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DOI: 10.1055/s-0038-1667208
Osteophytic Iliac Venous Compression: Technical Considerations for a Bony May-Thurner Syndrome Variant
Abstract
May-Thurner syndrome (MTS) results in compression of the left common iliac vein between the spine and right common iliac artery leading to symptomatic venous outflow obstruction. The authors depict a classic case of MTS followed by four variant cases in which the primary culprit lesions causing compression were degenerative vertebral osteophytes. The osteophytic variant of MTS poses distinct diagnostic and therapeutic challenges.
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Introduction
May-Thurner syndrome (MTS) classically refers to symptomatic venous outflow obstruction of the left lower extremity, with or without venous thrombosis, due to external compression of the left common iliac vein (LCIV) by the right common iliac artery (RCIA).[1] [2] Chronic compression and pulsatile biomechanics lead to venous intimal injury, which in turn causes obstruction and stenosis and can precipitate deep vein thrombosis (DVT).[1] [2] This article presents an MTS variant in which prominent vertebral osteophytes compress the involved iliac veins with or without contribution from the RCIA and LCIA. We highlight the importance of considering different clinical and technical aspects when diagnosing and treating this distinct MTS variant.
Classic Presentation and Treatment
Patients with MTS are typically teenagers or young adults and more commonly female. They may present acutely with left lower extremity pain and swelling or with signs of chronic venous insufficiency. When suspected, the presence and extent of DVT are often initially assessed with Duplex ultrasound (US). Additional imaging can be considered to confirm any underlying anatomic compression, including computed tomographic venography (CTV), magnetic resonance venography (MRV), and/or catheter venography.[3] Pulmonary arterial phase computed tomographic arteriography (CTA) or magnetic resonance arteriography (MRA) may be added if pulmonary embolism is suspected. Management of patients with MTS with DVT includes anticoagulation, catheter-directed thrombolysis, and/or angioplasty and stent placement at the obstructed site[4] ([Fig. 1]). Axial intravascular ultrasound (IVUS) is a useful adjuvant to plan stent placement and subsequently evaluate treatment.
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Clinical Consideration: Variant Demographics
Multiple studies have shown that classic MTS occurs more often in women of reproductive age.[5] [6] Although the relative frequency of osteophytic MTS variant across different demographic groups is unknown, its incidence is expected to be higher in older patients, who are more likely to experience degenerative spondylosis. When an older adult presents with the first episode of unprovoked unilateral lower extremity DVT, particularly if iliofemoral in distribution, an osteophytic MTS variant should be considered ([Fig. 2]).
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Clinical Consideration: Variant Laterality
Outside of situs inversus anatomy, classic MTS occurs on the left side due to the midline crossing of the RCIA and LCIV. Because of variable patterns of degenerative spondylosis, right-sided presentation of iliofemoral venous occlusion does not exclude a variant of MTS. The clinical features may be otherwise indistinguishable from classic MTS ([Fig. 3]).
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Technical Consideration: “Pseudothrombus”
Bulky osteophytes may cause marginal extrinsic compression, mimicking mural thrombus on digital subtraction venography ([Fig. 2]). Alternatively, a central impression on the vein may mimic the appearance of nearly occlusive thrombus ([Fig. 4]). Failure to recognize the nature of this problem may result in delayed IVC filter removal or prolonged anticoagulation therapy. When suspected, comparison to unsubtracted images and/or repeat imaging in various obliquities may be clarifying. If those tactics are insufficient, intravascular ultrasound or cone-beam CTV are useful problem-solving tools.
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Technical Consideration: Stent Construct Reinforcement
Stent placement across the area of occlusion is widely considered a standard therapy for MTS. The bony projections associated with the osteophytic MTS variant create a smaller surface area of compression and fulcrum effect. As a result, the compressive lesion may not respond as well to the same endovascular techniques. Despite initial apparent technical success, excessive extrinsic compression may promote early stent failure ([Fig. 5]). A stent or stent construct with higher radial force may be required to achieve durable patency. Alternatively, analogous to stent failures seen in venous thoracic outlet syndrome, the underlying musculoskeletal compressive etiology may need to be addressed surgically.[3] [7]
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Conclusion
We present a classic case of MTS as well as four examples of osteophytic variants with various clinical manifestations. In all cases, catheter venography confirmed hemodynamically significant iliac venous stenosis or occlusion with visualization of prominent collateral channels. Correlation with cross-sectional imaging demonstrated degenerative vertebral osteophytes disc herniation as the culprit compressive lesions.
Various causes of iliac vein compression leading to MTS have been reported, including gravid uterus,[5] ectopic kidney,[8] right iliac artery stent,[9] and orthopaedic hardware.[10] To the best of our knowledge, this variant of MTS in which bony structures are primarily responsible for the iliac vein compression is underreported. This underrecognized entity presents distinct diagnostic and therapeutic challenges compared with classic MTS.
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Main Points
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MTS classically refers to symptomatic venous outflow obstruction of the left lower extremity, with or without venous thrombosis, due to external compression of the LCIV by the RCIA.
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Typical treatment of MTS involves thrombolysis (when applicable) and placement of a self-expanding bare metal stent across the compressive lesion.
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An osteophytic variant of MTS may affect common iliac veins on either side, result in venographic pseudolesions, and require placement of stent constructs with additional radial force.
Ethical Approval and Conflict of Interest
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards with waiver of consent. Each author declares that he/she has no conflict of interest.
D. S. S., M. M., S. A., and E. J. M. have no financial disclosures or conflicts of interest.
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Acknowledgments
No acknowledgments.
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References
- 1 May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8 (05) 419-427
- 2 Cockett FB, Thomas ML, Negus D. Iliac vein compression—its relation to iliofemoral thrombosis and the post-thrombotic syndrome. BMJ 1967; 2 5543 14-19
- 3 Butros SR, Liu R, Oliveira GR, Ganguli S, Kalva S. Venous compression syndromes: clinical features, imaging findings and management. Br J Radiol 2013; 86 1030 20130284
- 4 Kim JY, Choi D, Guk KoY, Park S, Jang Y, Lee DY. Percutaneous treatment of deep vein thrombosis in May-Thurner syndrome. Cardiovasc Intervent Radiol 2006; 29 (04) 571-575
- 5 Wax JR, Pinette MG, Rausch D, Cartin A. May-Thurner syndrome complicating pregnancy: a report of four cases. J Reprod Med 2014; 59 (05) (06) 333-336
- 6 Murphy EH, Davis CM, Journeycake JM, DeMuth RP, Arko FR. Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed May-Thurner Syndrome. J Vasc Surg 2009; 49 (03) 697-703
- 7 Urschel Jr HC, Patel AN. Surgery remains the most effective treatment for Paget-Schroetter syndrome: 50 years’ experience. Ann Thorac Surg 2008; 86 (01) 254-260 discussion 260
- 8 Nwoke F, Picel AC. May-Thurner syndrome and horseshoe kidney. J Vasc Interv Radiol 2016; 27 (03) 369
- 9 Young L, Kwon J, Arosemena M, Salvatore D, DiMuzio P, Abai B. Symptomatic compression of right iliac vein after right iliac artery stent placement. J Vasc Surg Venous Lymphat Disord 2017; 5 (05) 735-738
- 10 Woo EJ, Ogilvie RA, Krueger VS, Lundin M, Williams DM. Iliac vein compression syndrome from anterior perforation of a pedicle screw. J Surg Case Rep 2016; 2016 (02) rjw003
Address for correspondence
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References
- 1 May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8 (05) 419-427
- 2 Cockett FB, Thomas ML, Negus D. Iliac vein compression—its relation to iliofemoral thrombosis and the post-thrombotic syndrome. BMJ 1967; 2 5543 14-19
- 3 Butros SR, Liu R, Oliveira GR, Ganguli S, Kalva S. Venous compression syndromes: clinical features, imaging findings and management. Br J Radiol 2013; 86 1030 20130284
- 4 Kim JY, Choi D, Guk KoY, Park S, Jang Y, Lee DY. Percutaneous treatment of deep vein thrombosis in May-Thurner syndrome. Cardiovasc Intervent Radiol 2006; 29 (04) 571-575
- 5 Wax JR, Pinette MG, Rausch D, Cartin A. May-Thurner syndrome complicating pregnancy: a report of four cases. J Reprod Med 2014; 59 (05) (06) 333-336
- 6 Murphy EH, Davis CM, Journeycake JM, DeMuth RP, Arko FR. Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed May-Thurner Syndrome. J Vasc Surg 2009; 49 (03) 697-703
- 7 Urschel Jr HC, Patel AN. Surgery remains the most effective treatment for Paget-Schroetter syndrome: 50 years’ experience. Ann Thorac Surg 2008; 86 (01) 254-260 discussion 260
- 8 Nwoke F, Picel AC. May-Thurner syndrome and horseshoe kidney. J Vasc Interv Radiol 2016; 27 (03) 369
- 9 Young L, Kwon J, Arosemena M, Salvatore D, DiMuzio P, Abai B. Symptomatic compression of right iliac vein after right iliac artery stent placement. J Vasc Surg Venous Lymphat Disord 2017; 5 (05) 735-738
- 10 Woo EJ, Ogilvie RA, Krueger VS, Lundin M, Williams DM. Iliac vein compression syndrome from anterior perforation of a pedicle screw. J Surg Case Rep 2016; 2016 (02) rjw003