Rare case of May-Thurner syndrome

May-Thurner Syndrome
Photographs of patient’s lower extremities in prone position before (A) and after thrombolysis, thrombectomy, and stenting of left iliac vein (B). Note the swelling and skin discolorations over the left calf (reddish alternating with bluish colored areas, blue arrows) due to obstructed venous return and resulting decreased in arterial inflow, representing impeding development of phlegmasia cerulea dolens, when compared to the right leg (green arrows). Complete resolution of the above physical examination findings (red arrows) after left iliac venous endovascular revascularization procedures via left popliteal venous access (black arrow). (Copyright and courtesy of author CI).

Deep vein thrombosis, a manifestation of May-Thurner syndrome

This article describes the case of a 78-year-old woman diagnosed with May-Thurner syndrome. The patient’s medical history was significant for hyperlipidemia, hypertension, and chronic obstructive pulmonary disease (COPD). She presented with a 1-month history of oedema, swelling and chronic lower-leg pain including an inability to move for up to 3 weeks. On examination, there were no signs of trauma, tick bites or fever. The patient also did not have a recent travel history. Her medical history did not reveal any bleeding disorders or previous clots. She also denied smoking. Doctors had prescribed her nifedipine, lisinopril, simvastatin, Ventolin, and umeclidinium.

Investigations and diagnosis

Physical examination showed that the left calf had a mottled appearance and bluish discolouration. These findings are consistent with the diagnosis of phlegmasia cerulea dolens. The left calf was further tender on palpation with a positive Homans sign, a test used to check for deep vein thrombosis (DVT). In addition, all pulses, motor reflexes and sensations were present in the left femoral, popliteal, posterior tibial and dorsalis pedis. Lab results showed leukocytosis and an elevated D-dimer. Whereas creatinine kinase (CK), C reactive protein (CRP), pro-BNP, erythrocyte sedimentation rate (ESR), international normalized ratio (INR), and fibrinogen were all within normal ranges.

Doctors further advised a left-lower extremity Doppler ultrasound which showed acute deep vein thrombosis (DVT), from the femoral vein to the popliteal vein level. The patient was started on a heparin drip and referred to an interventional radiologist (IR) for emergent endovascular percutaneous thrombolysis of extensive DVT. A CT scan was also done which showed an overlying atherosclerotic calcified right common iliac artery. The artery was further seen compressing the origin of the left illiac vein. CT scan of the chest was negative for an acute pulmonary embolism. Based on these findings, the patient was diagnosed with May-Thurner syndrome.

May-Thurner syndrome is rarely considered an aetiology of deep vein thrombosis. Also known as iliac vein compression syndrome, the condition is an anatomical variant in which the right common iliac artery compresses the left common iliac vein against the lumbar spine. This leads to an iliofemoral DVT.

Treatment included stent placement. The patient was continued on a heparin drip for 48 h after the procedure. He was discharged with a referral for a haematology follow-up.

Source: The American Journal of Case Reports

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.


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