A 36-year-old man with Sjögren's syndrome presented with a 3-year history of left pelvic pain and an inability to sit for long periods of time. Angiography revealed a filling defect at the proximal left common iliac vein (Fig. 1) consistent with May-Thurner syndrome. Intravascular ultrasound (IVUS) (Visions® PV8.2F catheter, Volcano Corporation; San Diego, Calif) revealed severe venous compression with reduced cross-sectional area (Fig. 2). Stenting was performed with a Palmaz 5010 stent (Cordis Corporation, a Johnson & Johnson company; Miami Lakes, Fla) on a Maxi LD™ 16 × 16-mm balloon (Cordis) (Fig. 3). After stenting, IVUS revealed good wall apposition and improved cross-sectional area (Fig. 4). On follow-up, the patient's symptoms had improved, and he had resumed all previous activities.
Fig. 1 Venous angiogram of the inferior vena cava reveals external compression of the left common iliac vein (arrow).
Fig. 2 Intravascular ultrasonogram reveals May-Thurner syndrome.
green = left common iliac vein; blue = left common iliac artery
Fig. 3 Venous angiogram shows the result of stenting the left common iliac vein.
Fig. 4 Intravascular ultrasonography shows the left common iliac vein after endovascular stenting.
green = left common iliac vein; blue = left common iliac artery
Comment
Obstructive compression of the left common iliac vein by the right common iliac artery was first described by May and Thurner in 1957.1 This compression of the iliac vein, known as May-Thurner syndrome, can cause iliofemoral deep venous thrombosis, leg or pelvic pain, edema, or limb-threatening acute inflammation.
Endovascular treatment of May-Thurner has emerged within the last decade as the cornerstone of therapy. Although endovascular balloon angioplasty has been attempted in May-Thurner syndrome, endovascular stenting remains the 1st-line therapy, due to continued arterial compression of the iliac vein. Small, nonrandomized studies of endovascular stenting for this condition2,3 have shown good initial patency rates and extensive symptomatic relief on long-term follow-up. As a result of high technical success rates and the clear relief of symptoms, endovascular stenting is now the preferred initial therapy.
Intravascular ultrasonography has aided in both the diagnostic and therapeutic aspects of intravascular interventions by providing valuable information on vascular size and morphology. In a small study of 16 patients who had May-Thurner syndrome,4 IVUS-guided endovascular repair influenced decisions on additional therapy in 50% of the patients.
In summary, IVUS provides an important diagnostic and therapeutic tool in the endovascular treatment of May-Thurner syndrome.
Footnotes
Address for reprints: Zvonimir Krajcer, MD, 6624 Fannin St., Suite 2780, Houston, TX 77030
E-mail: zvonkomd@aol.com
References
- 1.May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8(5):419–27. [DOI] [PubMed]
- 2.Patel NH, Stookey KR, Ketcham DB, Cragg AH. Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome. J Vasc Interv Radiol 2000;11(10):1297–302. [DOI] [PubMed]
- 3.O'Sullivan GJ, Semba CP, Bittner CA, Kee ST, Razavi MK, Sze DY, Dake MD. Endovascular management of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol 2000;11(7):823–36. [DOI] [PubMed]
- 4.Forauer AR, Gemmete JJ, Dasika NL, Cho KJ, Williams DM. Intravascular ultrasound in the diagnosis and treatment of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol 2002;13(5):523–7. [DOI] [PubMed]