Utilization of Intravascular Ultrasound in the May-Thurner Syndrome: A case series

Vivie Tran, Alistair Disraeli, Nate Fernandez, Karter Morris, Hoang Ho, Dixon Santana, MD, Mohammad M. Ansari, MD

PAD Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, TX, USA

Background

Iliac venous stenting, while effective, faces challenges like tortuous paths and variable diameters, affecting accurate deployment. May-Thurner syndrome (MTS) further complicates venous insufficiency management. This case series investigates the use of Intravascular Ultrasound (IVUS) to enhance precision and efficacy in iliac venous stent placement, particularly in two MTS cases.

Methods

Cases were selected based on the use of IVUS alongside conventional venography during iliac venous stenting procedures in patients with MTS. A thorough analysis was conducted to pinpoint instances where the application of IVUS provided additional, pertinent information that otherwise wouldn’t have been available with fluoroscopic venography alone.

Results

Male age 61 with a PMH of MTS diagnosed via clear imaging presents with severe lower extremity edema with a venous ulcer. IVUS revealed >58% in both the common iliac and external iliac veins. Balloon angioplasty and successful stent deployment were performed. Subsequent IVUS displayed complete resolution. The patient had instant symptom relief, and follow-ups demonstrated persistent relief, well-controlled venous insufficiency, and ulcer healing. This case underscores IVUS's effectiveness in guiding complex venous interventions for optimal stent placement and long-term benefits. It highlights the limitations of Doppler and pressured venography, emphasizing the crucial role of IVUS in accurate stent sizing and placement.

Female age 39, suspected of MTS of LLE with PMH of DM and obesity, presented with chronic leg swelling, induration, and pain. Duplex ultrasound revealed significant venous reflux. IVUS-guided intervention was performed to assess the extent of compression and plan stent placement. IVUS revealed a >53% stenosis in the external iliac vein. The patient had instant symptom relief, and follow-ups demonstrated persistent relief. Our case illustrates that venous insufficiency may stem not only from lower extremity valve issues but also from MTS itself. Addressing MTS can improve quality of life, especially in cases leading to DVT issues.

Conclusion

Our case series outlines two scenarios where IVUS-guided iliac venous stent placement in May-Thurner syndrome (MTS) yielded clear benefits for patients with lower extremity issues. MTS, often overlooked, poses long-term risks, such as DVT and ulcers. The resolution of MTS using dedicated stents can bring significant improvement. In all instances, IVUS should be mandatory for optimal outcomes.