|Year : 2019 | Volume
| Issue : 2 | Page : 154-156
S. Neethu1, Fathimath Sahla1, John Alexander2, Thara Pratap3, Muhammed Jasim Abdul Jalal4
1 Department of Family Medicine, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
2 Department of Internal Medicine, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
3 Department of Radiology, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
4 Department of Internal Medicine and Rheumatology, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
|Date of Submission||26-May-2019|
|Date of Decision||09-Jul-2019|
|Date of Acceptance||16-Oct-2019|
|Date of Web Publication||19-Dec-2019|
Muhammed Jasim Abdul Jalal
Department of Internal Medicine and Rheumatology, Lakeshore Hospital and Research Centre, Nettoor P.O., Maradu, NH 47 - Bypass, Kochi - 682 040, Kerala
Source of Support: None, Conflict of Interest: None
May–Thurner syndrome (MTS) is an anatomically variable clinical condition in which the left common iliac vein is compressed between the right common iliac artery and the underlying spine. This anatomic variant results in an increased incidence of left iliac or iliofemoral vein thrombosis. We would like to substantiate that MTS is often underdiagnosed, and it should always be suspected in left iliofemoral vein thrombosis in young individuals.
Keywords: Cockett syndrome, iliac vein compression syndrome, left iliac vein thrombosis, left iliofemoral vein thrombosis, May–Thurner syndrome
|How to cite this article:|
Neethu S, Sahla F, Alexander J, Pratap T, Abdul Jalal MJ. May–Thurner Syndrome. Indian J Community Fam Med 2019;5:154-6
| Introduction|| |
May–Thurner Syndrome (MTS), also known as iliac vein compression syndrome/Cockett syndrome is an anatomically variable clinical condition in which the left common iliac vein is compressed between the right common iliac artery, and the underlying spine leads to left iliac or iliofemoral vein thrombosis. It was first described by May and Thurner in 1957 as “a venous spur.”
| Case Report|| |
A 46-year-old Caucasian female with a past medical history of hypothyroidism presented with pain and swelling on the left lower limb of 5-day duration. It was associated with redness and warmth. She denied any history of trauma to the legs, similar episodes in the past, long travel, surgical procedures, and immobilization. There were no fever, no chest pain, or breathlessness. She had no significant past medical history. There was no family history of deep-vein thrombosis (DVT).
She was married with two children and denied the use of oral contraceptive pills. She had no history of recurrent miscarriages.
On physical examination, she was not dyspneic at rest. Vital signs showed a heart rate of 84 beats/min, blood pressure of 130/70 mmHg, and a respiratory rate of 16 breaths/min. The oxygen saturation was 100% on room air. The cardiovascular and respiratory examinations were unremarkable.
On examination of the lower limbs, the left lower limb was warm, swollen up to the thigh measuring 4 cm more than the right, shiny, and tender to touch. There was no evidence of stasis dermatitis, venous ulcers, or varicosities. The peripheral pulses were well felt. The left hip and knee joint movements were painful, tender, and restricted.
Investigations showed significantly elevated D-dimer level at 9.67 mg/L. Full blood count, renal and liver functions, and chest radiograph were normal. Electrocardiogram showed sinus rhythm.
She was given 1 dose of low molecular-weight heparin, enoxaparin, which was continued at a dose of 1 mg/kg body weight 2 times a day.
Computed tomography (CT) scan of the abdomen and pelvis showed diffuse venous thrombosis involving the left iliac vein down to the superficial femoral vein [Figure 1] and [Figure 2]. The thrombus terminated at the point where the left common iliac vein crosses posterior to the right common iliac artery. In the absence of any suspicious pelvic mass, these features were suggestive of MTS.
|Figure 1: Computed tomography scan of the abdomen and pelvis showed diffuse venous thrombosis involving the left iliac vein down to the superficial femoral vein (coronal view)|
Click here to view
|Figure 2: Computed tomography scan of the abdomen and pelvis showed diffuse venous thrombosis involving the left iliac vein down to the superficial femoral vein (axial view)|
Click here to view
Protein C, Protein S, lupus anticoagulant, anti-thrombin III, and autoimmune markers were unremarkable. Her symptoms of the swelling had improved on the day following admission. She was offered catheter-based thrombolysis with a possible angioplasty and intravascular stenting.
However, she opted for medical management first and intervention at a later date if symptoms recurred. The risk of postthrombotic syndrome and recurrent DVT with medical management alone was reinforced to her, but she declined intervention. She was then shifted to a Factor Xa inhibitor (rivaroxaban) for the treatment of the DVT. She was discharged on the 3rd hospital day on rivaroxaban to complete 6 months of treatment. On follow-up, the patient remained well and again declined any intervention.
Subsequent hypercoagulable workup excluded the diagnosis of Protein C, Protein S, antithrombin III deficiency, Factor V Leiden mutation, prothrombin gene mutation, antiphospholipid antibody syndrome, and hyperhomocysteinemia.
| Discussion|| |
MTS should be suspected in patients, in their second to the fourth decade of life, especially females (five times more prevalent) presenting with unprovoked deep venous thrombosis of the left leg., Most of the patients give a history of surgery, pregnancy, oral contraceptive use (birth control pill), dehydration, cancer, and infections. Symptoms include mild venous stasis ulcer to significant left leg venous claudication, DVT, and pulmonary embolism. An iliac venogram is the diagnostic test of choice for MTS. Various causes of iliac vein compression, such as pelvic mass, trauma, and prior surgeries, should be ruled out before diagnosing MTS.
The primary goals of treatment for MTS are to:
- Restore normal blood flow in the compressed common iliac vein
- Remove any clot that may have formed as a result of narrowing and
- Repair the anatomical defects.
Treatment strategies have evolved from more invasive, open surgical techniques to minimally invasive therapies using catheters and imaging guidance. These new techniques often use thrombolytics to dissolve the blood clot and balloons and stents to prop open the vein. Anticoagulation is also considered as the mainstay of treatment for DVT and is used in a combination with these techniques.
In general, long-term anticoagulation and elastic compression stockings are recommended following treatment to help prevent recurrent clot formation and limit the risk of postthrombotic syndrome. Less common treatment options for MTS include open surgical clot removal (thrombectomy) with repositioning of the right common iliac artery away from the left common iliac vein and various bypass procedures. These surgical procedures are usually reserved for cases in which minimally invasive therapies such as angioplasty and stent placement have failed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mako K, Puskas A. May-Thurner syndrome – Are we aware enough? Vasa 2019;48:381-8.
May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957;8:419-27.
Liddell RP, Evans NS. May-Thurner syndrome. Vasc Med 2018;23:493-6.
Desai J, Desai Z, Shah J, Hai O, Mignatti A, Zeltser R, et al.
Deep vein thrombosis of the left leg: A case of May-Thurner syndrome. Eur J Case Rep Intern Med 2018;5:000829.
[Figure 1], [Figure 2]