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Chapter 14
Contemporary Management of Non-Thrombotic and Thrombotic Iliocaval Compression Syndrome
Ariela Zenilman and Brian Derubertis
INTRODUCTION
Iliocaval compression syndrome is a well-described pathophysiologic entity that has taken
over 150years of investigation to define. As first described by Virchow, iliofemoral DVTs
were five times more likely to occur on the left lower extremity rather than the right. May and
Thurner then described iliocaval compression due to the chronic pulsation and mechanical
obstruction by the right iliac artery as a cause of left lower extremity venous hypertension.
The association of this with or without iliofemoral DVT became known as May-Thurner syndrome (MTS). As the pathophysiology of the disease became more widely studied and understood, MTS became recognized as the major contributing factor in lower extremity edema,
iliofemoral DVT, and the associated long-term sequela of post-thrombotic syndrome chronic
venous insufficiency.
siderably in the last decade. While symptomatic patients went undiagnosed or untreated for
several years, the progression of imaging and endovascular treatment modalities has offered
options for management. The focus of this chapter will be on management and treatment
algorithms of thrombotic and non-thrombotic iliocaval compression.
[1, 2]
Management of iliocaval compression syndromes has changed con-
PATHOPHYSIOLOGY
Although there are several variants of iliac compression syndrome, MTS is described as
compression of the left common iliac vein against the fifth lumbar vertebral body by the
right common iliac artery as the artery crosses anterior to the vein. The exact point of compression differs from individual to individual, and compression of the caval confluence has
also been described as well. Left iliac vein compression is a prevalent finding in the general
population, but only a small percentage of individuals with this radiographically recognized
phenomenon are symptomatic, so the true prevalence of iliac vein compression consistent
with the clinical diagnosis of MTS is unknown. Kibbe et al identified a 24% prevalence of
iliac vein compression in an asymptomatic population and concluded that this is a normal
anatomic variant.
18–49% of cases.
When the right common iliac artery crosses over the left common iliac vein it induces a
partial obstruction in two ways: (1) mechanical obstruction caused by compression of the
vein between the artery and vertebral body and (2) intimal hypertrophy of the vein from
repeated pulsation of overlying artery causing shear stress between the anterior and posterior vein walls.
predisposes them to thrombosis such as surgery, initiation of oral contraceptives, prolonged
immobility, malignancy, or a hypercoagulable state. The most common risk factors in patients
who progress to thrombosis are history of recent surgery or cancer (11.2%), hypercoagulable
DOI: 10.1201/9781003316626-17 141
[3]
In the setting of DVT, however, iliac vein compression can be present in
[3, 4]
[5, 6]
Generally, patients remain asymptomatic until exposed to a stressor that
142 Ariela Zenilman and Brian Derubertis
disorder (9.6%), immobilization (9%), hormone replacement therapy (6%), trauma (4.6%),
and pregnancy (3.2%).
[4]
The pathophysiology of disease in patients is important to under-
stand as it will guide management and categorize patients as candidates for intervention.
CLINICAL PRESENTATION
When a patient with venous disease is encountered, a careful history can help differentiate between
an acute DVT, chronic sequelae of DVT or post-thrombotic syndrome, or chronic venous disease
unrelated to venous thrombosis, including primary venous insufficiency. Left-sided clinical findings are presumed to be more likely associated with an obstructive iliac vein lesion, but lesions are
also reported near the confluence of the internal and external veins, so right-sided findings can
also indicate a pelvic source of obstruction.
[7]
Aliterature review in 2009 concluded that the disease predominantly affects female patients, and those with symptoms of acute iliofemoral venous
thrombosis tended to be young women in the second to fourth decades of life.
[8, 9]
As recognition
of the disease process was investigated further, studies found that while women tended to have a
higher degree of stenosis, anatomic compression is commonly present in both sexes.
[7]
Patients with occlusive or stenotic lesions of the iliocaval venous system tend to present as
two distinct scenarios: 1) May-Thurner compression of left common iliac vein with or without acute thrombosis or 2) post-thrombotic venous occlusion because of a prior deep venous
thrombosis from the iliac venous obstruction.
[10]
The degree of disability these presentations
cause is variable. On the milder end of the spectrum of symptoms of venous occlusive disease,
symptoms vary from mild swelling to unilateral leg heaviness, aching, and vague discomfort.
In the acute presentation, patients typically present with sudden onset of leg pain and swelling, and the diagnosis of deep venous thrombosis is confirmed with duplex ultrasound. While
the thrombus may be isolated to the iliac system, in those with thrombotic MTS, involvement
of the deep venous system is more extensive and symptoms are more severe in comparison to
those with DVT in the absence of compression syndromes.
[3, 11]
Furthermore, patients with
chronic venous occlusive disease and post thrombotic syndrome with symptoms of valvular
incompetence, varicosities, lower leg discoloration, and venous ulcerations can oftentimes be
attributed to underlying undiagnosed compression syndrome. With advancement in imaging
leading to changes in diagnosis, treatment of obstructive vein lesions has expanded as well.
DIAGNOSTIC EVALUATION
Initial evaluation of patients involves duplex sonography followed by computed tomography
venography (CTV) or magnetic resonance venography (MRV). Even with negative findings,
however, in patients with high suspicion of MTS, catheter-based venography with use of intravascular ultrasound (IVUS) is still warranted. These measures are both diagnostic and therapeutic.
MANAGEMENT
The current treatment of choice for venous compression syndrome is venography with IVUS
and consideration of endovascular iliac venous stenting. Before any treatment is undertaken,
a thorough history and physical exam that guides imaging is necessary. In those with acute
thrombosis, this includes hypercoagulable workup and investigation of underlying reasons for
thrombosis and the initiation of anticoagulation. In those with non-thrombotic compression
Non-Thrombotic and Thrombotic Iliocaval Compression Syndrome 143Non-Thrombotic and Thrombotic Iliocaval Compression Syndrome 143
syndrome, this includes compression therapy, exercise advancement, and weight loss as conservative means. If compression therapy has failed, venography with IVUS would be offered
to assess the venous system with possible intervention as well.
[3, 6, 11]
Technique
Catheter-Based Venography
Catheter-based venography is the gold standard for diagnosis of venous compression syndrome and allows for treatment in the same setting. Venous access is via the ipsilateral popliteal or femoral veins. Imaging is obtained in two orthogonal views as single-plane venography
provides a sensitivity of only 45% in diagnosing a venous stenosis of >70%.
may appear “pancaked” in the anterior-posterior plane: it can have a normal to slightly
widened diameter with a central translucency at the site of compression.
also show thrombus if present or venous collaterals in non-thrombotic or chronic lesions
(Figure14.1). Without these more obvious findings though, pressure gradients and use of
IVUS are necessary to determine the presence of hemodynamically significant lesions.
Intravascular Ultrasound
IVUS is invaluable when it comes to investigation, confirmation, and intervention in venous
compression syndrome. It will provide intraluminal measurement of diameter in order to
guide stent sizing and will also localize the site of maximal compression. The examination of
intraluminal characteristics ensures no lesions are missed particularly by illustrating lesions
near the iliac vein confluence that may be missed on standard venography. Up to one-third
of venous compressions detected on IVUS can be missed on initial CTV.
shown that standard venography underestimates the degree of stenosis by 30% compared
to IVUS. The full 360-degree field offered by IVUS better appreciates a stenotic lumen and
intravascular webs
[15]
(Figure14.2, Figure14.3).
[12]
The iliac vein
[4, 7]
Venography will
[14]
Studies have also
Figure 14.1 Venography showing occlusion of iliac vein with collateral formation.
[13]
144 Ariela Zenilman and Brian Derubertis
Figure 14.2 IVUS demonstrating stenotic lesion. Left iliac vein is externally compressed by crossing of right
iliac artery.
Figure 14.3 IVUS demonstrating non-stenotic venous lesions:(A)a network of echogenic intraluminal trabecu-
lae;(B)a chronic web with associated thrombus; or(C)an eccentric increase in vein wall echogenicity with
otherwise preserved vein wall and lumen.
[4]
[7]
Non-Thrombotic Syndrome
As mentioned earlier, first-line therapy for non-thrombotic compression syndrome in patients
with symptoms of unilateral left leg swelling is a trial of compression, exercise, and weight
loss. If conservative management fails, patients with life-limiting symptoms are then considered for venography with IVUS. Findings concerning for hemodynamically significant vein
compression include contrast stagnation within the left iliac venous system, reversal of flow
into the internal iliac system and drainage into the right iliac vein, and extensive collateralization pelvic collateralization. In the non-thrombotic presentation, access is typically via the
common femoral vein. In anticipation of stent placement, the puncture should be done below
all diseased segments to allow for stenting of all diseased segments of vein, although this is
generally a consideration reserved for MTS patients presenting with signs and symptoms of
chronic venous disease from a prior thrombotic episode. Crossing of the lesion is generally
straightforward, and a wire is placed into the IVC. IVUS is used to assess the iliac system
and identify the point of maximal compression of the left common iliac vein.If the degree
of stenosis requires intervention (>50% reduction in cross-sectional areal relative to normal
vein by IVUS measurements), the sheath is upsized to an appropriately size for stent delivery
(generally 10Fr), the patient is anticoagulated to a therapeutic level.
[10, 16]
Stent sizing based on IVUS includes diameters of the compressed vein and the proximal
vein. Oversizing of 20% is appropriate given the concern in the venous system for stent
Non-Thrombotic and Thrombotic Iliocaval Compression Syndrome 145
Figure 14.4 Venography (A) point of compression of left iliac vein, (B) balloon dilation, (C) following stent
placement.
Figure 14.5 IVUS. (A) Left iliac vein is externally compressed by crossing of right iliac artery, (B) luminal gain
achieved after stent placement.
[16]
[4]
migration. Stents are extended about 5 mm beyond the point of maximal compression, even
if this requires extension into the IVC. Balloon angioplasty follows stent deployment for
wall apposition. Completion venography and repeat IVUS should be performed to confirm
adequate luminal gain and stent apposition (Figures14.4 and 14.5).
Patients with non-thrombotic vein lesions have been shown to have better long-term patency
rates than patients presenting with thrombotic MTS. In one study, 98% primary stent patency
was observed with four years of follow-up.
[17]
In another, primary and secondary patency rates
were 79% and 100% for non-thrombotic lesions and 57% and 86% in those with a DVT
history at 72 months.
[18]
For this reason, most patients with non-thrombotic lesions do not
require anticoagulation. There are no specific guidelines for postoperative antiplatelet, and it
is generally at the discretion of the physician. Generally, dual antiplatelet is recommended for
a period of 6 weeks to 3 months, after which aspirin can be continued as single therapy.
[4, 17]
Thrombotic Syndrome
Acute DVT Associated with Iliac Vein Obstructive Lesion
Although the mainstay of treatment for an acute DVT is anticoagulation, severely symptomatic patients generally require thromboreductive therapy. In thrombotic MTS patients
presenting with acute iliofemoral DVT (<2 weeks duration), the need for intervention is
146 Ariela Zenilman and Brian Derubertis
based on symptom severity and extent of thrombosis, but most venous specialists believe that
iliofemoral DVT with presumed or documented iliac vein compression warrant an aggressive strategy of thrombus removal with catheter-directed thrombolysis or mechanical thrombectomy. When intervention is planned, clearance of clot burden is generally performed to
allow for identification and treatment of underlying venous compression pathology.
[4]
The
goal of intervention is to reduce the long-term sequelae of post thrombotic syndrome. The
ATTRACT trial, which randomized patients with acute proximal DVT to catheter-directed
thrombolysis or anticoagulation arms, did not find any difference in the development of
post-thrombotic syndrome. However, subset analysis of the ATTRACT trial demonstrated
a decreased incidence of severe post-thrombotic symptoms in those treated with aggressive
thrombus removal strategies, especially in those with extensive iliofemoral DVT.
[19]
The decision to intervene is therefore individually based with consideration given to these factors, as
well as the age and functional status of the patient.
Given the iliofemoral location, access is obtained via the popliteal vein as the common
femoral vein is commonly involved. Awire is crossed into the IVC, which in the chronic phase
can be more challenging and require a stiffer wire with a support catheter. Once crossed,
the decision of to perform catheter-directed thrombolysis overnight or in a single session
thrombectomy is then made, generally based on the chronicity and ease of wire crossing.
For patients with less than 1–2 weeks duration, an attempt at a single-session clearance of
the thrombus with pharmacomechanical thrombectomy is reasonable. The AngioJet system
(Boston Scientific, Minneapolis, MN) in the “power pulse” mode will lace the thrombus
with alteplase which can dwell for 10–20 minute. The system can then be switched to aspiration mode to aspirate the lysed thrombus.
[16, 20]
Newer devices, such as the ClotTriever
(Inari Medical, Irvine CA) and Lightning 12 (Penumbra Inc, Alameda, CA) provide clot clearance in a single session, but their comparison to catheter-directed thrombolysis in terms of
outcomes is not known in the setting of iliac compression syndromes.
[4]
Both modalities,
catheter-directed and pharmomechanical thrombectomy, however have shown similar rates
of thrombus removal overall (70% in catheter-directed and 75% in pharmomechanical).
[21]
Patients with a longer interval between initial symptom onset and treatment, overnight catheter-directed thrombolysis, typically at tissue plasminogen activator drip rates of 0.5–1.0 mg/
hr is recommended.
Following thrombus removal, venographic and IVUS evaluation for May-Thurner compression of the left common iliac vein is nearly identical to that discussed for non-thrombotic
May-Thurner patients. These patients, however, are more likely to have additional postthrombotic occlusive lesion. These residual occlusive lesions generally extend from the common femoral vein to the caval confluence and should be stented as angioplasty alone may not
be durable.
of postoperative early thrombosis.
[22]
Studies have shown that leaving these lesions unstented lead to a higher rate
[23, 24]
In patients that present with stent thrombosis and recurrent symptoms, undersizing of the
stent and inadequate extension should be considered as etiologies for these complications.
Reintervention can be difficult as these lesions are now more chronic, yet the same principles
of catheter-directed thrombolysis and pharmocomechanical thrombectomy still apply for
those with recent symptoms presumed to be due to acute stent thrombosis. Once recanalization is achieved, assessment and correction of the underlying pathology is required.
[4, 17]
Post-Thrombotic Syndrome with Iliac Vein Stenosis or Occlusion
The diagnosis of PTS is based on clinical signs and symptoms the patient experiences in the
affected leg after a DVT. IVUS remains the most sensitive examination to detect the extent of
Figure 14.6 (a) IVUS with trabeculations of the vein in a patient with PTS,(b) patent vein following stenting.
[13]
the lesion and typically will show trabeculations, thickness of the vein wall, external compression, and thrombus formation. Studies have shown that iliac vein stenting alone is sufficient
to control symptoms in a patient with outflow obstruction and deep reflux in the setting of
a chronic venous obstruction.
A similar technique of venography and intervention is performed. After confirming the
obstruction and the existence of collaterals, a stiff hydrophilic wire and supporting catheter
is usually needed to pass these obstructions. Pre-dilation of the obstructed venous tract is
performed next. After balloon dilation without stenting, immediate recoil occurs in most
cases and stenting is mandatory. Stenting with a self-expanding stent should be carried out
throughout the complete diseased post-thrombotic vein segment, from healthy segment to
healthy segment. To achieve the best possible alignment of the stent, the balloon used for predilation should have at least the same diameter as the stent. In patients with long-segment
post-thrombotic iliofemoral obstructions who need more than one stent, stent placement
should have 1–2 cm of overlap with stenting of the common iliac first to the common femoral vein. Post-dilation must always be performed, and completion venography obtained in
two views to exclude recoil and complications. IVUS upon completion is preferred as well
(Figure14.6).
Venous Stents
Veins have greater diameters than the corresponding arteries, therefore stenting of the iliofemoral venous system require stents of larger diameter. These typically include self-expandable, longitudinally flexible stents of diameters from 12 mm to 18 mm.
[7]
Additionally, post
thrombotic veins are typically fibrotic and compressed and need stents with more radial
force. There are venous stents that exhibit these characteristics, but the literature about their
outcomes is limited. Rollo et al, on the other hand, describes using braided stainless steel
stents, typically in diameters of 16–20 mm, for iliac vein stenting with good results prior to
the advent of dedicated venous stents.
[20]
The largest study investigating stenting for reconstruction of the femoroiliocaval venous system was published in 2017 by van Vuuren etal. In
221 patients operated on (196 for PTS), outcomes at 60 months, including primary patency,
assisted primary patency, and secondary patency rates were 64%, 81%, and 89%. Thirty-six
patients had a thrombotic stent occlusion, requiring thrombolysis and secondary stenting in
19 patients. All stents implanted in this study were dedicated venous stents [(sinus-XL), sinusXL Flex, sinus-Venous, and sinus-Obliquus (OptiMed); Vici Venous Stent (Veniti Inc); Zilver
148 Ariela Zenilman and Brian Derubertis
Vena (Cook Medical); and Venovo (Bard)]. Mortality was 0%, and significant improvement
of Villalta score was noticed.
[25]
CONCLUSIONS
Iliocaval compression syndromes are increasingly diagnosed due to increased awareness and
improved recognition of symptoms in the acute and chronic phases. Improved technology of
both imaging and intervention have improved patient outcomes and quality of life. Anatomic
anomalies are amenable to endovascular surgical techniques and stenting of these lesions,
while the literature is still ongoing, do show favorable short and long-term outcomes and
patency rates.
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