Case Report

Acute deep vein thrombus due to May-Thurner syndrome

Abstract

A 63-year-old white woman with a history of hypertension, hyperlipidemia, hypothyroidism, and transient ischemic attack, on Premarin, presented with a 2-week history of worsening edema and pain on the left side of the lower extremity associated with purplish discoloration and decreased temperature after a prolonged car travel. Physical examination revealed 2+ edema from the midthigh to the toes associated with purpuric discoloration. All arterial pulses were 4+. Ultrasound examination demonstrated an acute deep vein thrombus extending from the external iliac veins down throughout the visualized veins of the left calf. The patient was started on intravenous heparin and underwent venogram with subsequent thrombolysis. After 48 hours of alteplase infusion, Balloon angioplasty was performed and 2 stents were placed in the left common and external iliac veins. Premarin was discontinued and she remains on Oral anticoagulation with Coumadin. The patient did well clinically and a second ultrasound showed interval improvement. There is significant family history but no personal history of thrombotic events; however, thrombophilia evaluation is unremarkable.

May-Thurner syndrome more commonly affects the Left lower extremity, which is more attributed to the normal anatomy of the vessels on the left calf. May and Thurner found [1] that in an autopsy series of 430 cases, 22% had focal intimal vascular thickening with septae formation. Right common iliac artery crosses over the left iliac vein and compresses it against the lumbar vertebral body and results in the progressive fibrosis of the left iliac vein, which further results in the occlusive symptoms. Kibbe et al [2] found that the prevalence of left common illiac vein more common in asymptomatic individuals due to its anatomy. Various studies showed that the predominance of the involvement of the left side of the lower extremity is about 3 to 8 times that of the right side of the lower extremity [3,4]. The cause of this physiological phenom- enon leading to a pathological process is not known.

A 63-year-old white woman with a history of hypertension, hyperlipidemia, hypothyroidism, and transient ischemic attack, on Premarin, presented with a 2-week history of

worsening edema and pain on the left lower extremity, associated with purplish discoloration and decreased tempera- ture after a prolonged car travel. Physical examination revealed 2+ edema from the midthigh to the toes associated with purpuric discoloration (Fig. 1). All arterial pulses were 4+. Ultrasound examination demonstrated an acute deep vein thrombus extending from the external iliac veins down throughout the visualized veins of the left calf. The patient was started on intravenous heparin and underwent venogram with subsequent thrombolysis. After 48 hours of alteplase infusion, balloon angioplasty was performed and 2 stents were placed in the left common and external iliac veins. Premarin was discontinued and she remains on oral anticoagulation with Coumadin. The patient did well clinically and a second ultrasound showed interval improvement. There is significant family history but no personal history of thrombotic events; however, thrombophilia evaluation is unremarkable.

A history of left lower Leg swelling in a young to middle-aged woman with or without any obvious cause of deep vein thrombosis is an indication that a congenital variant May-Thurner syndrome should be considered. In our study, it was diagnosed in an Elderly woman, which is very uncommon at this age.

The prevalence of May-Thurner syndrome is yet unknown. May-Thurner is estimated to occur in only 2% to 5% of patients who undergo evaluation for the lower extremity venous disorder [5]. The Presenting complaints can be leg swelling, pain in the leg, varicosities, deep vein thrombosis, and venous ulceration and also lead to pulmonary embolism [5,6].

Fig. 1 Clinical presentation of acute venous occlusion. Note the marked purplish discoloration of the patient’s left extremity when compared with the right.

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The Diagnostic approach toward this syndrome is crucial, and venogram is still the diagnostic test used to rule out May-Thurner syndrome. Another test that could be performed in a clinical setting and that is noninvasive and reliable is Transabdominal ultrasound.

The treatment of this condition, considering the seriousness of it, should be taken into account. There are various treatment procedures available, with excellent success rates: venovenous bypass procedures, right common iliac artery mobilization of the left iliac vein with a flap or sling made from peritoneum or fascia lata, vein patch angioplasty, and recent advancements as percutaneous angioplasty with stent placement [7,8].

In our patient, initial treatment with intravenous heparin was started, and venogram with subsequent thrombolysis was done. After 48 hours of alteplase infusion, balloon angioplasty was performed and 2 stents were placed in the left common and external iliac veins. The Timely diagnosis, treatment decision, and excellent clinical improvement after the stent placement call for the early intervention of this condition to prevent long-term disabilities.

Ravneet K. Dhillon MD Department of Emergency Medicine Mayo Clinic College of Medicine Rochester, MN 55905, USA

E-mail address: [email protected]

Latha G. Stead MD

Department of Emergency Medicine

University of Rochester Rochester, NY, USA

doi:10.1016/j.ajem.2009.05.016

References

1. May R, Thurner JP. The cause of the predominately sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957;8:419-27.
2. Kibbe MR, Ujiki M, Goodwin AL, et al. Iliac vein compression in an asymptomatic patient population. J Vasc Surgery 2004;39: 937-43.
3. Patel NH, Stookey KR, Ketcham DB, Cragg AH. Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome. J Vasc Interv Radiol 2000;11: 1297-302.
4. Cockett FB, Thomas ML. The iliac compression syndrome. Br J Surg 1965;52:816-21.
5. Taheri SA, Williams J, Powell S, et al. Iliocaval compression syndrome. Am J Surg 1987;154:169-72.
6. Heniford BT, Senler SO, Olsofka JM, Carrillo EH, Bergamini TM. May-Thurner syndrome: management by endovascular surgical techni- ques. Ann Vasc Surg 1998;12:482-6.
7. Baron HC, Shams J, Wayne M. Iliac vein compression syndrome: a new method of treatment. Am Surg 2000;66:653-5.
8. Berger A, Jaffe JW. Iliac compression syndrome treated with stent placement. J Vasc Surg 1995;21:510-4.