Download PDF
CC BY-NC-ND 4.0 · Journal of Clinical Interventional Radiology ISVIR 2017; 01(01): 023-030
DOI: 10.1055/s-0036-1597954
Review Article
Indian Society of Vascular and Interventional Radiology

Evolving Concepts in the Diagnosis and Management of May–Thurner Syndrome

Murthy R. Chamarthy
1   Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
,
Patrick Sutphin
1   Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
,
Matthew Anderson
1   Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
,
Mark Reddick
1   Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
,
Sanjeeva P. Kalva
1   Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
› Author Affiliations
Further Information

Publication History

Publication Date:
28 July 2017 (online)

   Permissions and Reprints

Abstract

May–Thurner syndrome is a common cause of left lower extremity venous thrombosis resulting from repetitive and dynamic compression of the left common iliac vein by the right common iliac artery, commonly seen in young to middle-aged women. The diagnosis requires high clinical suspicion. Computed tomography venography and magnetic resonance venography depict the extent of venous thrombosis and iliac venous compression in patients with underlying thrombotic and nonthrombotic pathologies, respectively. Contrast venography allows detection of acute and chronic thrombus, associated venous obstruction, and collaterals but is of limited value to evaluate the early venous wall abnormalities. Endovascular ultrasound is highly useful to detect early mural changes and accurately quantify venous narrowing. Endovascular intervention with balloon dilatation and stenting with or without pharmacomechanical thrombectomy followed by long-term anticoagulation is the preferred treatment with excellent technical and clinical outcomes. This review focuses on the current understanding of the pathology, clinical presentation, and endovascular management of May–Thurner syndrome.

Keywords

May-Thurner Syndrome - iliac vein compression - stent - IVUS - thrombus - thrombolysis
 

  • References

  • 1 Cockett FB, Thomas ML. The iliac compression syndrome. Br J Surg 1965; 52 (10) 816-821
    CrossrefPubMedGoogle Scholar
  • 2 McMurrich JP. The occurrence of congenital adhesions in the common liac veins, and their relation to thrombosis of the femoral and iliac veins. Am J Med Sci 1908; 135 (03) 342-345
    CrossrefPubMedGoogle Scholar
  • 3 Ehrich WE. A frequent obstructive anomaly of the mouth of the left common iliac vein. Am Heart J 1943; 26: 18-31
    CrossrefPubMedGoogle Scholar
  • 4 May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8 (05) 419-427
    CrossrefPubMedGoogle Scholar
  • 5 Nazzal M, El-Fedaly M, Kazan V. , et al. Incidence and clinical significance of iliac vein compression. Vascular 2015; 23 (04) 337-343
    CrossrefPubMedGoogle Scholar
  • 6 Kibbe MR, Ujiki M, Goodwin AL, Eskandari M, Yao J, Matsumura J. Iliac vein compression in an asymptomatic patient population. J Vasc Surg 2004; 39 (05) 937-943
    CrossrefPubMedGoogle Scholar
  • 7 Narayan A, Eng J, Carmi L. , et al. Iliac vein compression as risk factor for left- versus right-sided deep venous thrombosis: case-control study. Radiology 2012; 265 (03) 949-957
    CrossrefPubMedGoogle Scholar
  • 8 Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med 2015; 20 (01) 74-83
    CrossrefPubMedGoogle Scholar
  • 9 Bozkaya H, Cinar C, Ertugay S. , et al. Endovascular treatment of iliac vein compression (May-Thurner) syndrome: angioplasty and stenting with or without manual aspiration thrombectomy and catheter-directed thrombolysis. Ann Vasc Dis 2015; 8 (01) 21-28
    CrossrefPubMedGoogle Scholar
  • 10 Fasanya AA, LaCapra G. May-Thurner syndrome with pulmonary embolism as the first presentation rather than deep vein thrombosis. Cureus 2016; 8 (02) e509
    PubMedGoogle Scholar
  • 11 Jiang J, Ding X, Zhang G, Su Q, Wang Z, Hu S. Spontaneous retroperitoneal hematoma associated with iliac vein rupture. J Vasc Surg 2010; 52 (05) 1278-1282
    CrossrefPubMedGoogle Scholar
  • 12 Vijayalakshmi IB, Setty HS, Narasimhan C. Unusual cases of right-sided and left-sided May-Thurner syndrome. Cardiol Young 2015; 25 (04) 797-799
    CrossrefPubMedGoogle Scholar
  • 13 Burke RM, Rayan SS, Kasirajan K, Chaikof EL, Milner R. Unusual case of right-sided May-Thurner syndrome and review of its management. Vascular 2006; 14 (01) 47-50
    CrossrefPubMedGoogle Scholar
  • 14 Molloy S, Jacob S, Buckenham T, Khaw KT, Taylor RS. Arterial compression of the right common iliac vein; an unusual anatomical variant. Cardiovasc Surg 2002; 10 (03) 291-292
    CrossrefPubMedGoogle Scholar
  • 15 Pandit AS, Hayes M, Guiney-Borgelt S, Dietzek AM. Iatrogenic May-Thurner syndrome after EVAR. Ann Vasc Surg 2014; 28 (03) 739.e17-739.e20
    CrossrefPubMedGoogle Scholar
  • 16 Fretz V, Binkert CA. Compression of the inferior vena cava by the right iliac artery: a rare variant of May-Thurner syndrome. Cardiovasc Intervent Radiol 2010; 33 (05) 1060-1063
    CrossrefPubMedGoogle Scholar
  • 17 Messina LM, Sarpa MS, Smith MA, Greenfield LJ. Clinical significance of routine imaging of iliac and calf veins by color flow duplex scanning in patients suspected of having acute lower extremity deep venous thrombosis. Surgery 1993; 114 (05) 921-927
    PubMedGoogle Scholar
  • 18 Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg 2007; 46 (01) 101-107
    CrossrefPubMedGoogle Scholar
  • 19 Wolpert LM, Rahmani O, Stein B, Gallagher JJ, Drezner AD. Magnetic resonance venography in the diagnosis and management of May-Thurner syndrome. Vasc Endovascular Surg 2002; 36 (01) 51-57
    CrossrefPubMedGoogle Scholar
  • 20 Ferris EJ, Lim WN, Smith PL, Casali R. May-Thurner syndrome. Radiology 1983; 147 (01) 29-31
    CrossrefPubMedGoogle Scholar
  • 21 Morelli MM, Burchi C, Battistini M, Capone AM, Cavallaro A. Veno-venous crossover bypass according to Palma: our experience [in Italian]. Ann Ital Chir 1996; 67 (04) 521-525 , discussion 525–526
    PubMedGoogle Scholar
  • 22 Jost CJ, Gloviczki P, Cherry Jr KJ. , et al. Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease. J Vasc Surg 2001; 33 (02) 320-327 , discussion 327–328
    CrossrefPubMedGoogle Scholar
  • 23 Meissner MH, Gloviczki P, Comerota AJ. , et al; Society for Vascular Surgery; American Venous Forum. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2012; 55 (05) 1449-1462
    CrossrefPubMedGoogle Scholar
  • 24 O'Sullivan GJ, Semba CP, Bittner CA. , et al. Endovascular management of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol 2000; 11 (07) 823-836
    CrossrefPubMedGoogle Scholar
  • 25 Suwanabol PA, Tefera G, Schwarze ML. Syndromes associated with the deep veins: phlegmasia cerulea dolens, May-Thurner syndrome, and nutcracker syndrome. Perspect Vasc Surg Endovasc Ther 2010; 22 (04) 223-230
    CrossrefPubMedGoogle Scholar
  • 26 Sapoval MR, Long AL, Raynaud AC, Beyssen BM, Fiessinger JN, Gaux JC. Femoropopliteal stent placement: long-term results. Radiology 1992; 184 (03) 833-839
    CrossrefPubMedGoogle Scholar
  • 27 Ahmed HK, Hagspiel KD. Intravascular ultrasonographic findings in May-Thurner syndrome (iliac vein compression syndrome). J Ultrasound Med 2001; 20 (03) 251-256
    CrossrefPubMedGoogle Scholar
  • 28 Butros SR, Liu R, Oliveira GR, Ganguli S, Kalva S. Venous compression syndromes: clinical features, imaging findings and management. Br J Radiol 2013; 86 (1030): 20130284
    CrossrefPubMedGoogle Scholar
  • 29 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 (05) 523-527
    CrossrefPubMedGoogle Scholar
  • 30 Moudgill N, Hager E, Gonsalves C, Larson R, Lombardi J, DiMuzio P. May-Thurner syndrome: case report and review of the literature involving modern endovascular therapy. Vascular 2009; 17 (06) 330-335
    CrossrefPubMedGoogle Scholar
  • 31 Chan KT, Popat RA, Sze DY. , et al. Common iliac vein stenosis and risk of symptomatic pulmonary embolism: an inverse correlation. J Vasc Interv Radiol 2011; 22 (02) 133-141
    CrossrefPubMedGoogle Scholar
  • 32 Shi WY, Gu JP, Liu CJ, He X, Lou WS. Endovascular treatment for iliac vein compression syndrome with or without lower extremity deep vein thrombosis: a retrospective study on mid-term in-stent patency from a single center. Eur J Radiol 2016; 85 (01) 7-14
    CrossrefPubMedGoogle Scholar
  • 33 Razavi MK, Jaff MR, Miller LE. Safety and effectiveness of stent placement for iliofemoral venous outflow obstruction: systematic review and meta-analysis. Circ Cardiovasc Interv 2015; 8 (10) e002772
    CrossrefPubMedGoogle Scholar