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May-Thurner syndrome

Author
Albeir Mousa, MD, FACS, MBA, MPH, RPVI
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

May-Thurner syndrome (MTS) is an anatomically and pathologically variable condition leading to venous outflow obstruction as a result of extrinsic venous compression in the iliocaval venous territory. With partial venous obstruction, the condition can be asymptomatic, but progression with symptoms related to chronic venous hypertension or venous occlusion can occur, with or without venous thrombosis. It is important to keep this condition in mind whenever a patient presents acutely with lower extremity swelling or deep vein thrombosis (DVT), particularly young women.

The approach to diagnosis and treatment depends upon whether venous thrombosis is present. When the diagnosis is highly suspected based upon clinical features or noninvasive vascular imaging, a definitive diagnosis is established using intravascular ultrasound (after removal of thrombus, if necessary). Minimally invasive treatment (angioplasty and stenting) of the venous lesion relieves outflow obstruction and provides immediate relief of symptoms with good long-term patency rates. For those with venous thrombosis, rates of post-thrombotic syndrome are reduced with endovascular treatment.

The clinical features, diagnosis, and management of MTS are reviewed here. General considerations for the diagnosis and management of venous thromboembolism are reviewed separately. (See "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

ANATOMY AND PATHOPHYSIOLOGY

May-Thurner syndrome (MTS) is defined as extrinsic venous compression by the arterial system against bony structures in the iliocaval territory. MTS is also referred to as iliocaval venous compression syndrome, iliac vein compression syndrome, Cockett's syndrome, and venous spur. The most common variant of MTS is due to compression of the left iliac vein between the overlying right common iliac artery and the fifth lumbar vertebrae, but others exist.

In the mid-19th century, it was observed that deep vein thrombosis was five times more likely to occur in the left leg [1]. However, left iliac vein compression as a cause of isolated left lower extremity swelling was not described until 1908 and not fully understood until the mid-20th century [2,3]. In approximately 22 percent of 430 cadavers, May and Thurner noted intraluminal thickening ("venous spurs"), which appeared to be directly and most commonly related to external compression of the left common iliac vein by the right common iliac artery against the fifth lumbar vertebra [3]. They suggested that the chronic pulsation of the right common iliac artery initiated a "spur" and caused venous outflow obstruction/stenosis and venous hypertension in the ipsilateral limb. They described three histologic types of spurs: central, lateral, and fenestrated. The relationship between iliac vein compression and post-thrombotic syndrome was later illustrated by Cockett in 1967 [4].

                               
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Literature review current through: Sep 2017. | This topic last updated: May 30, 2017.
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