IVUS-Guided Salvage of Acute Venous Stent Fracture at Compression Site in May-Thurner Syndrome

Abstract

Background

May-Thurner syndrome results from chronic compression of the left common iliac vein between the right common iliac artery and the lumbar vertebrae. It predisposes to iliofemoral deep-vein thrombosis.

Case Summary

A 40-year-old man presented with recurrent ulceration of the left medial gaiter region. Computed tomography venography revealed compression of the left common iliac vein. Endovascular therapy was performed and a dedicated venous stent was deployed. Postdilatation of the stent resulted in fracture of the stent at the compression point. Rescue was achieved by deploying an overlapping venous stent, restoring circular luminal geometry. The patient experienced symptomatic improvement, and the venous ulcer resolved within 5 months.

Discussion

This report illustrates a rare complication of venous stenting and emphasizes the critical role of intravascular ultrasound in recognizing device failure and guiding immediate corrective intervention.

Take-Home Messages

May-Thurner syndrome should be suspected in young patients with severe unilateral chronic venous disease. Fracture of venous stents may occur at the iliac compression site after deployment.

Visual Summary

Visual Summary.

Summary Figure Showing the Patient Course From the Clinical Presentation, Diagnosis, and Treatment to Clinical Outcome

CEAP = clinical, etiology, anatomy, and pathophysiology; CT = computed tomography; IVUS = intravascular ultrasound; N/A = not applicable.

History of Presentation

A 40-year-old man presented with a recurrent ulcer over the medial aspect of the left lower leg that had persisted for 18 months despite compression therapy. He had experienced 2 episodes of left iliofemoral deep-vein thrombosis over the past 2 years, both treated with 6 months of oral anticoagulation. There was no history of malignancy, prolonged immobilization, trauma, or known thrombophilia.

On examination, the limb demonstrated hyperpigmentation, lipodermatosclerosis, and a 3 × 4-cm ulcer in the medial gaiter region surrounded by indurated skin (Figure 1). The lower leg had a typical “champagne-bottle” appearance reflecting advanced chronic venous disease. Peripheral arterial pulses were normal. Clinical assessment classified the disease as CEAP (clinical, etiology, anatomy, and pathophysiology) C6, with a Villalta score of 18, indicating severe postthrombotic syndrome.

Figure 1.

Non Healing Ulcer on the Left Leg

(A) Depicting a nonhealing ulcer on the medial aspect of the shin. (B) Depicting the relative loss of hair on the left leg, with swelling of the left calf and a nonhealing ulcer on the left leg when compared with the right leg.

Past Medical History

No significant past medical history.

Investigations

Duplex ultrasonography of the left lower limb revealed postthrombotic changes within the femoral vein and minimal superficial venous reflux and also revealed decreased flow in the left common iliac vein (Figure 2A). The severity of skin changes appeared disproportionate to these findings, raising suspicion of proximal venous obstruction. Therefore, a contrast-enhanced computed tomography venography was done, which revealed severe compression (>90%) of the left common iliac vein between the right common iliac artery and the fifth lumbar vertebral body (Figures 2B and 2C). Poststenotic dilatation and prominent pelvic collaterals confirmed hemodynamically significant May-Thurner syndrome.

Figure 2.

Colour Doppler and Computed Tomography Images Showing the Compression of the Left Common Iliac Vein by the Right Common Iliac Artery

(A) Color Doppler depicting decreased flow in the left common iliac vein (LT CIV). (B) Depicting the compression of the LT CIV by the right common iliac artery (RT CIA) in the axial cross-sectional view. The green arrow depicts the LT CIV being compressed by the RT CIA against the spine. (C) Showing the compression of the LT CIV by the RT CIA in the sagittal view. The light green arrow depicts the RT CIA compressing the LT CIV against the lumbar spine. LT CIA = left common iliac artery; RT CIV = right common iliac vein.

Management

Following a multidisciplinary team review and shared decision-making, endovascular therapy was performed under fluoroscopy and intravascular ultrasound (IVUS) guidance. Right and left femoral venous access was obtained, and systemic anticoagulation was administered. Initial venography confirmed complete stenosis of the left common iliac vein with delayed contrast drainage through collateral channels. The lesion was crossed with a Terumo wire with some difficulty, but the IVUS catheter could not be negotiated across the lesion. Balloon predilatation was performed using a 5 × 60-mm balloon, following which IVUS could be negotiated across the lesion, and imaging with IVUS demonstrated a maximum area stenosis of >90%. A venogram and arteriogram were done simultaneously with a pigtail in the right femoral artery, which clearly revealed the compression of the left common iliac vein by the right common iliac artery (Figure 3). Following this, balloon predilatation was repeated using a 10 × 40-mm and 12 × 40-mm balloon, followed by deployment of a 14 × 80-mm dedicated venous stent (Venovo Stent and is marketed as the Venovo Venous Stent System and is manufactured by BARD) extending from the ilio-caval confluence into the external iliac vein (Figure 4A).

Figure 3.

Simultaneous Arteriogram of the Common Iliac Artery and the Common Iliac Vein Showing Compression of the Left Common Iliac Vein by the Right Common Iliac Artery

The wide blue arrow depicts the left common iliac vein which is being compressed by the right common iliac artery.

Figure 4.

Arteriograms of the Iliac Vein Taken Duirng the Procedure

(A) Fluoroscopic result of the venous stent following high-pressure noncompliant balloon dilatation, showing an indentation suspicious of a fracture (arrow). (B) Fluoroscopic result of the venous stent following deployment of the second stent across the site of fracture of the first venous stent. (C) The adequate angiographic final result after intravascular ultrasound–guided optimization.

To optimize luminal gain, high-pressure postdilatation was performed using a 14 × 40-mm Atlas Gold (which has a nominal pressure of 6 atm and a Rated Burst Pressure of 18 atm) noncompliant balloon up to a pressure of 10 atm. Immediately after balloon deflation, fluoroscopy demonstrated disruption of the stent architecture at the compression site (Figures 4A–C). Repeat IVUS confirmed circumferential fracture of the stent struts with focal scaffold collapse, producing residual luminal narrowing (Figure 5). Consequently, a second 14 × 60-mm venous stent was deployed across the fractured segment with adequate overlap (Figures 4B and 4C). Repeat IVUS demonstrated restoration of a fully expanded circular lumen without residual stenosis (Figure 6), and final venography showed brisk iliac venous outflow with disappearance of collateral channels. The procedure was completed without complications.

Figure 5.

Intra-Procedural IVUS Images

Intravascular ultrasound (IVUS) images with (B) revealing the absence of stent struts (orange arrows) in the lumen except at 2 to 4 o’clock (red arrow) where the struts are visible. (A) and (C) show the IVUS images distal to and proximal to the site of tent fracture with struts seen circumferentially around the lumen.

Figure 6.

Pre-Procedural and Final Post Procedural IVUS Images

Intravascular ultrasound images of the tightest stenotic segment to treatment (A) and the final result after optimization (B).

Outcome and Follow-Up

The patient was discharged on dual antiplatelets, apixaban, and compression stockings. There are no international guidelines for anticoagulation in such patients; therefore, clinicians must rely on consensus statements, and antithrombotic regimens are individualized based on the clinical scenario, taking into account the bleeding and the thrombotic risk involved in every individual patient.

This patient had postthrombotic syndrome and a nonhealing ulcer as a sequela of deep venous thrombosis due to May-Thurner syndrome. Most consensus statements dictate anticoagulation for a minimum of 6 months (extendable up to 12 months) with direct oral anticoagulants (DOACs) or vitamin K antagonists.¹ Our patient was young, had no other comorbidities, and was at a low bleeding risk from anticoagulation. As we had deployed 2 stents (due to stent fracture of the first one) with a considerable overlap between both the stents and the stents were considerably long, we were concerned about stent patency, and thus dual antiplatelet therapy was given for 6 weeks followed by single antiplatelet therapy + DOACS for the remaining 6 months followed by only DOAC for 6 additional months to prevent any stent patency-related problems.

The recent consensus statement from the venous community (POATIVES 2024 [Principles of Optimal Antithrombotic Therapy for Iliac VEnous Stenting]) favored at least 6 months of antithrombotic therapy after venous stenting for acute iliofemoral deep venous thrombosis, with longer treatment individualized according to recurrence and bleeding risk.¹

Lower limb swelling improved rapidly, and the venous ulcer achieved complete healing within 5 months (Figure 7). Follow-up duplex ultrasound confirmed patent stents with preserved structural integrity. At 6 months, the Villalta score improved from 18 to 6 with no recurrence of thrombosis.

Figure 7.

Ultrasound Doppler at Follow-Up Showing a Patent Stent and the Image of the Involved Limb With Complete Resolution of the Ulcer and Decrease in Swelling

Discussion

May-Thurner syndrome is frequently overlooked in patients with unilateral chronic venous disease. When clinical severity appears disproportionate to distal duplex findings, evaluation of the iliac venous system using cross-sectional imaging is essential.²

This case highlights 2 clinically important aspects of iliac venous intervention: accurate recognition of proximal venous obstruction and awareness of rare structural complications of venous stents.

Dedicated venous stents have demonstrated excellent long-term durability in large clinical trials.³ Stent fracture, therefore, represents an extremely uncommon event.⁴ In this case, a fracture occurred immediately following high-pressure postdilatation at the compression point. The region of compression in May-Thurner represents a unique biomechanical environment in which pulsatile arterial forces exert repetitive radial compression and bending stress on the venous scaffold.⁵ Balloon expansion may transiently amplify these forces and potentially exceed the mechanical tolerance of the device. Although Sen et al⁶ described a delayed symptomatic fracture of an iliac venous stent identified during follow-up after successful implantation, our case represents an acute intraprocedural stent fracture occurring immediately after deployment at the iliac compression site in May-Thurner syndrome. This distinction is clinically important because it suggests a different underlying mechanism, likely related to severe focal extrinsic compression and procedural mechanical stress rather than chronic fatigue-related structural failure. Furthermore, our report highlights the value of IVUS in the immediate recognition of this rare complication and in guiding successful endovascular salvage during the index procedure, thereby avoiding delayed diagnosis and potential adverse sequelae.

IVUS played a pivotal role in identifying the structural failure and guiding immediate rescue therapy.^7,6 Overlapping stent implantation restored luminal integrity and produced excellent hemodynamic and clinical outcomes.

This experience emphasizes the importance of meticulous imaging assessment during venous interventions and suggests that the iliac compression point may represent a zone of increased mechanical stress for venous stents.8, 9, 10

Conclusions

• •May-Thurner syndrome should be suspected in cases with severe, unilateral postthrombotic syndrome and refractory venous ulceration.
• •The role of IVUS is crucial in diagnosing iliac venous obstruction, optimizing stent deployment, and identifying rare structural complications.
• •
  Immediate venous stent fracture is a rare but important procedural complication in the mechanically constrained May-Thurner segment.

  Take-Home Messages

  • •
    This case illustrates that the iliac compression segment in May-Thurner syndrome may represent a unique biomechanical “stress zone” where aggressive balloon optimization may precipitate acute venous stent fracture.
  • •
    Real-time IVUS imaging enabled immediate recognition and successful endovascular rescue, resulting in complete ulcer healing and marked clinical recovery.
  • •
    Awareness of this rare complication may influence future stent optimization strategies during iliac venous interventions.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.