Left Non-thrombotic Iliac Vein Lesion with a Symptomatic Right Leg
Article Outline
Abstract
We report a case of left sided May–Thurner's syndrome in a 35-year-old female patient with features of chronic venous insufficiency of the right lower extremity in contrast to the more commonly found clinical presentation of involvement of the left lower limb. This patient showed dramatic improvement in relief of pain and swelling of the right lower limb after stenting the May–Thurner lesion with resolution of reflux in the femoral veins.
Keywords: May–Thurner syndrome, Non-thrombotic iliac vein lesion
Introduction
May Thurner's Syndrome (MTS) is an anatomical variant commonly described as stenosis of the left common iliac vein as a result of compression by the right common iliac artery running over it.1 It has a female preponderance (3:1). The diagnosis is often missed as it requires a venogram or intravenous ultrasound (IVUS). It is found in 2–5% of patients who undergo evaluation for lower extremity venous disorders.2 MTS can present as pedal oedema, varicose veins, deep venous thrombosis, chronic venous stasis ulcers, phlegmasia cerulea dolens on left leg and even pulmonary embolism.3 The diagnosis should be considered in patients with chronic, non-malignant venous outflow obstruction. MTS producing symptoms on the contralateral side have not been described.
Short Report
A 35-year-old lady presented with a history of significant pain and swelling of the right leg for about 8 years. She had undergone a right sided varicose vein operation with saphenofemoral ligation, stripping of the great saphenous vein and stab avulsion 8 years previously for similar complaints at another centre and had no copies of previous clinical records. She had relief of symptoms for 2 months postoperatively. The left leg had remained asymptomatic.
On examination, there was marked oedema of the right lower limb, scars of the previous operation and varicosities over the medial aspect of the right leg. A venous duplex showed an absent right saphenofemoral junction, consistent with the previous surgery and significant deep venous reflux in the femoral and popliteal veins. The sapheno-popliteal junction was competent. A venogram showed normal flow through the right iliac veins. However, there was a complete block of the left iliac vein with multiple collaterals draining into the right iliac vein (Fig. 1).
Figure 1
Venogram showing obstructed left common iliac vein with beaking and large collaterals draining into the right common iliac vein.
The left common iliac and external iliac veins were stented using Wallstents. Following this, there was a remarkable reduction in the shunt and in size of collaterals (Fig. 2).
Figure 2
Post-stenting, free flow in the left common iliac vein with significant reduction in the size and number of collaterals.
Postoperatively, she had a remarkable clinical improvement with relief of pain and swelling and continues to be asymptomatic in both lower limbs after 1 year follow-up. Duplex ultrasonography performed during follow-up shows absence of reflux in both femoral and popliteal veins bilaterally.
Discussion
Currently May–Thurner syndrome is thought to occur predominantly in patients with left iliofemoral deep venous thrombosis or in patients with signs or symptoms of left lower extremity venous hypertension.3 MTS producing symptoms of the right lower limb are not common. One possible mechanism could be due to the right hypogastric artery crossing over the right external iliac vein. In MTS, there is extensive intimal hypertrophy of vein due to chronic pulsatile force of the right iliac artery.4 Diagnostic modalities include iliac venogram (subtracted), non-subtracted frontal venogram, CT scan (arterial phase), CT venography and intravascular ultrasound. However, IVUS is the gold standard.
Surgical management is by venous angioplasty with excision of intraluminal bands, division and relocation of right common iliac artery behind the left common iliac vein or IVC, contralateral saphenous vein graft bypass to the ipsilateral common femoral vein with creation of a temporary A–V fistula. 5 Endovascular stent placement and catheter directed thrombolysis, in patients with deep venous thrombosis, are today the preferred modality of management.
A left sided MTS producing symptoms on the contralateral side has not been described before. Our patient has an underlying MTS on the left side and symptoms of chronic venous insufficiency (CVI) on the right side. We believe that her CVI on the right side was secondary to the left sided MTS because of the following reasons – (a) the venous system of the right iliac vein was normal, (b) pre-stenting, there were multiple collaterals draining the obstructed left system into the right iliac vein, (c) post-stenting, these collaterals dramatically decreased in size, and (d) patient had dramatic improvement post-stenting and remains asymptomatic at 1 year follow-up. Why this mechanism has not been noticed in other cases of MTS is a point left open to debate.
Conflicts of Interest
None.
References
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- . Venous outflow obstruction: an underestimated contributor to chronic venous diseases. J Vasc Surg. 2003;38(5):879–885
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- . Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May–Thurner syndrome. J Vasc Interv Radiol. 2000;11:1297–1302
PII: S1533-3167(08)00020-4
doi:10.1016/j.ejvsextra.2008.08.010
© 2008 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Left Non-thrombotic Iliac Vein Lesion with a Symptomatic Right Leg , 17 October 2008
