VCOM Louisiana Research Day Program Book 2024

Case Studies

43 LEFT COMMON ILIAC VEIN OBSTRUCTION WORSENING SYMPTOMS AND PRESENTATION OF MAY-THURNER SYNDROME: A CASE REPORT

Dev Amin, OMS-III; Stephen Rice, MD; VCOM; Minimally Invasive Image Guided Specialists

Background: May-Thurner syndrome is a condition when the right iliac artery compresses the left iliac vein, leading to venous outflow obstruction. This syndrome is present in young women’s 2nd to 4th decades of life. The patient commonly presents with left unilateral pain at rest with or without exertion. The obstruction of venous flow leads to lower extremity edema, varicosities, and venous ulcers. The gold standard for diagnosing May-Thurner Syndrome is venography with intravascular ultrasound (IVUS). The first-line treatment for symptomatic patients is thrombolysis and stenting to help remove the clot and restore venous drainage. A 45-year-old female presents at our clinic with left leg swelling with a left medial ankle non healing wound. The patient complains about left lower leg swelling and intermittent resting leg pain bilaterally, worse on the left. The patient was previously diagnosed with May-Thurner syndrome, and a stent was placed to correct the compression. Diagnostic Venogram reveals complete occlusion of the left common iliac vein with a previously placed stent that appears to be in a sacral collateral vein caging the iliac veins. A guidewire and a multipurpose catheter were placed through the old stent with manual control pressure to enter the IVC. The left common iliac vein was then stented with a self-expanding stent and was post-dilated with a balloon. Rapid flow was established, and the collateral veins diminished. The patient shows a good prognosis post-endovascular therapy with less pain, less swelling, and improved quality of life. Methods: A 45-year-old female presents to the primary with an approximate 1-month onset of open ulcer to the left medial lower extremity after bumping her leg. The patient has a known history of bilateral lower extremity DVT, formerly treated with Eliquis, now with a Greenfield

filter placed in 2020. The primary care physician discontinued the Eliquis at the time of the visit. She states that she is a reformed smoker in 2021. She has smoked a pack a day for the past 24 years. She is a local waitress, and this ulcer has caused restrictions in standing for long hours. The patient was previously on an IUD placement but has been recently removed. She is currently not on any other birth control medications. Denies any other abnormal bleeding and chest pain/shortness of breath. Patient denies any history of diabetes. The patient has a past history of deep vein thrombosis that is resolved. Past surgical history of uterine fibroid removal. The patient is referred to wound care and interventional radiology for further workup. The patient is seen by wound care for evaluation and management. The patient was taught how to clean and dress their wound. Cultures were negative. Labs were within normal limits. The patient still had the same complaint of intermittent burning sharp leg pain with a nonhealing ulcer on the left medial aspect of the foot. The peripheral wound margin is well-defined and has an improved appearance without exudate. The periwound skin texture and moisture are normal. Periwound skin does not exhibit signs or symptoms of infection. Local pulse is present. Lastly, the patient is seen by an Interventional Radiologist for vascular referral. The patient has similar symptoms as mentioned during her visit with her primary care physician. The symptoms of intermittent burning, sharp leg pain, and lower leg edema have not improved. The patient previously underwent treatment for May Thurner syndrome at an outside facility. The patient has pedial pulses present. Venous Duplex Lower Extremity showed probable chronic non-occlusive thrombus in left femoral vein proximal, middle, distal thigh, and pop v. Deep venous reflux noted left femoral vein and popliteal

vein, probable perforator superior to wound with reflux noted in distal calf. After reviewing the imaging, the patient received a diagnostic venogram to treat left common iliac vein occlusion. Venogram reveals complete occlusion of the left common iliac vein with a previously placed stent extending from the left to the right common iliac vein. After further review, the previous stent appears to be in a sacral collateral vein and is caging the iliac 7 veins, as seen in Figure 1. A guidewire and a multipurpose catheter were placed through the old stent with manual control pressure to enter the IVC, as seen in Figure 2. The occlusion was crossed, and the left common iliac vein ballooned with a 10 mm x 40 balloon. The left common iliac vein was then stented with a 12.0 mm x 80 self-expanding stent (smart control) and was post-dilated with a 10.0 mm x 40 balloon. Rapid flow was established, and the collateral veins diminished, as seen in Figure 3. After the procedure, the patient was placed on Plavix 75 mg daily and told to return for follow-up in 2-3 weeks. If her ankle wound does not improve, then a discussion for ablation of a perforator has been seen through ultrasound. Conclusions: In this case, the patient was diagnosed with May-Thurner syndrome, which led her to develop left lower extremity swelling with a non-healing wound. May Thurner syndrome is usually an asymptomatic incidental finding except in the case the patient had symptoms of venous obstruction in her left leg. Also, another unique feature of this case is that the original stent placed for the May-Thurner syndrome added another layer of obstruction of flow to the left common iliac vein. This case benefits physicians by providing an example of a common May Thurner syndrome presentation with unique features that guided the treatment plan and management of the patient.

62