Endovascular Management of Chronic Left Iliac Vein Occlusion in May-Thurner Syndrome

Abstract

A 41-year-old female presented with post-thrombotic syndrome following diagnosis of deep vein thrombosis, treated with anticoagulation and placement of an IVC filter. Further work-up revealed chronic left iliac vein occlusion secondary to May-Thurner syndrome, successfully treated with left iliac vein stenting and resolution of symptoms.

VASCULAR DISEASE MANAGEMENT 2012:9(8):E139-E142

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Case Report

A 41-year-old female was referred for further evaluation of a totally occluded left iliac vein after presentation with post-thrombotic syndrome (PTS) following deep vein thrombosis (DVT). Her past medical history included endometriosis following 2 uneventful pregnancies, requiring total abdominal hysterectomy several years earlier. The patient was more recently hospitalized approximately 1 year prior for acute appendicitis requiring appendectomy during which she developed leg swelling and pain, was diagnosed with DVT, prompting inferior vena cava (IVC) filter placement, and discharged with warfarin therapy.

The patient presented 8 months later to the referring physician with complaints of unilateral lower extremity edema, heaviness, and pain diagnosed as PTS, despite being compliant with warfarin therapy and therapeutic internatinal normalized ratio. Computed tomography venography demonstrated complete occlusion of the left common femoral vein extending proximally to the left common iliac vein (Figure 1) with compression by the overlying right common iliac artery, which is consistent with May-Thurner syndrome. She was subsequently referred to our institution for further evaluation and treatment.

Selective bilateral venography was scheduled and the patient placed in prone position with ultrasound-guided bilateral popliteal vein access. A 7 Fr Ansel sheath (Cook Medical) was placed in the left popliteal vein and a 5 Fr Ansel sheath in the right popliteal vein. Selective venogram of the left popliteal vein confirmed occlusion of the left common femoral vein with extensive collateral network (Figure 2). Selective venogram of the right iliac vein demonstrated normal flow into the IVC (Figure 3) with normal appearance and positioning of the IVC, filter free of filling defects with brisk flow.

A Wildcat chronic total occlusion catheter (Avinger) was advanced in active and passive modes to traverse the occlusion (Figure 4) followed by a glidewire (Terumo) with confirmation of intraluminal position within the IVC via contrast injection (Figure 5). Serial balloon venoplasty was performed in ascending fashion using EverCross 6 mm x 100 mm, 7 mm x 120 mm, and 12 mm x 60 mm balloons (Covidien) and subsequent stenting with Protégé Everflex 12 mm x 80 mm and 8 mm x 150 mm self-expanding stents (Covidien) in overlapping fashion from the ostium of the left common iliac vein (Figure 6) to the common femoral vein. The entire stented segment was post-dilated with the EverCross 12 mm x 60 mm balloon and final venography demonstrated brisk flow through the left common femoral to common iliac vein stent (Figure 7).

The patient was discharged home the next day with marked improvement in her symptoms. Her medical regimen at discharge included aspirin indefinitely, clopidogrel for 1 month, and warfarin for 3 months. Outpatient follow-up at 3 months maintained complete resolution of symptoms.

Discussion

DVT of the lower extremities occurs in about 1 per 1000 people/year and is associated with significant morbidity.¹ Although anticoagulation effectively prevents thrombus extension, pulmonary embolism, death, and recurrence,² many patients develop venous dysfunction resulting in PTS, often characterized by pain, swelling, heaviness, edema, pigmentation, skin breakdown, and even ulceration.³ PTS is associated with reduced individual quality of life and increased cost of health care.⁴

May-Thurner syndrome is an often unrecognized etiology of DVT, due to left common iliac vein compression from the right iliac artery, first described by May and Thurner in 1956.⁵ The true prevalence of May-Thurner syndrome is unknown but various authors have reported 49%-62% prevalence within patients with DVT.^6,7

The clinical features of May-Thurner syndrome were initially described by Cockett and Thomas in 1965:⁸ female predominance in third to fourth decade of life presenting with a left leg DVT after a period of immobilization resulting in chronic edema, recurrent DVT, and venous claudication.

Therapy for May-Thurner syndrome has evolved over the years. Conservative therapy with compression stockings has been largely unsuccessful due to the proximal mechanical obstruction.⁸ Surgical procedures including venovenous bypass grafts have shown moderate success, while best surgical results have been demonstrated with vein patch angioplasty and rerouting of the right iliac artery to a retrocaval position.⁹ More recently, with the advancement of endovascular treatments, percutaneous iliac vein angioplasty with stent placement has been performed successfully with excellent patency rates.¹⁰

There is increasing evidence that early recognition and invasive treatment of DVT can reduce the incidence of PTS. In the acute setting of DVT, catheter-directed thrombolysis has been shown to be efficacious with low risk of bleeding for patients with high proximal DVT.¹¹ Pharmacomechanical thrombectomy offers a safe and effective alternative for treatment of acute DVT,¹² although limited by age of clot when greater than 3 days old.¹³ In chronic DVT, standard endovascular chronic total occlusion revascularization techniques are employed to traverse the occlusion. The Wildcat catheter has previously been reported for use in crossing a chronic venous stent occlusion¹⁴ and was used successfully in this case as the first reported use of the device in de novo venous occlusion. Subsequent endovenous angioplasty combined with stenting has been demonstrated as a safe and effective treatment strategy with good long-term patency rates.¹⁵

References

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Editor’s Note: From the ¹Deborah Heart and Lung Center, Browns Mills, New Jersey and the ²Catheterization Laboratory, Hanover Hospital, Hanover, Pennsylvania.

Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. George reports consultancy for Covidien and Avinger. Drs. VanHise and Gilbert have no potential conflicts.

Manuscript submitted June 27, 2012 and final version accepted July 9, 2012.

Address for correspondence: Jon C. George, MD, Director of Clinical Research, Division of Cardiovascular Medicine, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ, 08015, USA. Email: georgej@deborah.org