CardioVascular and Interventional Radiology

ª Springer Science+Business Media, Inc. 2006 Published Online: 21 February 2006

Cardiovasc Intervent Radiol (2006) 29:571–575 DOI: 10.1007/s00270-004-0165-7

Percutaneous Treatment of Deep Vein Thrombosis in May-Thurner Syndrome Jong-Youn Kim,1 Donghoon Choi,1 Young Guk Ko,1 Sungha Park,1 Yangsoo Jang,1 Do Yun Lee2 1

Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea 2 Department of Diagnostic Radiology, Yonsei University College of Medicine, Seoul, Korea

Abstract Background/Purpose: May-Thurner syndrome is an uncommon disease entity in which the left common iliac vein is compressed by the right common iliac artery with subsequent development of deep vein thrombosis and chronic venous insufficiency. We report our experience on the treatment of extensive iliofemoral deep venous thrombosis due to MayThurner syndrome using endovascular techniques. Methods: The study group comprised 21 patients (8 men, 13 women; mean age 51 years) diagnosed with May-Thurner syndrome by venogram. Eighteen patients were treated with catheter-guided thrombolysis; 3 patients with short segment involvement did not require thrombolysis. After completion of the thrombolytic therapy, the residual venous narrowing was treated by balloon angioplasty and/or placement of a selfexpandable stent. Results: The mean total dose of urokinase was 4.28 € 1.89 million units, and the mean duration of infusion was 72 € 35 hr. Eighteen of the 21 patients received stent deployment. The mean diameter of the stents was 12.9 € 2.0 mm. Initial technical successes with immediate symptom resolution were achieved in 20 of the 21 patients (95%). We performed a follow-up venogram 6 months after procedure and checked clinical symptoms at outpatient clinics (mean follow-up duration 10.8 months). Among the patients who received stent implantation, 2 had recurrent thrombotic occlusion during the follow-up period. Three patients, who did not receive stent implantation, all had recurrent thrombosis. There were no major bleeding complications except in 1 patient who developed retroperitoneal hematoma. Conclusion: Catheter-guided thrombolysis and angioplasty with stent implantation is a safe and effective method for the treatment of May-Thurner syndrome.

Correspondence to: Donghoon Choi, M.D., PhD; email: cdhlyj@yumc. yonsei.ac.kr

Key words: Deep vein thrombosis—May-Thurner syndrome—Stent—Thrombolysis

May and Thurner first described a spur-like formation of the left common iliac vein in 22% of autopsies in 1956 [1]. Chronic pulsatile compression of the left common iliac vein between the right common iliac artery and the lumbar vertebral body may induce excessive local intimal proliferation, resulting in impaired venous return and massive venous thrombosis [2]. Usually, these patients present with left leg edema, pain, or deep vein thrombosis (DVT). Because of the chronic physical compression by the right common iliac artery and due to the large size of the thrombus that develops at the iliac vein, anticoagulation alone is usually ineffective in resolving the DVT and subsequently preventing pulmonary embolisms. Previous reports have shown that anticoagulation alone and thrombectomy combined with prospective anticoagulation have a rethrombosis rate of up to 73% in patients with a venous spur [3]. Therefore, corrective treatment is required to prevent the development of pulmonary embolism and the long-term complications of post-thrombotic syndrome including chronic leg edema, pain, hyperpigmentation, and skin ulcers. Recently, catheter-directed thrombolysis and endovascular angioplasty with stents have been used to treat DVT in these patients. We report our experience and treatment efficacy of endovascular venous angioplasty in patients with DVT due to May-Thurner syndrome.

Materials and Methods Retrospective analysis was done on 21 patients diagnosed with May-Thurner syndrome with venogram performed during treatment of DVT and treated with catheter-guided local thrombolysis and endovascular venous angioplasty between August 1999 and December 2002. Sixteen patients presented with acute iliofemoral venous thrombosis and 5 patients presented chronic venous out-

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flow obstruction with thrombus. The characteristic May-Thurner syndrome lesion was diagnosed by a radiologists who had no venographic information about the patients. These lesions are defined by stenosis of the proximal left common iliac vein, including the portion underlying the right common iliac artery, as well as the presence of significant venous collateral vessels (Fig. 1). After ipsilateral puncture of the popliteal vein using a modified Seldinger technique (early in this series other access sites were utilized, including the right internal jugular (n = 2), right common femoral vein (n = 1), and left common femoral vein (n = 2)), a 6.5 Fr hemostatic sheath was inserted. We used urokinase for local thrombolysis. Through the hemostatic sheath, a 5 Fr multisideport infusion catheter (60 cm, Cook, Bloomington, IN, USA) was inserted and passed through the thrombotic occlusion of the left common iliac vein. In case of total occlusions, the infusion catheter was placed just distal to the occlusion. When the lesion was partially recanalized at follow-up, the infusion catheter was passed across the lesion and urokinase infusion was continued. In addition to continuous urokinase infusion, heparin infusion through the hemostatic sheath was performed to maintain the aPTT between 60 and 90 sec. The venogram was performed once a day to assess the status of the thrombotic occlusion. The endpoints of thrombolytic therapy were near clot dissolution, lytic stagnation (no interval change for 24 hr), or development of a major complication (in one case, retroperitoneal bleeding developed). Residual stenosis combined with organic change of the vein was treated by angioplasty and stent implantation. Stent size was determined by measuring the diameter of the patent distal common iliac vein. Stenting was performed through an 8 Fr hemostatic sheath exchanged for the 6.5 Fr sheath. Through the sheath, a 0.035-inch hydrophilic guidewire was passed across the lesion and angioplasty with stent implantation was done with a self-expanding Wallstent (Boston Scientific, Watertown, MA, USA) (Fig. 2). All patients had 10,000 units of heparin administered at the start of the procedure and systemic heparinization was done after the procedure to maintain the aPTT between 60 and 90 sec for 5 days. Coumadization was started simultaneously with heparinization to maintain an INR of 2–3. Coumadization was continued for 6 months. A venogram was performed 1 week after the procedure immediately before discharge and 6 months after the procedure to assess the patency rate.

Results The 21 patients comprised 8 men and 13 women with an average of 51 years. Three of the patients were shown to have pulmonary thromboembolism by lung perfusion scan before treatment. The patient characteristics are shown in Table 1. Three patients did not undergo catheter-guided thrombolysis due to short length of the lesion. The average infusion rate and total dose of urokinase was 92,000 € 30,000 IU/hr and 4,280,000 € 1,890,000 IU respectively with a total infusion time of 72 € 35 hr. Eight patients (44%) had complete thrombus lysis after urokinase infusion. For the treatment of residual stenosis, balloon angioplasty alone was performed on 3 patients and stent implantation was done in 18 patients. A Wallstent (Boston Scientific, Watertown, MA, USA) was used for stent implantation in all the patients with an average profile of

Fig. 1. A, B. A 39-year-old man complained of left leg swelling and pain for 7 days. A The venogram on admission showed a total occlusion of left iliac and femoral veins. B Follow-up digital subtraction angiography after urokinase infusion for 3 days showed remaining thrombi and an obstructive lesion at the left common iliac vein (arrow) with extensive cross-pelvic and hypogastric collateralization.

12.9 € 2 mm and a length of 65.4 € 18.2 mm. Six patients had two stents implanted and the others had a single stent implanted. After the procedure, all patients showed good patency of the common iliac vein. The follow-up venogram performed 7–10 days after the procedure showed absence of residual thrombi in all 18 patients implanted with stents, with resolution of leg edema.

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There was a single case of major bleeding complication resulting in retroperitoneal hematoma which extended to the lower portion of the psoas muscle and resolved spontaneously in 13 days. After the procedure, none of the 21 patients showed evidence of newly developed pulmonary embolism at a follow-up lung perfusion scan performed within 7 days of the procedure. Follow-up venograms were performed on 17 of the 18 patients with a stent and showed recurrent thrombus formation in 2 patients. All 3 patients who underwent balloon angioplasty alone showed recurrence of thrombotic occlusion, with 2 patients developing signs of post-thrombotic syndrome resulting in debilitating pain, leg edema, and recurrent ulcer formation. One patient implanted with a stent showed leg edema with post thrombotic syndrome despite the absence of recurrent thrombi at the follow-up venogram (Table 2).

Discussion

Fig. 2. A Completion digital subtraction angiography after deployment of two Wallstents (12 · 46 mm, 10 · 83 mm) showed a satisfactory angiographic result, with abolition of collaterals and rapid, in-line flow superiorly into the inferior vena cava. B Follow-up venogram performed 6 months after the procedure revealed patent stents. The patients had no symptom 17 months after the procedure.

One of the 3 patients who underwent balloon angioplasty alone showed severe residual stenosis. Due to the presence of underlying colon cancer in that patient, we did not proceed with stenting and only inserted an inferior vena cava filter.

May-Thurner syndrome is a spur-like formation of the left common iliac vein resulting from chronic pulsatile compression of the left common iliac vein between the right common iliac artery and the lumbar vertebral body that causes excessive local intimal proliferation, impaired venous return, and venous thrombosis [1, 2]. This may account for the higher frequency of left side compared with the right side common iliac vein thrombosis [6]. The chronic vibratory pulsation of the common iliac artery on the venous wall may result in frictional damage on the intimal wall that may cause subsequent intimal proliferation and venous thrombosis [5]. This disease is reported to be more frequent in women, which was the case in our study as well [7]. Because of the chronic nature of the disease process, patients typically present with symptoms and signs of post-thrombotic syndrome such as pigmentation, varicose vein, chronic leg pain, phlebitis, and recurrent skin ulcer [2]. Also acute thrombosis may develop in patients with a high risk of DVT, such as those undergoing orthopedic surgery [2]. In our study, 16 patients presented with acute DVT. Five of the patients had a history of cerebrovascular disease or trauma resulting in prolonged immobilization and 4 of the patients were in an early postoperative state after surgical treatment of malignancies. The two major treatment goals of DVT are the prevention of the development of pulmonary embolism and the prevention of post-thrombotic syndrome. The pathogenesis of post-thrombotic syndrome is known to be due to chronic venous obstruction and venous valve insufficiency due to the formation of thrombi. A previous report by Eklof and Kistner showed that patients with DVT treated by thrombectomy showed no evidence of post-thrombotic syndrome whereas 18% of those treated with anticoagulation showed signs of post-thrombotic syndrome after 4 years of followup [8]. The results of that study show that it is imperative to remove the thrombi as early as possible. Thrombolytics are an effective treatment for the resolution of venous thrombi,

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Table 1. Clinical characteristics of patients Patient no.

Sex

Age (years)

Chief complaint

Symptom duration (days)

Pulmonary embolism before therapy

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

F F M M F M F M F F M F F F F M M F F F M

53 31 59 59 38 39 19 74 70 63 51 59 66 65 33 54 58 22 36 72 45

Lt leg pain and swelling Lt leg swelling Lt leg swelling Lt leg pain and swelling Lt leg pain and swelling Lt leg pain and swelling Lt leg swelling Lt leg pain and swelling Lt leg swelling Lt. Leg swelling Lt leg pain and swelling Lt leg pain Dyspnea, Lt leg swelling Lt leg pain and swelling Lt leg pain and swelling Lt leg pain and swelling Lt leg swelling Lt leg swelling Lt leg pain and swelling Lt leg pain and swelling Lt leg pain and swelling

10 53 38 4 7 7 6 7 3 40 7 20 5 5 6 14 180 3 70 10 25

N N N N N Y N N N N N N Y N N N N N Y N N

Combined morbidity

Extent of thrombus Lt CIV-EIV Lt CIV Lt CIV Lt CIV-Pop CIV Lt CIV Lt CIV Lt CFV Lt CIV-EIV Lt CIV Lt CIV-Pop Lt CIV Lt CIV Lt CIV Lt CIV Lt CIV-SFV Lt CIV-CFV Lt CIV Lt CIV Lt CIV Lt CIV

Spinal cord injury Spinal cord injury

Intracranial hematoma Esophageal cancer Intracranial hematoma Rectal cancer Rt renal cell cancer Advanced gastric cancer End-stage renal disease

Rt femur fracture

Lt, left; Rt, right; N, no; Y, yes; CIV, common iliac vein; EIV, external iliac vein; Pop, popliteal vein; SFV, superficial femoral vein

Table 2. Treatment and follow-up results of patients Patient no.

Therapy

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

UK + balloon + UK + balloon + UK + balloon + UK + balloon + UK + balloon UK + balloon + UK + balloon UK + balloon + UK + balloon + Balloon + stent UK + balloon Balloon + stent UK + balloon + UK + balloon + UK + balloon + UK + balloon + Balloon + stent UK + balloon + UK + balloon + UK + balloon + UK + balloon +

stent stent stent stent stent stent stent

stent stent stent stent stent stent stent Stent

Total urokinase (million IU)

Urokinase result

Initial success

Follow-up venogram (months)

Follow-up venogram results

Last follow-up (months)

Symptoms at last follow-up

2.76 3.78 6.50 1.25 4.92 6.10 5.91 3.06 3.20 Not done 4.86 Not done 5.16 3.84 5.46 2.98 Not done 8.13 6.25 1.44 2.64

Complete Complete Partial Complete Complete Partial Partial Partial Partial

Y Y Y Y Y Y Y Y Y Y n Y Y Y Y Y Y Y Y Y Y

6 6 6 6 6 6 3 6 6 6 5 6 6 6 6 Not done 6 6 6 6 6

Patent stent Patent stent Patent stent Thrombotic occlusion Thrombotic occlusion Patent stent Thrombotic occlusion Patent stent Patent stent Patent stent Thrombotic occlusion Patent stent Patent stent Patent stent Patent stent,

27 7 15 6 13 17 12 11 13 6 17 8 6 11 11 16 7 6 6 7 5

N N N Swelling Pain, swelling N Pain, swelling, ulcer N N N Death N N N N N Pain, swelling N N N Swelling

Partial Partial Complete Complete Partial Complete Complete Partial Partial

Patent stent Patent stent Patent stent Patent stent Thrombotic occlusion

UK, urokinase; N, no; Y, yes

with systemic thrombolytic therapy being reported to be superior to anticoagulation in preventing post-thrombotic syndrome [9]. But the use of systemic thrombolytic therapy is limited by the possibility of severe bleeding complications, making it a contraindicated in the patient population at a high risk of DVT formation such as pregnant women, surgical candidates, and those with cerebrovascular disease [10, 11]. Localized thrombolytic therapy is commonly performed to decrease the risk of major bleeding. Theoretically,

local infusion of thrombolytic agents at the site of thrombotic occlusion maximizes the therapeutic effect while minimizing the risk of major bleeding [12, 13]. Recently, the pharmacomechanical thrombolysis method (directed thrombolysis with reteplase and the Helix mechanical thrombectomy device) has been used to reduce lytic infusion time and complication [14]. The rationale for angioplasty with stent implantation in residual stenosis is that a stent is effective therapy for ve-

J.-Y. Kim et al.: Percutaneous Treatment of DVT in May-Thurner Syndrome

nous obstruction [15] and superior to balloon dilatation alone [16]. Especially in May-Thurner syndrome, where previous reports have shown that anticoagulation alone and thrombectomy combined with prospective anticoagulation have a rethrombosis rate of up to 73% [3], stent insertion for organic abnormality may be important [17]. The possible problem of valve destruction by the stents and subsequent development of venous insufficiency does not apply to femoral veins because of the absence of valves in the iliac veins. Complete resolution of the residual stenosis may not be possible with balloon angioplasty, which may result in higher risk of rethrombosis. In fact, all 3 patients who underwent balloon angioplasty alone showed restenosis and rethrombosis, which re-emphasizes the importance of complete resolution of the residual stenosis. This is demonstrated by the fact that only 2 of the 17 patients showed thrombus formation at the stent implantation site at followup. To minimize remnant clot propagation and pulmonary embolism, all the patients received standard prophylactic treatment with coumadine for 6 months. This study shows excellent immediate results and early venographic patency rate with minimal complications using localized catheter-guided thrombolysis plus angioplasty with stent implantation. Further studies to demonstrate the long-term patency rate in a larger population of patients will be needed. References 1. May R, Thurner J (1956) Ein Gefassporn in der Vena iliaca communis sinistra als wahrscheinliche Ursache der uberwiegende linksseitigen Beckenvenenthrombose. Z Kreisl-Forsch 45:912–922 2. Baron HC, Sharms J, Wayne M (2000) Iliac vein compression syndrome: A new method of treatment. Am Surg 66:653–655 3. Burroughs KE (1999) New considerations in the diagnosis and therapy of deep vein thrombosis. South Med J 92:517–520

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