Society For Clinical Vascular Surgery

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Atypical May-Thurner Syndrome Caused by Endovascular Aneurysm Repair
Jamie B. Hadley, MD, Jeniann Yi, MD, David Kuwayama, MD.
University of Colorado, Aurora, CO, USA.

DEMOGRAPHICS: May-Thurner syndrome (MTS) is characterized by unilateral lower extremity venous hypertension and stasis due to compression of the iliac vein between an iliac artery and the lumbar spine. In almost all cases, the left common iliac vein is compressed between the right common iliac artery and L5 vertebral body; however, other patterns have been described. Although nearly always idiopathic, iatrogenic MTS may also be caused by iliac arterial stenting. We present a unique case of new left common iliac vein compression by the left common iliac artery following aorto-bi-iliac endovascular aneurysm repair (EVAR). This iatrogenic MTS caused complete thrombosis of the left CIV, which was subsequently treated successfully by venous stenting.
HISTORY: A 71-year old female underwent multi-stage hybrid repair of an extent III thoracoabdominal aortic aneurysm. Aneurysmal degeneration had displaced her aortic bifurcation to the right of midline. Severe bilateral iliac arterial stenosis mandated bilateral open common iliac to common femoral bypasses and aorto-bi-iliac endografting to permit subsequent safe delivery of fenestrated aortic devices. Following EVAR, she developed left lower extremity pain, swelling, and edema. CT angiography demonstrated new onset compression of the left common iliac vein by the stented left common iliac artery, with associated venous thrombosis from the bifurcation of the inferior vena cava to the origin of the left hypogastric vein.
PLAN: Venography from a left common femoral access point confirmed occlusion of the left common iliac vein, with venous outflow via hypogastric cross-pelvic collaterals. Iliac vein stenting was performed with a Wallstent 16mm x 60mm (Boston Scientific). Completion venography demonstrated restoration of normal antegrade venous flow. The patient’s symptoms subsequently resolved. CT imaging at 3 months post-procedure demonstrated preserved patency of the stent.
DISCUSSION: Iatrogenic MTS is a rare but known complication of iliac arterial stenting, including EVAR. Variations in arterial anatomy, such as those caused by aneurysmal degeneration, may predispose to atypical compression patterns. Providers must have a high index of suspicion for MTS after iliac arterial stenting or EVAR in patients with new onset leg pain, swelling, or deep vein thrombosis. Iliac vein stenting may be successful at restoring venous patency.


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