CASE 10054 Published on 18.07.2012

Cocket-May-Thurner syndrome and endovascular treatment by catheter guided stent placement

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Rio Tinto H, Bilhim T, Fernandes L, Duarte M, Pisco J

Centro Hospitalar de Lisboa Central,
Hospital de São José, Radiology;
Rua José António Serrano
1150 Lisbon, Portugal;
Email:hugo.tinto@gmail.com
Patient

55 years, female

Categories
Area of Interest Veins / Vena cava ; Imaging Technique Catheter venography
Clinical History
A 55-year-old woman presented with left leg swelling and heaviness. Occasionally she had leg mild pain and oedema, symptoms exacerbated after standing erect for some time and improved with overnight rest.
Imaging Findings
An iliac venogram was performed before and after the stent placement.

Figure 1 – Before stent placement. Narrow area caused by compression by the right common iliac artery.
Figure 2 – Stent placed in the left common iliac vein.
Figure 3 – After stent placement.
Discussion
Background: May and Thurner described for the first time in 1956 a spur-like formation on the left common iliac vein in 22% of autopsies [1].
May-Thurner syndrome, also known as Iliac Venous Compression Syndrome (IVCS), is a condition of venous compression by the overlying artery, usually the left common iliac vein by the right common iliac artery.

Clinical Perspective: This disease is reported to be more frequent in women and the main clinical presentation is deep vein thrombosis. The true prevalence of this condition is unknown, but some autopsies series reported 22% to 33% [2, 3].
May-Thurner syndrome is a progressive vascular disease with long-term disabling complications. It is important to recognise that persistent oedema of the left leg may be caused by May-Thurner syndrome, especially in young women. A pre-thrombotic venous hypertension may be also present. So, the main symptoms are varicose veins, leg pain and heaviness, tiredness and swelling but it often is mild and the diagnostic is difficult. Patients can notice a difference in leg or feet size.

Imaging Perspective: Iliac vein compression, with or without thrombosis, should be treated if symptomatic. The procedure includes an ascending venogram through the iliac vein to show the stenotic area. A guidewire is advanced through the lesion and a stent is than placed over-the-wire. Balloon angioplasty can also be performed before and/or after the stent placement. The stent size should be decided depending on vein calibre but normally it should be between 14-16 mm and its length depends on the stenosis itself.
In this case we used an ipsilateral approach and we used a 16/60 stent followed by a balloon dilation. Finally we performed a final venography to confirm the venous calibre and permeability. Mussa et al considered that treating iliac vein compression self-expanding stents have the advantages of longer lengths, large diameters, flexibility at the groin, and less susceptibility to permanent deformation by the pulsatile artery and the inguinal ligament.

Outcome: Since 1995 venous stents have been placed into the narrowed vein area. Stents seem to be beneficial, improving the clinical outcome and the quality of life of these patients. Angioplasty alone has also a role in the treatment of this condition.

Take Home Messages: If a patient has discomfort, swelling or deep venous thrombosis (DVT), in the iliofemoral vein territory, especially on the left side think about May-Thurner syndrome although it represents about 5% of lower extremity venous diseases.
Differential Diagnosis List
Cocket-May-Thurner syndrome
Deep vein thrombosis
Lymphoedema
Chronic Venous Insufficiency
Final Diagnosis
Cocket-May-Thurner syndrome
Case information
URL: https://eurorad.org/case/10054
DOI: 10.1594/EURORAD/CASE.10054
ISSN: 1563-4086