Abstract | May 7, 2021
Late presentation of Iliac vein compression syndrome in a patient with multiple Hypercoagulable factors
Learning Objectives
- May-Thurner syndrome is largely underdiagnosed as it is an anatomic variant . Hence all patients with extensive DVT on doppler scan should have CT angiography to rule out anatomical abnormalities like May- Thurner syndrome.
- The late presentation of extensive DVT in this patient with May-Thurner syndrome makes the predisposing factors more likely to be her multiple co-morbidities which made her hypercoagulable.
Case:
68 y/o F patient presented with left medial thigh pain and gradual swelling for approximately three weeks with worsening pain and redness on the day of presentation. She had a sibling who died at the age of 40 from a blood clot. No personal history of VTE . She denied chest pain, shortness of breath, fever, chills. She has cor- pulmonale with emphysema, CHF,HTN,, recent hospital admission for CHF exacerbation requiring thoracentesis.
She is a current every day smoker, On examination Vitals Temp 98.5. PR 98.5, RR :18, BP :116/93. Pulse oximetry 100 on room air. Left lower extremity examination revealed edema with erythema to the medial thigh, tenderness, normal sensation and cold Toes and diminished pulses. Right lower extremity examination was unremarkable. Initial Laboratory investigations HGB 14.5 HCT 46.7, Platelet count 354, the rest of hematology and metabolic panels were normal.
Duplex ultrasound evaluation showed extensive DVT of the leg. Following vascular surgery consultation CTA arterial and venous phases was obtained, which showed a clot up to and including the left common iliac vein with appearance of May Thurner syndrome. She was started on IV heparin and underwent placement of lytic catheter for lysis and thrombectomy and subsequent staged angioplasty and stenting to treat the extensive DVT with underlying May-Thurner syndrome.
Discussion:
May-Thurner syndrome is an anatomically variant condition in which the left common iliac vein is compressed between right common iliac artery and the spine and the incidence is highest among females between ages 20 – 30 (1.) which can result in left lower extremity DVT. Hemodynamically significant left common iliac vein compression is a frequent anatomic variant in asymptomatic individuals (3.) However there have been reported cases of incidental diagnosis of May-Thurner syndrome with underlying hypercoagulable state such as pregnancy and OCP use following development of left sided DVT (2.) For patients like this lady who present late with extensive DVT and underlying May-Thurner syndrome it would be advisable for them to be followed up for underlying hypercoagulability rather than just May-Thurner being the only reason for unprovoked DVT considering her medical history of CHF, cor-pulmonale, and smoking history as well which are well established hypercoagulable states.
