were registered.
May-Thurner syndrome constitutes a permanent and underdiagnosed risk factor for the development of DVT of LLL. Our findings suggest that long-term anticoagulation therapy might be considered in selected cases.
Analizar la prevalencia del síndrome de May-Thurner (SMT) en una cohorte de pacientes con trombosis venosa profunda (TVP) en el miembro inferior izquierdo (MII), y las complicaciones durante el seguimiento a largo plazo.
Estudio observacional retrospectivo que incluyó a pacientes mayores de 18 años con diagnóstico de TVP en el MII y SMT.
Entre los 760 pacientes diagnosticados de TVP en el MII, ocho pacientes fueron diagnosticados de SMT (1,05%), con una media de edad de 39 años. Todos los pacientes recibieron tratamiento anticoagulante a largo plazo, con una media de 31,9 (± 25,2) meses. Se realizó tratamiento invasivo con trombectomía fármaco-mecánica en cinco pacientes (62,5%). Durante el seguimiento (media de 32,4 meses), el 25% de los pacientes sufrieron recurrencia de TVP. Solo se registró un sangrado mayor y no se registraron muertes.
El síndrome de May-Thurner constituye un factor de riesgo infradiagnosticado y permanente para el desarrollo de TVP en el MII. Nuestros hallazgos sugieren que la anticoagulación a largo plazo podría ser considerada en casos seleccionados.
Endovascular and medical therapy of May–Thurner syndrome: Case series and scoping literature review
2021, JMV-Journal de Medecine Vasculaire
Citation Excerpt :
Imaging is essential to assure the stent's placement because its occlusions will be more frequent if the venous lesions are not completely covered [22,23]. Angioplasty and stent in chronic cases solve chronic venous compression and prevent future recurrences [2,41]. Endovascular stenting success rates with or without adjunct of thrombolysis range from 83% to 93% [1,32,33,38,39,42–44], which was seen in this case series.
May–Thurner syndrome has been recognized as a cause of chronic venous insufficiency and a trigger for venous thromboembolism. There is no consensus about the definition, diagnosis, and therapeutic approach. We are aiming to describe its characteristics and a scoping literature review.
A retrospective review of patients with May–Thurner syndrome from March 2010 to May 2018 and scoping literature review were made.
Seven patients were identified. All patients were female with a median age of 36 (20–60) years. The median time from the first symptom to diagnosis was 3.41 (0.01–9) years. The primary clinical presentation was post-thrombotic syndrome (4 patients). Six patients had at least one risk factor for deep venous thrombosis. All patients underwent angioplasty with stent; patients with acute deep venous thrombosis, furthermore mechanic thrombectomy with or without catheter-directed thrombolysis were done. There were three complications (one patient, lymphedema, and two venous stent thrombosis). Scoping review results were descriptively summarized.
May–Thurner syndrome has a varied spectrum of clinical presentation, and clinical awareness is paramount for diagnosis. Its principal complication is the post-thrombotic syndrome, which is associated with high morbidity. There is no consensus on the antithrombotic treatment approach.
Cauda Equina Syndrome Caused by Epidural Venous Plexus Engorgement in a Patient with May-Thurner Syndrome
2019, Annals of Vascular Surgery
Citation Excerpt :
In the present case, radiological examinations could not explain the exact cause of the symptoms and only perimedullary venous dilations and left iliac vein stenosis were observed on medullary angiography, consequently, faced with these findings, we decided that cauda equine syndrome justified performing a phlebography and endovascular treatment with venous stent placement, which has been reported as an effective and safe treatment with low MTS recurrence.11 In this case, venous stent placement was performed before detecting positive results of thrombophilia, and as it is known, in this group of patients the patency results are worse,14 therefore, this condition could increase doubts relating to MTS treatment. However, with the acquired experience in the present case, we would act the same way despite positive thrombophilia results.
The purpose of this article is to present a case of cauda equina syndrome in a patient with incomplete motor and sensory deficits due to epidural venous plexus engorgement, owing to May-Thurner syndrome successfully treated with venous iliac stenting. A 40-year-old woman, with previous history of deep vein thrombosis and miscarriages, gradually developed right leg and back pain, with functional limitation, perineal hypoesthesia, and sphincter incontinence. Magnetic resonance imaging revealed epidural venous plexus engorgement and cauda equina roots involvement. Phlebography showed perimedullary venous enlargement and left common iliac vein stenosis, leading to the diagnosis of May-Thurner syndrome. Stenting of the left common iliac vein was performed resulting in pain improvement and disappearance of neurological symptoms. Thrombophilia study was positive to heterozygous factor V Leiden. Cauda equina syndrome as the first presentation of a May-Thurner syndrome is very rare. In this case, venous iliac stent placement was an effective and safe treatment.
Recanalization of Inferior Vena Cava and Bilateral Iliac Veins 15 Years after May–Thurner Syndrome-Related Occlusion
2023, American Surgeon
Deep vein thrombosis associated to mutation in factor V Leiden, MTHFR and May-Thurner syndrome
2022, Medicina Interna de Mexico
Added value of computed tomography venography in the identification of abnormities in veins of lower extremities
2022, Current Medical Research and Opinion

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^☆: The authors have no financial or other conflicts of interest to disclose.

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SPECIAL FEATUREMay-Thurner Syndrome☆

Abstract

Introduction

Section snippets

Cases

Discussion

Conclusions

J Vasc Surg

Chest

J Vasc Interv Radiol

J Vasc Surg Venous Lymphat Disord

Ann Vasc Surg

J Vasc Interv Radiol

J Vasc Surg

The cause of the predominantly sinister occurrence of thrombosis of the pelvic veins

Angiology

SPECIAL FEATURE
May-Thurner Syndrome☆