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Objectives: Physiologically-significant May-Thurner (MT) compression of the left common iliac (LCIV) vein is likely an under-recognized phenomenon and can present as unilateral left leg swelling with or without associated deep venous thrombosis (DVT). This report describes our diagnostic approach (with emphasis on the importance of intravascular ultrasound (IVUS), management, and outcome in these patients.
Methods: Retrospective analysis of all patients evaluated for May-Thurner Syndrome between 2006-2011.
Results: Twenty-seven patients who presented with unilateral left leg swelling were diagnosed with MT syndrome with (n=15, thrombotic) or without (n=12, non-thrombotic) associated DVT during the study period. All patients underwent duplex ultrasonography and contrast angiography, while IVUS was performed in 11 patients (83% of those with non-thrombotic MT). Mean age was 42.9 yrs, 63% were female, and prior DVT, PE, and hypercoaguable state were each present in 25% of non-thrombotic patients and in 80%, 33%, and 53% of thrombotic patients, respectively. Pain and swelling were present in all patients, and venous claudication was present in 63%. At presentation, all non-thrombotic patients were CEAP class 3, while thrombotic patients were class 3 (86.7%) or 6 (13.3%). Of the non-thrombotic patients, four were treated conservatively; 8 underwent successful LCIV stenting, leading to reduction/amelioration of symptoms in 87.5% and decrease in CEAP score in 75%. For thrombotic patients, all but one underwent successful stenting (+/- lysis) of the LCIV, resulting in alleviation/amelioration of symptoms in 100% and decrease in CEAP score in 85.7%. Angiographic findings in non-thrombotic patients included LCIV stenosis, collateralization, and contrast stagnation in 91.7%, 83.3%, and 75% respectively. However, contrast angiography overestimated LCIV minimum diameter by 61% (7.0mm vs 4.2mm) and cross-sectional area two-fold (104cm² vs 53cm²) relative to IVUS. Correction of underlying LCIV compression in non-thrombotic patients was associated with a three-fold increase in mean cross sectional area (53cm² to 166cm²). One-year primary patency (at 9.7 month mean follow-up) was 100% for non-thrombotic patients and 78.6% for thrombotic patients, with 100% secondary patency for both groups. Complications included two early re-occlusions (successfully treated with re-intervention), no PEs or mortality.
Conclusions: Excellent 1-year patency rates and significant reduction in symptoms and CEAP classification can be attained with percutaneous intervention for MT syndrome. IVUS is essential for accurate diagnosis and stent sizing in patients with non-thrombotic MT syndrome.