Venogram of May-Thurner s/p Stent

May-Thurner Syndrome

Clinical History

A 42 yo female with history of extensive left lower extremity DVT treated with pharmacomechanical thrombolysis with good result returns to the clinic with persistent leg swelling and negative duplex ultrasound study.  She underwent diagnostic venography with IVUS (intravascular ultrasound) which revealed May-Thurner Syndrome.  This was treated with primary stenting with excellent technical and clinical result.


Diagnostic Venography

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Image 1.1.

Diagnostic venogram of the left common iliac vein in a prone patient. Note the large caliber common iliac vein with the subtle en face filling defect near the confluence which represents compression from the right iliac artery. This illustrates why venography is not a sensitive tool for detecting venous stenosis.







Intravascular Ultrasound (IVUS)

Image 2.1.

IVUS images taken at the IVC, iliac confluence, area of maximal stenosis and distal common iliac vein. Here the extrinsic compression is easily appreciated. IVUS is an excellent tool for detecting and characterizing venous stenosis.

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Post Treatment Venography

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Image 3.1.

Venogram after treatment with an 18 x 90mm Wallstent shows excellent angiographic appearance with no residual stenosis. The native vessel measured 18 centrally but only 14 peripherally. The stent was dilated to 16mm.








Case Discussion

May-Thurner remains an underdiagnosed phenomenon which contributes to significant morbidity throughout the world.  Some clinical clues include persistent swelling after successful catheter directed treatment of DVT, persistent swelling after Treatment of varicose veins, or concomitant deep and superficial venous insufficiency on venous Doppler ultrasound studies.

Comments are welcome, or feel free to start a thread in the forum if you prefer.

Peace and kindness.

 


Case Credits

Images and content graciously provided by:

Jhimmelvir

 


2 replies
  1. Marsha
    Marsha says:

    Hello, thank you for this artical i was diagnosed with MTS. I was stented but i continue to swell. Often times i have pain with the sweeling only on the left side. I did not have DVT, I was tild i had a 90% blockage.

    I have gone to my coordioligist on several occusions since March 9th 2017 when the stent was placed and nothing has changed. HELP ME, i want to live a normal life without swelling and often times pain.

    Reply
    • jhimmelvir
      jhimmelvir says:

      Hi Marsha. I’m sorry you continue to suffer. Often times patients with MTS have chronic damage to the valves of the deep and superficial veins which can result in persistent swelling and pain even after the stenosis has been stented. Sometimes these problems can be addressed with additional procedures, but sometimes not. Unfortunately, most cardiologists are well trained in placing stents, especially in arteries, but lack comprehensive training in venous conditions such as MTS. This is true for many specialties that practice vein care. There are cardiothoracic surgeons, dermatologists, plastic surgeons and primary care physicians that all perform “vein” care because it can be very lucrative, particularly if it is cosmetic. In most cases, however, these specialists do not offer the type of comprehensive vein care that a patient such as you requires. There is currently no reliable method to determine which practitioners are best qualified to provide comprehensive vein care. My recommendation is that you seek out interventional radiologists or vascular surgeons near you and interview them about their experience with MTS, deep and superficial venous insufficiency, and EVLT, sclerotherapy and phlebectomy of varicose veins. If they don’t do it all, then thank them kindly for their time and move on. Word of mouth referrals may be your best bet. Best of luck!

      Reply

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