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10-15 years, angioplasty and stenting of the iliac veins has gained momentum as a therapy for
chronicvenousthrombosisandthesymptomsofPTS.Raju47reviewedstudiesoniliacendovascular
intervention(angioplastyand/orstenting)noting3-5-yearstentpatencyratesinthe74%-89%range
among postthrombotic cases. Iliac intervention led toless edema, more venous ulcer healing, and
painrelief.Thestudiesdid notreportany cases ofiatrogenic PE.A systematic reviewandmetaanalysis48showediliacveinstentingforbothnonthromboticandthromboticiliacveinstenosistobe
safeandefficacious,withtechnicalsuccessratesofapproximately95%,majorbleedingupto1.1%,
PE up to 0.9%, and early thrombosis up to 6.8%. At 1-year follow-up, primary patency for
postthromboticpatientswas79%andsecondarypatencywas94%.
B.TreatmentandManagement
In patients with chronic DVT and disabling PTS, it is currently our practice to perform balloon
angioplastyfollowedbystentingtofibrosedand/orstenosediliacveins,butwerarelydeploycurrently
available stents distal to the inguinal ligament owing to potential concerns over stent fracture and
occlusion.Ifmore distal venous segments are fibrosed andnarrowed, balloonangioplasty alone (and
occasionally venous atherectomy) can be used. After venous stenting in a postthrombotic patient, we
prefer full-dose enoxaparin for the first month, after which the patient is transitioned to an oral
anticoagulantforafurther5months.Therearenorobustdataonoptimalanticoagulantstrategy.
VIII.ImagingofVenousThromboembolism
A.Ultrasound
Ultrasoundistheprimaryimagingmodalityforevaluationofvenousthrombosis.Freshthrombuscanbe
anechoic,49butlackofveincompressibilitywiththeultrasoundprobeisdiagnosticforDVT50asisthe
absence of color flow.51 An abbreviated and simple test for leg DVT is the so-called two-point
technique, where the common femoral region and popliteal veins are interrogated. More detailed
protocols,sometimesreferredtoas“wholeleg,”arealsoavailable.Thelattertechnique,althoughmore
complexandtime-consuming,diagnosesIDDVTsthatwouldotherwisebeundetectedwiththetwo-point
technique.
52
Computedtomography(CT)venographycanalsobeusedtodiagnoseDVTandhashighsensitivity(over
95%)andspecificity(96%)withtheaddedabilitytobetterdistinguishacutefromchronicthrombus.
53,54
In our experience, it is a good tool particularly when evaluating iliac vein or IVC thrombosis. One
challengeofCTvenographyisthepropertimingoftheimageacquisitionaftercontrastinjection.
B.MagneticResonance
Magneticresonance(MR)venographyisalsoagoodtoolforevaluationofDVT(particularlyiliacand
IVC) with high sensitivity and specificity and has the capability to distinguish fresh from residual
thrombus.
55,56
Gadoliniummayhavetheadvantageofbettervenousphasedistribution.
IX.VenousThromboembolismandRiskofSubsequent
ArterialThrombosis
A.AssociatedDisorders
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VTEandarterialthromboticdiseases(eg,myocardialinfarction[MI],ischemicstroke)havetraditionally
been regarded as separate disease entities, with different pathophysiology and therapy. There are,
however,anumberofwell-knowndisorderscharacterizedbybotharterialandvenousinvolvement,such
as heparin-induced thrombocytopenia, antiphospholipid antibody syndrome, and myeloproliferative
disorders.Inaddition,thereisevidencetosuggestthatVTEmayleadtoincreasedarterialischemicevent
rates.
B.TrialsandStudies
A 20-year Danish population–based cohort studyevaluated the risk of myocardial infarctionand
stroke among 25,199 patients with DVT and 16,925 patients with PE.57 Patients with known
cardiovascular disease were excluded. Inthe firstyearafterthe thrombotic event,comparedwith
controls,DVT patientshadarelativeriskof1.60 forMI (95%CI1.35-1.91)and2.19 forstroke
(1.85-2.60). PEpatientshad a relative risk of 2.60 (2.14-3.13) for MI and 2.93 (2.34-3.66) for
stroke.RelativerisksdidnotdiffersignificantlyforthosewithprovokedversusunprovokedVTE.
Theincreasedrelativeriskremainedraisedfortheensuing20years.
AnotherScandinavianpopulation–basedstudyfoundanassociationbetweenVTEandfuturearterial
eventsinallwomanandmenaged<65years,overamedianfollow-upof12.2years.Womenwith
VTEhad3.3-foldhigherriskofsubsequentarterialdisease;menunderage65yearshadahazard
ratioof2.06.
58
a. Hereditary thrombophilia or other hypercoagulable disorders may explain some of the
increasedarterialthromboticdiseaseafterVTE.59Inaddition,thereareanumberofcommon
factorsthatappeartopredisposetobotharterialandvenousdisease:plateletactivation,higher
clotting factor concentration, older age, smoking, obesity, inflammatory cytokines, and
estrogens.
60
In animal studies, VKA therapy resultsin arterial calcification.61 In humans, prolonged VKA therapy
appearedtobeassociatedwith(extracoronary)vascularcalcification.
62
X.ThePotentialRoleofStatinsinVenousDisease
A.JupiterTrial
In 2009, theJupiterTrialevaluatedrosuvastatin20mginpatientswithelevatedhsCRP (>2mg/L) and
madetheobservationthatoveramedianfollow-upof1.9years,thestatin-treatedgrouphadlowerrates
ofVTE(hazardratioforrosuvastatin,0.57;95%confidenceinterval,0.37-0.86;P=.007).
63
B.StatinTherapy
AnexcellentsystematicreviewbyRodriguez64discussesthedataforstatintherapyanditspotential
antithromboticandanti-inflammatoryroles.Forexample,IL-6–inducedCRPisdecreasedbystatins.
65
A2009meta-analysis66appearstosupportthepotentialroleofstatintherapyinthepreventionof
VTE.
In a murine DVT model, treatmentof mice withdailystatin reduced thrombus burden and DVTinduced venous scarring.67 Venous scarring and valvular damage have been attributed to the
developmentofPTS.Statinsreducedplateletaggregation,tissuefactor(TF),andmyeloperoxidase.
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67
Inthesamestudy,statintherapyalsoreducedTFlevelswithinthrombus.
C.PlateletRecruitment
Plateletrecruitmentandactivitymayalsoallowdeepveinthrombusformationandextension.
68,69
Statins
appeartolimitcyclooxygenase-1(COX-1)activation,whileenhancingnitricoxidesynthase,whichcan
inhibitplateletactivationandaggregation.
70
D.OralAnticoagulation
InandofitselforalanticoagulationdoesnoteliminatePTS,althoughtheinabilitytoanticoagulateraises
the risk.71 A clinical prospective randomized single-center open-label trial evaluated rosuvastatin in
patientstreatedwithlow-molecular-weightheparinsforDVT(n=234).Thetreatmentgroupreceived510mgdailyrosuvastatinplusLMWH.ThecontrolgroupreceivedLMWHonly.After3-months,D-dimer
levelswerenotsignificantlydifferent,butCRPlevelswerelowerinthestatin-treatedgroup.TheVillalta
scoreforPTSwassignificantlylowerinthestatingroup(3.45±6.03vs7.79±5.58,P=.035),andthere
waslowerincidenceofPTSinstatingroup(38.3%vs48.5%,P=.019).72Themajorlimitationofthis
trialwasitsopen-label,single-centerdesign.
XI.Summary
VTEisadisabling,potentiallylethaldiseasewithlong-termsequelaeandahighrateofrecurrence.The
currentguidelinescanhelpdefine therecommendeddurationofanticoagulation required.Morestudies
areunderwaytodeterminetheoptimaltreatmentalgorithmforanacuteVTEaswellaspharmaceutical
therapiestoreducerecurrenceanddisability.
73,74
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C H A P T E R 2 3
May-ThurnerSyndrome
S.ElissaAltinMD
GabriellaWilsonMD
I.Introduction
A.History
B.Studies
C.SettingofIliacVeinThrombosis
II.Epidemiology
A.May-ThurnerSyndrome,IlliacVeinCompressionSyndrome,orCockettSyndrome
B.May-ThurnerSyndromeandDeepVeinThrombosis
III.Pathophysiology
IV.ClinicalPresentation
A.History
B.PhysicalExamination
V.Diagnosis
A.DifferentialDiagnosis
B.Imaging
VI.TreatmentOptions
A.NoninvasiveTreatment
VII.EndovascularApproachestoManagementofMay-ThurnerSyndrome
A.IliacVeinCompressionWithAcuteDeepVeinThrombosis
B.IliacVeinCompressionWithPostthromboticSyndrome
C.IliacVeinCompressionWithSymptomaticNonthromboticChronicVenousInsufficiency
VIII.DeterminantsofStentPatency
A.EndovenousInterventionWithBalloonAngioplastyandStenting
B.RecurrentStenosis
IX.Follow-up
X.Summary
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I.Introduction
A.History
May-Thurnersyndrome(MTS)isasyndromeofvenousoutflowobstructionduetoextrinsiccompression
by the arterial system against bonystructures. In 1908, McMurrich first described isolated leftlower
extremityswellingduetoleftiliacveincompression.Inthiscadaverstudy,heobservedthatadhesionsof
the iliac veins were present inabout one-third ofthe cadavers studied. Of these, the vastmajorityof
adhesionsattachedtotheiliofemoralvesselswerepresentontheleftside.Thisstudythusproposedthat
adhesions could be a possible explanation for the left-sided predilection for iliofemoral thrombosis
formation that Virchow first notedin 1851. Almost 40 years after McMurrich,EhrichandKrumbhaar
performedanautopsystudythat revealed increased collagenandelastin depositionoftheleftcommon
iliac vein, causing obstruction and possibly contributing to the increased prevalence of left-sided
iliofemoralthrombosis.
1
B.Studies
1.AhallmarkstudywasconductedbyMayandThurnerin1957thatproposedananatomicvariantasthe
underlyingcause forincreased prevalenceofleft-sided iliofemoralvenous thrombosis.Theyevaluated
430cadaversandnoted that22% ofthe cadavers exhibitedcompressionofthe left commoniliac vein
betweenthe rightcommoniliac arteryandthe fifth lumbarvertebra. Theypostulatedthatthis anatomic
abnormalitycouldbeanexplanationforthissidepreferenceofiliofemoraldeepveinthrombosis(DVT)
first described by Virchow.They hypothesizedthat bothpulsation andmechanical compressionof the
overlyingrightcommoniliacarteryinthesevariantsleadstofocalstenosisofthewalloftheunderlying
leftcommoniliacvein.Theyreferredtothisareaofstenosisasa“venousspur”andalsoproposedthat
this“spur”mightplayaninstigativeroleinlowerextremityvenousoutflowobstruction.
2
2.Theassociationbetweeniliacveincompressionandpostthromboticsyndrome(PTS) was shownby
Cockettetalin1967.3Theyfoundthatthisanatomicvariantmayserveasboththemaininitiatingfactor
iniliofemoralvenousthrombusformationandthelimitingfactorinvesselrecanalizationafterthrombosis.
Thisstudyinvestigated48 cases of postthrombotic iliacvenous obstructionwithoutinferior vena cava
involvementandfoundthatofthese48cases,39wereconfinedtotheleftleg.Ofthese,33showedthe
levelofobstructionoccurringatthejunctionwheretherightcommoniliacarterycrossestheleftcommon
iliacvein.
C.SettingofIliacVeinThrombosis
In thesettingofiliacveinthrombosis,thevesselcaneithercompletelyorincompletelyrecanalize.The
subsequent thrombophlebitis triggers anacute inflammatory responsewithinthe vessel, which leads to
scarringofthevein.Thisprocessdrivesrecanalizationand,inthemajorityofcases,resultsinincomplete
recanalization.Inthissetting,adequacyofvenousoutflowdependsonwhetherornotthebodyisableto
develop sufficient collateral circulation. In the event of incomplete recanalization and inadequate
collateralformation,theresultisiliacveinobstructionmanifestingclinicallyasPTS.
II.Epidemiology
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A.May-ThurnerSyndrome,IlliacVeinCompressionSyndrome,orCockett
Syndrome
1. Thepresenceofa compressed leftcommoniliac veinbythe overlying rightcommoniliac artery is
widelyreferredtoasMay-Thurnersyndrome(MTS),althoughsomerefertothisanatomicvariantasiliac
vein compression syndrome or Cockett syndrome. MTS is most commonly seen in patients aged 2040years,disproportionatelyaffectingfemalesmorethanmales.TheautopsystudiesofMayandThurner
inthe 20thcentury demonstratedleft commoniliac veincompressionin22% of cadavers, althoughthe
actualprevalenceofthisanatomicvariantinthegeneralpopulationremainsunknown.
4
2.AstudyperformedbyKibbeetalattemptedtobetterdefinetheprevalenceofleftcommoniliacvein
compression in the asymptomatic population by performing a retrospective review of CT scans to
determinethepresenceorabsenceofleftiliacveincompressioninpatientswithoutunderlyingevidence
oforriskforiliacveincompressionorDVT.Ofthe50CTscansreviewedinthisgroup,meanleftiliac
veincompressionwas35.5%±2.4%.Additionally,24%ofpatientCTscansrevieweddemonstratedat
least50%compressionoftheleftiliacvein.
5
B.May-ThurnerSyndromeandDeepVeinThrombosis
MTS-associatedDVTaccountsforapproximately2%-3%ofoverallcasesoflowerextremityDVT,and
MTS has only been diagnosed in 2%-5% of patients with venous disease of the lower extremity.
4,6
However,thereareotherstudiesthatsuggestahigherprevalencethanthis.InanMRIstudyof24patients
with unilateral left lower extremity edema, 37% of these patients had evidence of MTS on magnetic
resonancevenography(MRV).7Anotherstudyonvenousregistrydatafoundthatinabout62%ofpatients
withacuteiliofemoralDVT,“spurlikelesions”werefound.8Thisfindingmaysuggestthattheassociation
ofleft-sidediliofemoralDVTwithleftcommoniliacveincompressionismorecommonthanpreviously
thought.9ThetrueassociationbetweenMTSandlowerextremityvenousdiseaseisnotwelldefinedand
islikelyunderestimated.
III.Pathophysiology
MTS refers to extrinsic compression of the iliac venous system by an overlying iliac arterial vessel
againstthelumbarvertebrae.Inthevastmajorityofcases,thisinvolvescompressionoftheleftcommon
iliacveinbetweenthefifthlumbarvertebraandtheoverlyingrightcommoniliacartery.4However,other
variantshavebeenidentifiedandincludetherightiliacarterycompressingtheinferiorvenacava,right
internaliliacarterycompressingtherightiliacvein,andleftinternaliliacarterycompressingtheleftiliac
vein.Thecompressionandpulsationoftheoverlyingarterycausesincreaseddeposition ofelastin and
collagenintheiliacveinwallandintimalproliferation,whichleadstotheformationofa“spur”thatcan
cause complete or partial occlusion of the iliac vein. Over time, venous thrombosis may occur and
withoutproperrecanalizationanddevelopmentofcollateralcirculation,venousoutflowobstructionand
venoushypertensionresult.
3
IV.ClinicalPresentation
A.History
1. Patientswiththeanatomic variationunderlyingMTSare usuallyasymptomatic untilthrombosisand
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venous outflow obstruction occur, usually inthe second to fourth decades of life. The locationofthe
symptoms is important to determine, as this suggests which vessels may be involved. If pain is the
primary symptom, the patient should be prompted to localizethe pain to the calf,thigh, groin,and/or
pelvis.Additionally,whenMTSandiliofemoralDVTareconsideredonthedifferentialdiagnosis,afull
historyshouldbetakentoincludethepresenceofanypriorDVTsincludinglocation,ageofoccurrence,
provokingfactors,treatmentcourse,andcomplications.9Finally,thehistoryshouldalsoinvestigateany
current riskfactors for DVT,including recent surgery, prolongedimmobilization, extended travel with
prolongedmotionlessness,hormonereplacementtherapy/oral contraceptive pilluse,pregnancy,clotting
disorder,malignancy,smoking,andobesity,astheseriskfactorshavebeenimplicatedinMTSsyndrome.
2. Theclinicalpresentationischaracterizedbyeitheracutethrombosiswithunilateral edemaor more
chronic progressive left lower extremity edema and pain with development of chronic venous
insufficiency.Lowerextremityskinchangesduetovenousstasismaydevelop,suchashyperpigmentation,
skininduration,andsubcutaneousfatinflammation,consistentwithlipodermatosclerosis.4Asthevenous
outflow obstructionpersists,patientsmaydemonstrate signs of chronicvenous insufficiency, including
venous ulceration, varicose veins, and superficial venous thrombophlebitis. Additionally, those with
longstandingvenousoutflowobstructioncanalsodevelopvenousclaudication.Finally,thoughrare,itis
importanttorecognizethatMTScanalsopresentwithcomplications,includingpulmonaryembolusand
left commoniliac veinrupture.6 Suspicion for MTS should increase when a patient presents with a
historyconcerningforDVToftheentirelimb,primarycomplaintsofvenousclaudication,andrecurrent
DVTinthesamelocation.
9
B.PhysicalExamination
On physical examination, both lower extremities should be examined specifically for assessment of
edema,erythema,tenderness,skinchanges,varicoseveins,andulcers.Additionally,alllowerextremity
peripheral pulses should be palpated, and the pelvis and lower abdomen should be examined for the
presenceofvaricoseveinsoranyotherchangesconsistentwithchronicvenousstasis.Followingphysical
examination, duplex ultrasound can help determine compressibility of the common femoral vein with
Dopplerwaveformphasicitytocompareaffectedlegwithunaffected.
9
V.Diagnosis
A.DifferentialDiagnosis
ClinicalsuspicionmayleadacliniciantoconsiderMTSonthedifferentialdiagnosisforunilaterallower
extremity edema,but there are many conditions that may presentsimilarly toMTS.Therefore,various
imagingtechniqueshaveprovenusefulinbothevaluatingforthepresenceofiliacveincompressionand
also excluding other possible conditions that may mimic MTS. Currently color Doppler ultrasound
(CDUS),conventionalvenography,computedtomographyimaging(CT),magneticresonancevenography
(MRV), and intravascular ultrasound (IVUS) are the most commonly used imaging techniques for
evaluation of chronic venous insufficiency and possible MTS. These techniques differ in cost,
invasiveness,andtheirabilitytovisualizetheiliofemoralvessels,identifycompressionoftheiliacvein,
andruleoutothercausesofunilaterallowerextremityedema.Althoughconventionalvenographyremains
thegoldstandardfordiagnosis,theseothermodalitiesarenoninvasiveandclinicallyuseful.
B.Imaging
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1.ColorDopplerUltrasound
a. Although many imaging modalities are currently used in the workup of MTS, color doppler
ultrasound (CDUS) is the mostcost-effective and noninvasive imagingmodality for evaluation of
lowerextremity superficialanddeep veinsandistherefore commonlyusedasastarting pointfor
diagnosticimaging,withparametersdescribedbyLabropoulosetal.Theyinvestigated37patients
withlowerextremityswellingwithorwithoutpainusingduplexultrasound,venography,andIVUS
to localize and diagnose venous stenosis and define criteria for diagnosis. Using a 2-4 MHz
transducer to evaluate theiliacveins andinferior venacava, an angle ofinsonation of <60° was
appliedinB-modesettingforcomparisonofveindiameterreduction.Theyfound thatapeakvein
velocity ratio of>2.5 across the stenosis could most reliably predict thepresenceof a pressure
gradientof3mmHg,whichrepresenteda>50%reductioninluminaldiameter.Theyidentifiedthe
followingparametersfordiagnosisofcentralvenousstenosis:mosaiccolorindicatingpoststenotic
dilatation,abnormalDopplersignalatthesiteofstenosis,asymmetryofDopplerwaveform ofthe
affectedextremitycomparedwithunaffectedextremity,poorflowaugmentation,andlowamplitude
signals.
10
b. Duplex ultrasound has been a mainstay in diagnostic workup for DVT and chronic venous
insufficiency and is particularlyuseful for evaluation ofthecalf, popliteal, andfemoral veins.In
comparison,pelvicveinsaremoredifficulttovisualizewithduplexduetobowelgas,bodyhabitus,
or location of the veins with respect to the bladder or adipose tissue. Additionally, CDUS can
identify mostcasesofiliofemoralDVTbyassessingforvesselpatencybutlacks thesensitivityto
detect nonocclusive thrombosis of the common iliac vein and as a result may be insufficient to
diagnose MTS.11 In a prospective study quantifying the accuracy of duplex imaging in patients
suspectedof having DVT,dupleximagingcouldadequately assess the commonandexternal iliac
vein in only 47% of cases. For the external iliac vein alone, though, 79% of cases could be
adequately assessed, underscoring the difficultyofvisualizing the common iliac veinwith CDUS
withinthepelvis.
12
2.VenousPhaseCTandMagneticResonanceVenography
a. CTimagingin thevenousphaseprovidesbettervisualization ofthe pelvic vessels incomparison
withCDUSandisconsideredasensitiveandspecifictestfordiagnosingiliofemoralthrombosis.CT
isabletoassessforvesselobstructionduetoextrinsiccompressionwithinthepelvisnotonlyfrom
MTS, but also from malignancy, hematoma, or fibrosis as well. Limitations includevisualization
distortionincasesofchronicDVTwherefibrosiswithintheveinmayalterthevesselstructure.
11
Additionally, CT imaging is costly, requires the use of IV contrast, is relatively contraindicated
during pregnancy, and is technicallydifficult to time in thevenous phase becauseofvariationsof
cardiacoutputandthedegreeofstenosis.9Finally,degreeofluminalcompressionmaybeaffected
bythepatient’svolumestatus,withdehydrationoverestimatingdegreeofcompression.
b. MRVisanotherimagingtechniquethat,similarlytoCTimaging,providesimprovedvisualizationof
the pelvic vessels. MRV is also comparable to CT scan in its ability to rule out extrinsic
compressionoftheiliacveinsandisconsideredsuperioratassessingtheanatomyoftheiliofemoral
venous system. A primary advantage of MRV over CT venography is use of contrast agents that
remainwithinthevascularsystemlonger,eliminatingthecontrasttimingdifficultyencounteredwith
venous phase CTimaging.9Additionally,enhancementsincluding spin-echoimagingcanevaluate
inflammatory changes in the vessel wall that may help differentiate between acute and chronic
thrombus.13MRVdoes sharesome limitationswithCTscanning, includingcost,contrastuse,and
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