When the theoretical becomes real – a case of May-Thurner syndrome, its treatment and complications.
Critical Care Case Reports: Hematology, Oncology, Rheumatology and Immunology
Introduction: May Thurner Syndrome (MTS) is an often under diagnosed condition which leads to extensive thrombosis of veins in the lower extremity most commonly secondary to compression of the iliac vein by the iliac artery. There is no consensus on the acute and long-term treatment of this syndrome, but it is usually managed with a combination of thrombectomy, stent placement and anticoagulation. Case: A 62-year-old female presents for worsening left lower extremity pain and swelling. Venous ultrasound of the lower extremity revealed extensive thrombus extending from the iliac vein to the popliteal vein. High resolution doppler revealed compression of the iliac vein by the iliac artery and a significantly increased reflux time in the great saphenous vein consistent with MTS (figure 1). She underwent elective placement of three stents in the left iliac vein and inferior vena cava (figure 2). Repeat imaging of the abdomen revealed only two stents (figure 3). Imaging of the chest revealed stent migration to the heart and the patient subsequently had to undergo open heart surgery for stent retrieval (figure 4). Her post-operative course over the next month was complicated by pericardial effusion and tamponade requiring pericardial window, atrial fibrillation, extensive right lower extremity thrombosis requiring thrombectomy with IVC filter placement, and massive bilateral pulmonary emboli requiring fibrinolytics. After stabilization of acute events, the patient was managed with lifelong anticoagulation and daily compression stockings. At 5-year follow-up, the patient's iliac stents are noted to be patent. There is no evidence to suggest new thrombus formation or bleeding complications related to anticoagulation. Discussion: MTS is a rare condition that is under-diagnosed clinically. There is no consensus on treatment and long-term data describing complications of various treatments are limited. We describe a case of MTS treated with iliac stenting with migration leading to open heart surgery. She then suffered several life-threatening post-operative complications. To our knowledge, there have only been three reported cases of iliocaval stent migration in patients with MTS. It raises the question of whether anticoagulation alone may have altered her clinical course and prevented significant morbidity. We hope this case emphasizes the importance of further studies to assess the safety and efficacy of treatment of MTS.
Mando R, Sigua Arce P, Spencer L, Sandhu R, Halalau A. When the Theoretical Becomes Real-A Case of May-Thurner Syndrome, It'sTreatment and Complications. InD46. CRITICAL CARE CASE REPORTS: HEMATOLOGY, ONCOLOGY, RHEUMATOLOGY AND IMMUNOLOGY 2019 May (pp. A6540-A6540). American Thoracic Society.