Case report
Endovascular treatment of iliac vein compression syndrome
(May-Thurner) – a case report
Tratamento endovascular da síndrome de compressão da veia ilíaca (May-Thurner) –
relato de caso
Jorge Ribeiro da Cunha Júnior1, Daniel Queiroz Neves2, Fernando Azambuja Fontes3, Gustavo Petorossi Solano4,
Marcio Cerbazzi Tavares Cardoso5, Mauro Henrique de Lima6, Irlandia Figueira Ocke Reis7, Paulo Eduardo Ocke Reis8
Abstract
May-Thurner Syndrome is an uncommon cause of venous symptoms and signs related to the left lower limb. It is characterized by compression of the
left common iliac vein by the right common iliac artery and, when such anatomical change causes symptoms that may impair the patients’ quality
of life, surgical treatment is indicated. This article addresses a case of May-Thurner syndrome in which we opted for endovascular treatment with
satisfactory outcome, as well as a discussion about indications, nuances, and expected results. We concluded that endovascular treatment is effective
in treating this syndrome, for it resolves the symptoms by recanalization of the venous system with little risks during the procedure and with short
hospital stay.
Keywords: iliac vein, iliac artery, varicose veins, edema, phlebography
Resumo
A Síndrome de May-Thurner é uma causa pouco comum de sinais e sintomas venosos relacionados ao membro inferior esquerdo. Esta síndrome
é caracterizada pela compressão da veia ilíaca comum esquerda pela artéria ilíaca comum direita e, quando tal alteração anatômica causa sintomas
que venham a prejudicar a qualidade de vida do paciente, existe a indicação de tratamento cirúrgico ou endovascular para correção desta alteração
anatômica. Este artigo é o relato de um caso, no qual optou-se pelo tratamento endovascular com resultado satisfatório e as indicações, as nuances e
os resultados esperados para esta técnica no tratamento da Síndrome de May-Thurner são discutidos. Foi concluído que, nesta síndrome, há eficácia
do tratamento endovascular com melhora dos sintomas pela recanalização do sistema venoso, sem grandes riscos inerentes ao procedimento e com
curto período de internação hospitalar.
Palavras-chave: veia ilíaca; artéria ilíaca; varizes; edema; flebografia
Introduction
The iliac vein compression syndrome, also referred
to as May-Thurner syndrome, is a rare condition caused
by the compression of the left iliac vein by the right iliac
artery. It causes a variety of symptoms according to the
level of compression, such as: asymmetric edema of the
left lower limb, pain, varicose veins and vein thrombosis1-3. The first case of this syndrome was described in
1956 by May and Thurner, after dissecting cadavers, being characterized as the anatomical variations of the left
iliac vein with interruption of venous flow 4,5,7-9. Fibrous
vascular lesions (called spurs) were found at the level
of compression of the left iliac vein against the fifth
Auxiliary surgeon at Angiocare; Resident at the Service of Vascular Surgery of Hospital Universitário Antônio Pedro, Universidade Federal Fluminense (UFF) – Niterói (RJ), Brazil.
Auxiliary surgeon at Angiocare; Resident at the Service of Vascular Surgery of Hospital Universitário Antônio Pedro, Universidade Federal Fluminense (UFF) – Niterói (RJ), Brazil.
3
Anesthesist at Angiocare, Niterói (RJ), Brazil.
4
Auxiliary surgeon at Angiocare, Niterói (RJ), Brazil.
5
Auxiliary surgeon at Angiocare; Post-Graduation student at the Service of Vascular Surgery of Hospital Universitário Antônio Pedro, Universidade Federal Fluminense (UFF) – Niterói (RJ), Brazil.
6
Auxiliary surgeon at Angiocare; Post-Graduation student at the Service of Vascular Surgery of Hospital Universitário Antônio Pedro, Universidade Federal Fluminense (UFF) – Niterói (RJ), Brazil.
7
Nurse at Angiocare, Niterói (RJ), Brazil.
8
Head surgeon at Angiocare; Head of the Service of Vascular Surgery of Hospital Universitário Antônio Pedro, Universidade Federal Fluminense (UFF) – Niterói (RJ), Brazil.
Received on: 18.09.10. Accepted on: 15.03.11
J Vasc Bras. 2011;10(1):72-76.
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May-Thurner syndrome - Cunha Júnior JR et al
lumbar vertebra by the right iliac artery5,10. In 1965,
Cockett and Thomas described a series of 35 patients
with iliofemoral segment thrombosis who also had the
iliac vein obstructed 5. All patients who were subjected
to surgical treatment had intimal hyperplasia of the
iliac vein.
The treatment of this disease was once restricted
to an ineffective clinical management, as open surgery
was the alternative in severe cases6,3,11. With the advent
of the endovascular approach, a less invasive therapeutic strategy with better outcomes was established: balloon angioplasty with stenting1,12,13.
We report the case of a patient with May-Thurner
syndrome who was successfully treated by balloon angioplasty with stenting.
Case report
Case of a Caucasian 21-year-old female patient,
from Niterói, Rio de Janeiro, Brazil. She had no past
comorbidities, but referred pain on the left lower limb
and edema, which worsened during the day, associated
with small caliber varicose veins since she was 18 years
old. She denied any other symptom.
On physical examination, she had circumferential
increase of the left lower limb compared to the right
limb, diffuse edema, telangiectasias and small caliber
varicose veins especially in the thigh. The calves presented no signs of rigidity. Pulses were palpable and
had good amplitude.
Color-assisted Doppler ultrasound of the left lower
limb showed patent common femoral vein, deep vein
and superficial vein with dense walls and moderate reflux. The peak systolic velocity of the left common femoral vein in relation to the right one was 0.74. RM angiography showed compression of the left iliac vein by
the right common iliac artery, causing an accentuated
reduction in the venous caliber and characterizing the
May-Thurner syndrome. As the patient reported interference of the symptom on her daily activities, we opted
for endovascular treatment by balloon angioplasty with
stenting.
The procedure was performed under spinal anesthesia. Both femoral veins were punctured with an 18gauge needle, with passage of a 0.35 guide wire, followed
by insertion of an11F sheath and phlebography, which
showed intense collateral circulation on the left common iliac vein and compression of the vein by the right
iliac artery (Figure 1). The patient was given 5,000 U
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73
of intravenous heparin. After identifying the lesion, we
performed balloon venoplasty (Figure 2) with progressive dilatation with balloon-catheters measuring 15 x
60 mm and 18 x 60 mm. After dilatation of the vein,
we chose to implant a 18 x 60 mm WALLSTENT® stent,
aiming to maintain venous system patency (Figure 3).
The stent was deployed in two stages. First, it was
released 1/3 of its length. It was then repositioned 1 cm
into the inferior vena cava and fully released. After that,
control phlebography was performed, which showed
maintenance of the venous flow in both iliac veins and
immediate reduction of collateral circulation, confirming the effectiveness of the procedure (Figure 4). The
patient had a good recovery in the immediate postoperative period and was discharged 24 hour later. With
the goal of maintaining patency and preventing deep
vein thrombosis, she was given Clopidogrel 75 mg/day
for six months.
Discussion
Compression of the left iliac vein, first described
in 1851 by Rudolph Virchow, is a common anatomical
variation that may cause pain, edema, unilateral varicose
veins, ulcers and recurrent deep vein thrombosis14,15.
In 1956, May and Thurner described the physiopathology of the disease studying cadavers, and showed
that hypertrophic alterations in the intimal venous
layer are associated with chronic mechanical stress, induced by the pulsation of the right common iliac vein
over the left common iliac vein against the lumbar
vertebra4,5,10,15,16.
Also in 1956, Cockett and Thomas described the
iliac vein compression syndrome correlating the symptoms (edema, pain and deep vein thrombosis) with the
alterations described by May and Thurner 5,10,15. Since
then, the treatment of this syndrome has been discussed
and has also divided opinions as to choosing conservative treatment or surgical correction, especially after
the advent of endovascular treatment12,14,16-19.
Before balloon dilatation and stenting to treat venous obstructions, many conventional surgical techniques were described for the treatment of iliac vein
compression syndrome. Even so, the progress in the
surgical approach of chronic venous lesions has evolved
quite slowly in comparison to the treatment of arterial
lesions.
The first attempt to surgically treat this kind of lesion was
described by Palma and Esperon in 1958. It consisted on the
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May-Thurner syndrome - Cunha Júnior JR et al
confection of a cross-over femorofemoral bypass6. Later on,
Cormier described the reinsertion of origin of the right iliac
vein, moving it down the iliac vein in order to decompress it.
However, these surgical techniques were too complex
and aggressive, and the patients ewere left with large scars
from the surgical access. Therefore, the operative trauma
Figure 1 – Perioperative phlebography showing intense collateral circulation and the iliac artery over the iliac vein.
Figure 3 – Placement of the stent in iliac vein.
Figure 2 – Balloon venoplasty.
Figure 4 – Follow-up perioperative phlebography showing patency of
both iliac veins and absence of collateral circulation.
May-Thurner syndrome - Cunha Júnior JR et al
and the expected outcomes were little attractive and the
surgical treatment was indicated only in severe cases.
Current literature has shown that the endovascular
technique combining balloon angioplasty with stenting
provides excellent results as to the recanalization of the
iliac venous system and subjects the patient to a minimum surgical trauma2,12,20-23, as in the case we described.
There is no consensus about the administration of
venous anticoagulation. Most authors follow a protocol
that demands heparin anticoagulation during the procedure and then for 24 to 72 hours, using AAS 75 to
250 mg/day or clopidogrel 75mg/day for a six-month
preoperative period7,8,15.
Considering the patient’s good recovery, the endovascular treatment seems to be superior to the conventional techniques and to clinical management regarding May-Thurner syndrome. It has been the treatment
of choice in symptomatic patients, although there are
no long-term studies addressing the subject yet 3,9,11.
Endovascular treatment is less invasive and provides
little chance of complication; moreover, the patients
can return earlier to their daily activities.
Conclusion
Endovascular treatment is feasible and promising
for May-Thurner syndrome, with low rates of peri- and
postoperative complications, it is less invasive than the
conventional surgical approaches, has less morbidity and
requires a shorter hospital stay. Because it is a relatively
new procedure, longer follow-up of patients is needed,
as well as further studies addressing the endovascular
technique on the venous segment. The outcomes of the
current case and the literature review point out to an
increasing use of this technique1,2,3,7-9,11,13,20,22,23.
References
1. Mickley V, Schwagierek R, Rilinger N, et al. Left iliac venous
thrombosis caused by venous spur: treatment with thrombectomy and stent implantation. J Vasc Surg. 1998;28:492-7.
2. Heniford BT, Seyhan SO, Olsofka JM, et al. May-Thurner syndrome: management by endovascular surgical techniques.
Ann Vasc Surg. 1998;12:482-6.
3. O’Sullivan GJ, Semba CP, Bittner CA, et al. Endovascular management of iliac vein compression syndrome. J Vasc Interv
Radiol. 2000;11:823-36.
4. May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology. 1957;8:
419-27.
J Vasc Bras 2011, Vol. 10, Nº 1
75
5. Cockett FB, Thomas ML. The iliac compression syndrome. Br
J Surg. 1965;52:816-21.
6. Halliday P, Harris J, May J. Femoro-femoral crossover grafts
(Palma operation): a long term follow-up study. In: Bergan
JJ, Yao JST, eds. Surgery of the Veins. Orlando, FL: Grune &
Stratton; 1985. p. 241-54.
7. Patel NH, Stookey KR, Ketcham DB, et al. Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome. J Vasc Interv Radiol.
2000;11: 1297-302.
8. Grunwald M, Goldberg M, Hoffman L. Endovascular management of May-Thurner syndrome. AJR. 2004;183:1523-4.
9. Jeon UB, Chung JW, Jae HJ, et al. May-Thurner syndrome
complicated by acute iliofemoral vein thrombosis: helical CT venography for evaluation of long-term stent patency and changes in the iliac vein. AJR Am J Roentgenol.
2010;195(3):751-7.
10. Thomas M, Fletcher W, Cockett, et al. Venous collaterals in
external and common iliac vein obstruction. Clin Radiol.
1967;18: 403-11.
11. Dhillon RK, Stead LG. Acute deep vein thrombus due to MayThurner syndrome. Am J Emerg Med. 2010;28(2):254.e3-4.
12. Oderich G, Treiman G, Schneider P, et al. Stent placement
for treatment of central and peripheral venous obstruction: a long-term multi-institutional experience. J Vasc Surg.
2000;32:760-9.
13. Lamont JP, Pearl GJ, Patetsios P, et al. Prospective evaluation
of endoluminal venous stents in the treatment of the MayThurner syndrome. Ann Vasc Surg. 2002;16:61-4.
14. Kibbe M, Ujiki M, Goodwin A, et al. Iliac vein compression in
an asymptomatic patient population. J Vasc Surg. 2004;39:93743.
15. Taheri SA, Williams J, Powell S, et al. Iliocaval compression syndrome. Am J Surg. 1987;154:169-72.
16. Nazarian GK, Austin WR, Wegryn SA, et al. Venous recanalization by metallic stents after failure of balloon angioplasty or surgery: fouryear experience. Cardiovasc Intervent Radiol. 1996;19:
227-33.
17. Akesson H, Brudin L, Dahlstrom JA, et al. Venous function assessed during a 5 year period after acute ilio-femoral venous
thrombosis treated with anticoagulation. Eur J Vasc Surg.
1990;4:43-8.
18. Gruss JD, Hiemer W. Bypass procedures for venous obstruction. In: Raju S, Villavicencio L, eds. Surgical Management of
Venous Disorders. Baltimore, MD: Williams and Wilkins; 1997.
p. 289-305.
19. Raffini L, Raybagkar D, Cahill A, et al. May-Thurner syndrome
(iliac vein compression) and thrombosis in adolescents.
Pediatr Blood Cancer. 2006;47:834-8.
20. Baron HC, Shams J, Wayne M. Iliac vein compression syndrome: a new method of treatment. Am Surg. 2000;66:653-5.
21. França LHG, Tavares V. Insuficiência venosa crônica. Uma atualização. J Vasc Br. 2003;2(4):318-28.
76
J Vasc Bras 2011, Vol. 10, Nº 1
22. Neglen P, Berry MA, Raju S. Endovascular surgery in the treatment of chronic primary and post-thrombotic iliac vein obstruction. Eur J Vasc Endovasc Surg. 2000;20:560-71.
23. Sandri JL. Síndrome de May-Thurner-Tratamento Endovascular.
In: Brito CJ (Org.). Cirurgia Vascular. 2ª ed. Rio de Janeiro:
Livraria e Editora REVINTER Ltda; 2007. p. 1653-64.
Correspondence
Jorge Ribeiro da Cunha Júnior
Rua Marques de Paraná, 303 – 3º andar – Centro
CEP 24033-900 – Niterói (RJ), Brazil
Phone: (21) 2629-9320
E-mail: [email protected]
May-Thurner syndrome - Cunha Júnior JR et al
Authors’ contribution
Study conception and design: Jorge Ribeiro da Cunha Júnior, Paulo Eduardo Ocke Reis, Daniel Queiroz Neves
Data analysis and interpretation: Jorge Ribeiro da Cunha Júnior, Marcio
Cerbazzi Tavares Cardoso
Data collection: Gustavo Petorossi Solano, Mauro Henrique de lima,
Fernando Azambuja Fontes
Writing: Jorge Ribeiro da Cunha Júnior
Critical analysis: Paulo Eduardo Ocke Reis, Irlandia Figueira Ocke Reis
Final approval: Todos os autores
Overall responsibility: Jorge Ribeiro da Cunha Júnior, Paulo Eduardo Ocke
Reis