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Systematic review of May-Thurner syndrome with emphasis on gender differences
From the American Venous Forum
Systematic review of May-Thurner syndrome with emphasis on gender differences Christof T. Kaltenmeier, MD, PhD,a Young Erben, MD,b Jeffrey Indes, MD,c Alfred Lee, MD, PhD,d Alan Dardik, MD, PhD,b Timur Sarac, MD,b and Cassius Iyad Ochoa Chaar, MD, MS, FACS,b Pittsburgh, Pa; and New Haven and Storrs, Conn
ABSTRACT Objective: May-Thurner syndrome (MTS) is increasingly recognized as a frequent source of leg swelling and a precipitating factor for venous thromboembolism. This paper is a systematic review of the English literature on MTS with an analysis focusing on gender differences in presentation and treatment. Methods: A systematic review of the English literature between April 1967 and December 2014 was performed using the following terms: “May-Thurner syndrome,” “Cockett syndrome,” and “iliac vein compression syndrome.” After review, there were 174 articles in the analysis. We first analyzed all presented cases, followed by a gender comparison if case reports and case series had detailed description. Asymptomatic patients with just anatomic compression without symptoms were excluded. Statistical differences between data sets were assessed using c2 test and Student t-test. Results: There were 1569 patients with MTS after exclusion of articles based on our criteria. The female to male ratio was 2:1 (976 [67.1%] vs 480 [32.9%]). Women presented at a younger age compared with men (38.7 6 14.0 years vs 46.2 6 16.9 years; P ¼ .02). Gender comparison at presentation, which was available for 254 patients, showed that men had significantly more reported leg swelling (92.7% vs 80.8%; P ¼ .037) and more leg pain (88% vs 74.3%; P ¼ .045) compared with women. There was no difference in the reported proportion of patients presenting with deep venous thrombosis between the two groups (88.9% vs 81.7%; P ¼ .14). However, women were significantly more likely to have a pulmonary embolus on presentation compared with men (9.9% vs 1.6%; P ¼ .035). Treatment modalities included endovascular interventions without thrombolysis (53%) or with thrombolysis (33.2%), open surgery (6.8%), and medical management (7%). Endovascular treatment was more common than surgical or medical treatment (P < .001). Because of lack of granularity in the data, it was not possible to distinguish treatment methods between female and male patients. There was no statistically significant difference in complication rate between men and women based on the articles that provided that information (P ¼ .34). However, open procedures had significantly higher complications compared with endovascular interventions (P ¼ .021). Conclusions: Based on the reported literature, MTS is more common in women and is at least twice as frequent in women as in men. Men tend to have more pain and swelling in the legs, whereas women tend to be younger and more likely to have a pulmonary embolus on presentation. MTS and iliac vein compression are sometimes used interchangeably in an inaccurate manner. (J Vasc Surg: Venous and Lym Dis 2017;-:1-8.)
May-Thurner syndrome (MTS), also known as Cockett syndrome or iliac vein compression syndrome, results typically from compression of the left common iliac vein (CIV) between the right common iliac artery (CIA) and the vertebrae. The resultant venous stasis from this compression can lead to venous congestion and the
development of deep venous thrombosis (DVT) in the left lower extremity. Virchow1 was the first to describe a left-sided predominance of iliofemoral DVT caused by venous stasis disease in 1851. Since Virchow made the observation, this has always been explained by an obstruction of the flow in the CIV caused by compression
From the Department of Surgery, University of Pittsburgh Medical Center, Pitts-
333 Cedar St, Boardman 204, PO Box 208062, New Haven, CT 06520-8039
burgha; the Section of Vascular Surgery, Department of Surgery,b and Section
(e-mail: [email protected]).
of Hematology, Department of Internal Medicine,d Yale University School of
The editors and reviewers of this article have no relevant financial rela-
Medicine, New Haven; and the Section of Vascular Surgery, Department of
tionships to disclose per the Journal policy that requires reviewers to
Surgery, University of Connecticut, Storrs.c Author conflict of interest: none. Poster and short oral presentation at the Twenty-eighth Annual Meeting of the American Venous Forum, Orlando, Fla, February 24-26, 2016. Additional material for this article may be found online at www.jvsvenous.org. Correspondence: Cassius Iyad Ochoa Chaar, MD, MS, FACS, Assistant Professor
decline review of any manuscript for which they may have a conflict of interest. 2213-333X Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvsv.2017.11.006
of Surgery, Section of Vascular Surgery, Yale University School of Medicine,
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of the crossing iliac artery.2 In 1950, Wanke further suggested that narrowing of the common and external iliac veins due to extrinsic compression can lead to sclerotic transformation and inflammation in the vessel. However, May and Thurner were the first to carry out a close investigation of this description reported in 1957. They performed a large autopsy study on 430 cadavers and observed compression of the left CIV by the overriding right CIA in 22% of cadavers.2 Cockett and Thomas3 coined the term iliac compression syndrome in 1965 and gave the first description of a large series of patients with the diagnosis, including clinical and angiographic findings in 29 patients. In addition to the detailed clinical reporting, their study was the first to recognize that symptoms can be right sided or even bilateral, depending on the anatomy and the configuration of the compressing structure.4 MTS is diagnosed in 2% to 5% of all patients being evaluated for chronic venous insufficiency of the lower extremity.5,6 Besides the classic presentation, there have been several variations described in the literature, such as right-sided disease4,7-13 and compression by other anatomic structures, including the bladder and kidney.12,14 Despite the increasing awareness of the syndrome, most of the literature written on the topic is based on case reports and case series. Even though MTS is more prevalent in women, gender differences with respect to presentation and treatment are not known. This paper presents a systematic review of the English literature on MTS and summarizes patients’ presentations, diagnostic modalities, and treatment strategies, focusing on the differences between men and women.
METHODS Search strategy. A systematic review of the English literature was performed between April 19674 and December 2014. The first article included in 1967 was the case series described by Cockett and had a detailed clinical description of 57 patients with the condition. A search of PubMed, OVID and Embase databases using the terms “May-Thurner syndrome,” “Cockett syndrome,” and “iliac vein compression syndrome” was performed. The abstracts of all papers were reviewed by two independent reviewers (C.T.K. and C.I.O.C.). All case reports and case series that had detailed description of cases with MTS were included. Papers that reported patients with DVT describing some patients with MTS and some without the syndrome were excluded when the characteristics of the group of patients with MTS could not be determined. The articles were reviewed, and patient demographics, presentation, risk factors, laterality, and anatomy of the compression were extracted. The methods of imaging as well as treatment modalities and complications were also noted. The length of follow-up and long-term results were recorded when available.
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Analysis. A descriptive analysis was performed of all cases of MTS looking at age, gender, laterality, presentation, and details of the anatomy of the compression when available. The general modalities of treatmentd medical, open surgical, and endovascularewere noted. Next, comparison of men and women with respect to presentation and association of MTS with DVT and pulmonary embolism (PE) was performed using a subset of articles. Papers that did not have detailed descriptions to allow differentiation based on gender were excluded. Statistical differences between men and women were assessed using c2 test and Student t-test.
RESULTS Search results The literature search resulted in 174 articles describing patients with MTS selected on the basis of review of the abstracts. After review of the manuscripts, 37 additional articles were excluded because of lack of detailed patient information or the description of mixed populations of patients (patients with DVT but no MTS) was presented and the characteristics of patients with MTS could not be extracted. Asymptomatic patients with just anatomic compression without symptoms were excluded. A general descriptive analysis based on 137 articles (n ¼ 1569 patients) was performed looking at presentation, anatomy, modalities of treatment, and complications. Subsequently, a comparison of men and women with MTS was performed. An additional 33 articles were excluded because of the inability to separate the characteristic of men and women. Gender comparison of patients with MTS was performed on the basis of 104 articles providing relevant information for 254 patients. The search strategy, including a flow chart and reasons for exclusion of articles, is presented in the Fig. All the papers are listed in the Supplementary Table (online only). General analysis Presentation. The mean age at presentation was 42.6 6 16.9 years. MTS was more common among women, with a female to male ratio of 2:1 (976 vs 480). Overall, 27 patients (1.9%; 18 female, 9 male) presented at young age up to 18 years. MTS most frequently presented as DVT with leg swelling and pain. There were 822 patients (52.4%) presenting with DVT. Leg swelling and leg pain were the most frequent symptoms on presentation and were reported in 52.2% (n ¼ 819/1569) and 38.5% (n ¼ 605/1569), respectively. The proportion of patients presenting with lower extremity ulcers was 5.9% (n ¼ 92/1569). With acute presentations, PE was reported in 122 of 1569 patients (7.8%). In addition, 2.2% (n ¼ 34/1569) of patients presented with an acute critical limb condition, such as phlegmasia (n ¼ 33) or compartment syndrome
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Fig. Flow chart: search results and reasons for exclusion.
(n ¼ 1). One patient had to undergo below-the-knee amputation15 (Table I). MTS was discovered after renal transplantation and manifested by deterioration of graft function in four patients.16-19 Salvage of the transplanted kidney using endovascular techniques and thrombolysis was possible in three patients.16,18,19 In one case, the patient had to undergo surgical removal of the kidney after loss of function.17 The patient developed left leg swelling and cyanosis in addition to anuria shortly after surgery. Open exploration with attempted thrombectomy was performed 24 hours after transplantation, but the kidney showed severe cyanosis and was not salvageable. MTS with acute left-sided DVT has been reported after laparoscopic donor nephrectomy as well.20 Jacob et al21 described a young patient on hemodialysis who developed left leg swelling only after an access was placed in the left leg. The patient was treated with an iliocaval bypass that resolved the symptoms. Several authors described patients suffering from embolic strokes due to MTS in the setting of a patent foramen ovale.22-25 Interestingly, stroke as initial presentation was found in 2.2% (35/1569) of the reported cases in this review. A few patients with MTS presented with bleeding. Most had acute bleeding into the retroperitoneum from ruptured pelvic varix,26-30 and one patient presented with chronic gastrointestinal bleeding from congested rectal varices.31 Male patients with MTS have been reported also to present with urologic conditions. Alhalbouni et al32 reported a case of a 42-year-old man suffering from venous-related priapism, and Bomalaski et al33 reported a case of a teenager with varicocele. In addition, MTS can sometimes be incidentally discovered during unrelated procedures. The presence of MTS during cardiac electrophysiologic catheterization can hinder access from the femoral vein, necessitating use of alternative access.9,34 Furthermore, Burnand et al35
Table I. Presentation of patients with May-Thurner syndrome (MTS) Presentation Age at presentation, years
42.6 6 16.9 (7-83)
Duration of symptoms, days
181.2 (<1 day-13 years)
Leg swelling
52.2 (819/1569)
Leg pain
38.5 (605/1569)
Leg ulcer DVT
5.9 (92/1569) 52.4 (822/1569)
PE
7.8 (122/1569)
Chest pain
0.3 (5/1569)
Shortness of breath
0.8 (12/1569)
Critical limb conditiona
2.2 (34/1569)
Stroke
2.2 (35/1569)
DVT, Deep venous thrombosis; PE, pulmonary embolism. Values are reported as mean 6 standard deviation, median (range), or % (n/N). a Critical limb condition includes phlegmasia and compartment syndrome.
noted a large left-sided abdominal varicocele during laparoscopy that triggered a workup for MTS. MTS has been reported in association with other vascular anomalies, such as Klippel-Trénaunay syndrome.36,37 Risk factors for venous thromboembolism (VTE). Recent surgery was present in 16.9% (139/822) and history of cancer was reported in 11.2% (92/822) of patients as the most common risk factors for patients with MTS who developed VTE. Immobilization was found in 9% (74/822) of presented cases. Trauma was the precipitating factor in 4.6% (38/822) of patients. Thirty-one patients presented during pregnancy (n ¼ 30) or in the postpartum period (n ¼ 1), accounting for 3.2% (31/976) of all women with MTS. Hypercoagulable disorders were found in 9.6% (79/822) of patients with VTE and 5.0% (79/1569) of the total
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Table II. Risk factors for venous thromboembolism (VTE) in patients with May-Thurner syndrome (MTS) Presentation Recent surgery
16.9 (139/822)
History of cancer
11.2 (92/822)
Immobilization
9.0 (74/822)
Hypercoagulable disorder
9.6 (79/822)
Factor V Leiden Antiphospholipid Protein C or S
39.2 (31/79) 2.5 (2/79) 29.1 (23/79)
Resistance of C activated protein
1.3 (1/79)
Prothrombin gene mutation
2.5 (2/79)
Increased anticardiolipin
3.8 (3/79)
Lupus anticoagulant
7.6 (6/79)
Antithrombin III
3.8 (3/79)
Hyperhomocysteinemia
1.3 (1/79)
Trauma
4.6 (38/822)
Hormone replacement therapy
6.3 (62/976)
Values are reported as % (n/N).
population. Factor V Leiden in 39.2% (31/79) and protein C or S deficiency in 29.1% (23/79) were the most common reported hypercoagulable disorders in all patients (Table II). Six percent (62/976) of women reported in the literature were taking hormone replacement therapy. Murphy et al38 reported DVT related to MTS in seven adolescent women after initiation of hormone replacement therapy. Only three patients were found to have an abnormality on hypercoagulable workup consistent with being heterozygous for factor V Leiden mutation. It is unclear whether there is a genetic predisposition to development of MTS. At least one case report described siblings with MTS and DVT.39 Imaging and anatomy. The most common diagnostic modalities were computed tomography venography (44.8%) and venography (38.7%), followed by magnetic resonance imaging (6.6%). Intravascular ultrasound was used in only 8.8% of cases. Gurel et al40 suggested that direct injection of contrast material by injector into the bilateral pedal veins would enhance visualization of the deep veins as well as the pattern of collaterals. The most common anatomic location of MTS is on the left side in 98.0% (1537/1569) due to compression by the right CIA in 91.9% (1442/1569). However, there were 34 cases that exhibited a different pattern, accounting for 2.2% (34/1569) of all reported cases of MTS. Right-sided MTS was reported in 1.4% (22/1569)7-9,11-13 and bilateral compression in 0.8% (12/1569).41 Other compressed structures reported were the right CIV and inferior vena cava (IVC). Alternative structures that could cause compression were a transplanted kidney, bladder in the setting of prostatism,12 arterial aneurysm,42 and left iliac artery stent graft.43
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A tortuous left CIA,44 left internal iliac artery,45 and right internal iliac artery10 could cause compression in certain cases. Ectopic kidneys have been reported to contribute to MTS by direct compression of the left CIV by a left pelvic kidney46 or by exacerbating the compression by the right CIA in a patient with a fused ectopic kidney.14 A case of reverse MTS, in which the left CIA compresses the right CIV, was reported in a patient with situs inversus.9 These cases are probably best referred to as iliac vein compression syndrome as there is no true anatomic compression similar to the seminal cases described by May and Thurner. Treatment. Multiple treatment modalities have been used to treat MTS, including endovascular interventions without thrombolysis (53%) or with thrombolysis (33.2%), open surgery (6.8%), and medical management (7%). Endovascular treatment was more common compared with surgical or medical treatment (Table III). Before the year 2000, 75% of procedures were performed by open surgery (39/52) and 25% were endovascular (13/52). In contrast, during the following period (2000-2014), 4.1% of treatment involved open surgery (45/1099) and 95.9% (1054/1099) were endovascular interventions. Medical management consisted of anticoagulation for patients presenting with VTE with compression therapy for patients with swelling, but no interventions were performed. Berger et al47 performed the first known venous stent placement to relieve iliac compression in 1995. Stents were placed in 1048 patients, with an average stent size of 12.5 mm (8-20 mm). Balloon angioplasty without stenting was performed in six patients (1%). The AngioJet (Boston Scientific, Natick, Mass; n ¼ 33) and Trellis (currently off the market; n ¼ 7) were used for pharmacomechanical thrombolysis (PMT) in patients with acute DVT. Treatment of acute iliofemoral thrombosis related to MTS has also been performed through hybrid procedures, such as open thrombectomy and on-table angiography and stenting.48 Open surgical procedures included venous patch angioplasty (n ¼ 18), venous bypasses with prosthetic (n ¼ 3), and saphenous vein (Palma procedure, n ¼ 6). Lysis of adhesions around the iliac vein was described in 7 cases and creation of a concomitant arteriovenous fistula in 13 patients. Because of lack of details of multiple articles, it was not possible to extract genderspecific information for treatment modalities. Several strategies have been reported for treatment of extensive DVT related to MTS during pregnancy. Treatment included anticoagulation and stent placement (n ¼ 1), venous thrombectomy (n ¼ 2), and PMT and definitive stent placement post partum (n ¼ 3). DeStephano et al49 suggested PMT with clot removal after suprarenal IVC filter placement in one session during pregnancy to minimize risks of irradiation and bleeding. Patients presented post partum for iliac vein stenting and removal of the IVC filter. The babies were born
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Table III. Treatment modalities and complications Treatment modality Medical
7.0 (86/1237)
Open surgery
6.8 (84/1237)
Endovascular
86.2 (1067/1237)
Endovascular without lysis
53.0 (656/1237)
Endovascular with lysis
33.2 (411/1237)
Open (n ¼ 84)
Endovascular (n ¼ 1067)
Bleeding/transfusion required
3.5 (3/84)
1.3 (11/1067)
.04
Thrombosis
3.5 (3/84)
1.0 (11/1067)
.04
Prolonged pain
1.2 (1/84)
0.6 (6/1067)
.49
Complications
P value
Perforation
d
0.09 (1/1067)
.78
HIT
d
0.09 (1/1067)
.78
PE
d
0.2 (2/1067)
.69
Total
8.1
3.3
.021
HIT, Heparin-induced thrombocytopenia; PE, pulmonary embolism. Values are reported as % (n/N).
with no complications; however, no long-term follow-up was reported. Complications. The overall complication rate for patients with MTS managed surgically was 2.1% with associated mortality rate of 0.07%. The most common perioperative complications reported were bleeding (n ¼ 14) and thrombosis (n ¼ 14); heparin-induced thrombocytopenia (n ¼ 1), intraoperative perforation of external iliac vein (n ¼ 1), and one death occurred. Complications were more common after open compared with endovascular procedures (8.1% vs 3.3%; P ¼ .021; Table III). The death occurred in a 49-year-old perimenopausal women with factor V Leiden and extensive left iliofemoral DVT. She was heterozygous for factor V Leiden. The patient was admitted for an IVC filter placement. After the procedure, the patient died of acute intra-abdominal hemorrhage related to spontaneous rupture of the left CIV. Autopsy revealed a 0.5-cm transmural defect of the left CIV; there was no evidence of laceration or mural dissection.50 Long-term follow up. The mean reported follow-up time was 25.8 6 16.4 months, and 20 patients had to undergo reinterventions after open (3.2%; n ¼ 3/94) or endovascular (1.6%; n ¼ 17/1067) treatment. The patency of the treated vein after 12 months was superior for endovascular treatment (96% [576/599]) compared with open surgery (64.2% [20/31]; P < .01). Information on follow-up could be extracted from 79 articles, most of them being single case reports or large case series if detailed information was provided. Follow-up imaging was performed using venography or computed tomography. Gender comparison The differences in gender are based on a subgroup analysis of 254 patients who had details of presentation.
Women presented at a younger age compared with men (38.7 6 14.0 years vs 46.2 6 16.9 years; P ¼ .02). On presentation, men had significantly more reported leg swelling (92.7% vs 80.8%; P ¼ .037) and more leg pain (88% vs 74.3%; P ¼ .045) compared with women. However, there was no difference in the reported proportion of patients presenting with DVT between the two groups (88.9% vs 81.7%; P ¼ .14). Women were significantly more likely to have PE on presentation compared with men (9.9% vs 1.6%; P ¼ .035). There was no difference in reported leg ulcers (P ¼ .17), shortness of breath (P ¼ .82), or chest pain (P ¼ .63). There were no significant differences in risk factors between the two groups (Table IV). Because of lack of granularity of the data, it was not possible to distinguish treatment methods between female and male patients.
DISCUSSION MTS is increasingly recognized as a cause of chronic venous insufficiency and a precipitating factor for VTE. Despite ongoing controversy about the exact definition of its pathologic process,51 endovascular treatment has been shown to be safe and effective for treatment of acute venous thrombosis or chronic compression.52 Furthermore, Raju53 has shown that iliac vein stenting is a safe and effective alternative to traditional open surgery to correct iliac vein compression. This systematic review provides a detailed description of the literature reporting on the syndrome since it was first clinically described in patients by Cockett et al4 in 1967. Our findings support the current paradigm of endovascular therapy as a modality of choice for MTS and iliac vein compression as well. In a limited comparison of a predominantly historical group of patients treated with a variety of open surgical procedures (venous bypass, patch angioplasty, lysis of adhesions, with creation of fistula/ thrombectomy), patients treated with endovascular stenting with lysis as needed developed significantly fewer perioperative complications and had superior patency after 1 year of follow-up. Even though the mortality from endovascular therapy is low, technical expertise is important to avoid serious complications. Mullens et al54 reported late migration of two stents after treatment of a patient with MTS who subsequently required open heart surgery and annular repair of the tricuspid valve. In pregnancy, VTE is an important cause of morbidity and mortality. PE remains a leading cause of maternal death in the United States, accounting for 9.3% of maternal mortality.55 The incidence of VTE events in pregnancy or the postpartum period is estimated at 1.72 to 2 per 1000 births, four to five times higher than the expected incidence for nonpregnant women at the same age.56,57 There are no current guidelines regarding treatment of pregnant patients presenting with DVT due to underlying MTS, and there is divergent opinion in the literature reviewed. Several authors in the current
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Table IV. Gender comparison: Differences in presentation Female Age at presentation, years Duration of symptoms, days
Male
38.7 6 14.0 (7-83)
46.2 6 16.9 (10-82 years)
183.9 (<1 day-13 years)
173.6 (<1 day-11 years)
P value .02 .3
Leg swelling
80.8 (130/161)
92.7 (51/55)
.037
Leg pain
74.3 (107/144)
88.0 (44/50)
.045
Leg ulcer DVT
1.0 (2/191) 88.9 (160/180)
3.7 (2/54)
.17
81.7 (49/60)
.14
PE
9.9 (19/192)
1.6 (1/62)
.035
Chest pain
1.9 (3/155)
4.3 (2/47)
.63
Shortness of breath
4.2 (7/167)
5 (2/40)
.82
DVT, Deep venous thrombosis; PE, pulmonary embolism. Values are reported as mean 6 standard deviation, median (range), or % (n/N).
literature have discussed the management of VTE during pregnancy, but there is no clear consensus.58-60 In contrast to May and Turner’s seminal report of leftsided MTS, several authors reported on cases with atypical patterns, including right-sided and bilateral disease.11,41 In fact, Raju and Neglen61,62 recognized the presence of those patterns in patients with severe chronic venous insufficiency and coined the term nonthrombotic iliac vein lesions as a broader term describing occult stenosis of the iliac veins typically by arterial bifurcations in the pelvis that are best diagnosed by intravascular ultrasound. Several articles described different anatomic structures causing compression, such as the right CIA and other pelvic organs, and more recently compression from an iliac artery stent has been reported.63,64 Even though these patterns are very discrepant from the initial description, they are referred to as iliac vein compression syndrome and were included in our analysis. The current literature on MTS was derived mostly from case reports or case series. Several larger studies provide information on larger cohorts of patients with heterogeneous populations that lack detailed patient information. This enabled us to have a detailed review of patients suffering from MTS who present with rare findings, including loss of renal graft function,16-19 cryptogenic stroke,24 priapism,32 and variceal bleeding.31 These presentations are less prevalent in real life, especially because the entity of MTS is known to be underdiagnosed.65,66 Interestingly, Kiernan et al24 analyzed 470 patients with cryptogenic stroke who underwent closure of a patent foramen ovale. They showed that 6.3% of the patients, predominantly women, had features consistent with MTS on magnetic resonance venography. The current review showed that 2.2% (35/1569) of all patients with MTS can present with an initial stroke; however, after removal of the case series of Kiernan et al,24 which included 30 patients, this number is then reduced to 0.3% (5/1569). It is interesting to state that on the basis of the reported literature, there are significant gender differences in
presentation of patients with MTS. The current review showed that female patients tend to be younger and are more likely to have PE on presentation.66 Chan et al67 have shown that patients with DVT due to MTS and high-grade stenosis (CIV <4 mm) have an 83% lower risk for development of PE compared with patients with a CIV luminal diameter >4 mm. This observation is most likely due to the protection of the iliocaval compression and thereby prevention of embolization. As such, patients with MTS and VTE were less likely to develop PE than the general population, in which it is estimated that 20% to 30% of patients with DVT would present with PE.68 The younger age at presentation of women compared with men could be partially attributed to increased chances for hypercoagulability with the use of hormone replacement therapy and pregnancy. Both conditions have been reported to be associated in women presenting with DVT due to MTS.38,49 Murphy et al38 therefore recommend screening for hypercoagulable disorders and underlying May-Thurner anatomy in women receiving hormone replacement presenting with leftsided iliofemoral DVT. Blanco-Molina et al69 analyzed sex differences in patients receiving anticoagulant therapy for VTE. In their study of 47,499 patients, they found that women presenting with acute VTE were older, more likely to present with PE or recent immobilization, but less likely to have cancer compared with men. This study is consistent with our findings; however, it analyzed VTE in general and does not specifically identify a diagnosis of MTS. This study is a comprehensive and unique review of the literature on MTS. The major limitation was the presence of many papers that described patients with and without MTS, with lack of granularity to be able to separate the information on patients with MTS. That led to significant decrease in sample of patients analyzed to derive specific characteristics and outcomes. The review is comprehensive and included a large number of case reports, introducing the chance of a bias toward complications and atypia. The gender analysis was particularly difficult
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as patients were described as heterogeneous groups regarding their gender for the most part, and that significantly decreased the number of patients.
CONCLUSIONS MTS, classically described as compression of the left CIV by the right CIA, is used sometimes inaccurately in the literature to describe iliac vein compression. It is more common in women, with a ratio of at least 2:1 compared with men. Women with MTS tend to present at a younger age and have increased risk of PE compared with men.
AUTHOR CONTRIBUTIONS Conception and design: CK, JI, TS, CC Analysis and interpretation: CK, YE, JI, AL, AD, TS, CC Data collection: CK, CC Writing the article: CK, CC Critical revision of the article: CK, YE, JI, AL, AD, TS, CC Final approval of the article: CK, YE, JI, AL, AD, TS, CC Statistical analysis: CK, YE, JI, AL, AD, TS, CC Obtained funding: TS, CC Overall responsibility: CC
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31. Baran M, Kanik A, Can E, Parildar M, Pala EE, Helvaci M. Rectal bleeding and hypertensive colopathy in May-Thurner syndrome. J Pediatr Gastroenterol Nutr 2013;56:e42-3. 32. Alhalbouni S, Deem S, Abu-Halimah S, Sadek BT, Mousa A. Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis secondary to May-Thurner syndrome. Vasc Endovascular Surg 2013;47:488-92. 33. Bomalaski MD, Mills JL, Argueso LR, Fujitani RM, Sago AL, Joseph AE. Iliac vein compression syndrome: an unusual cause of varicocele. J Vasc Surg 1993;18:1064-8. 34. Billakanty S, Burket MW, Grubb BP. May-Thurner syndrome: a vascular abnormality encountered during electrophysiologic study. Pacing Clin Electrophysiol 2006;29:1310-1. 35. Burnand K, Lahiri R, Petridou E, Shoukry M, Minocha A. Varicosities in an adolescent girl on laparoscopy: an unusual presentation of May-Thurner syndrome. Pediatr Surg Int 2011;27:1371-3. 36. Lu T, de Grandis E, Gloviczki P, Glockner J, Shepherd RF. May-Thurner syndrome associated with Klippel-Trenaunay syndrome. Perspect Vasc Surg Endovasc Ther 2012;24:155-60. 37. Srisuwan T, Arworn S, Rerkasem K. Case series of isolated primary persistent sciatic vein. Int J Low Extrem Wounds 2013;12:219-22. 38. Murphy EH, Davis CM, Journeycake JM, DeMuth RP, Arko FR. Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed MayThurner syndrome. J Vasc Surg 2009;49:697-703. 39. Jones WM, Taylor I, Stoddard CJ. Common iliac vein compression syndrome occurring in siblings. Br J Surg 1973;60:663-4. 40. Gurel K, Gurel S, Karavas E, Buharalioglu Y, Daglar B. Direct contrast-enhanced MR venography in the diagnosis of MayThurner syndrome. Eur J Radiol 2011;80:533-6. 41. Knipp BS, Ferguson E, Williams DM, Dasika NJ, Cwikiel W, Henke PK, et al. Factors associated with outcome after interventional treatment of symptomatic iliac vein compression syndrome. J Vasc Surg 2007;46:743-9. 42. Marano GD, Horton JA, Savrin RA. Aorto-iliac aneurysm in iliac compression syndrome. W V Med J 1982;78:87-9. 43. Pandit AS, Hayes M, Guiney-Borgelt S, Dietzek AM. Iatrogenic May-Thurner syndrome after EVAR. Ann Vasc Surg 2014;28:739.e17-20. 44. Hassell DR, Reifsteck JE, Harshfield DL, Ferris EJ. Unilateral left leg edema: a variation of the May-Thurner syndrome. Cardiovasc Intervent Radiol 1987;10:89-91. 45. Steinberg JB, Jacocks MA. May-Thurner syndrome: a previously unreported variant. Ann Vasc Surg 1993;7:577-81. 46. Eng JM, Walor DM, Michaels LA, Weiss AR. An unusual presentation of May-Thurner syndrome in a pediatric patient with a pelvic kidney. J Pediatr Urol 2013;9:e72-5. 47. Berger A, Jaffe JW, York TN. Iliac compression syndrome treated with stent placement. J Vasc Surg 1995;21:510-4. 48. La Hei ER, Appleberg M, Roche J. Surgical thrombectomy and stent placement for iliac compression syndrome. Australas Radiol 1997;41:243-6. 49. DeStephano CC, Werner EF, Holly BP, Lessne ML. Diagnosis and management of iliac vein thrombosis in pregnancy resulting from May-Thurner Syndrome. J Perinatol 2014;34:566-8. 50. Hughes RL, Collins KA, Sullivan KE. A case of fatal iliac vein rupture associated with May-Thurner syndrome. Am J Forensic Med Pathol 2013;34:222-4. 51. Hameed M, Onida S, Davies AH. What is pathological MayThurner syndrome? Phlebology 2017;32:440-2. 52. Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med 2015;20:74-83.
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53. Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg 2013;57:1163-9. 54. Mullens W, De Keyser J, Van Dorpe A, Meuris B, Flameng W, Herregods MC, et al. Migration of two venous stents into the right ventricle in a patient with May-Thurner syndrome. Int J Cardiol 2006;110:114-5. 55. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015;125:5-12. 56. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006;194:1311-5. 57. Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005;143:697-706. 58. Kawamata K, Chiba Y, Tanaka R, Higashi M, Nishigami K. Experience of temporary inferior vena cava filters inserted in the perinatal period to prevent pulmonary embolism in pregnant women with deep vein thrombosis. J Vasc Surg 2005;41:652-6. 59. Nakajima Y, Masaoka N, Tsuzuki Y, Morooka M, Sakai M. MayThurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy. J Obstet Gynaecol Res 2012;38:1106-10. 60. McConville RM, Kennedy PT, Collins AJ, Ellis PK. Failed retrieval of an inferior vena cava filter during pregnancy because of filter tilt: report of two cases. Cardiovasc Intervent Radiol 2009;32:174-7. 61. Raju S, Neglen P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg 2006;44:136-43; discussion: 144. 62. Neglen P, Raju S. Intravascular ultrasound scan evaluation of the obstructed vein. J Vasc Surg 2002;35:694-700. 63. Im S, Lim SH, Chun HJ, Ko YJ, Yang BW, Kim HW. Leg edema with deep venous thrombosis-like symptoms as an unusual complication of occult bladder distension and right MayThurner syndrome in a stroke patient: a case report. Arch Phys Med Rehabil 2009;90:886-90. 64. Hermany PL, Badheka AO, Mena-Hurtado CI, Attaran RR. A unique case of May-Thurner syndrome: extrinsic compression of the common iliac vein after iliac artery stenting. JACC Cardiovasc Interv 2016;9:e39-41. 65. Dogan OF, Boke E. Three cases with May-Thurner syndrome: a possibly under-reported disorder. Vasa 2005;34:147-51. 66. Donatella N, Marcello BU, Gaetano V, Massimo P, Massimo M, Giancarlo B. What the young physician should know about May-Thurner Syndrome. Transl Med UniSa 2015;12:19-28. 67. Chan KT, Popat RA, Sze DY, Kuo WT, Kothary N, Louie JD, et al. Common iliac vein stenosis and risk of symptomatic pulmonary embolism: an inverse correlation. J Vasc Interv Radiol 2011;22:133-41. 68. White RH. The epidemiology of venous thromboembolism. Circulation 2003;107(Suppl 1):I4-8. 69. Blanco-Molina A, Enea I, Gadelha T, Tufano A, Bura-Riviere A, Di Micco P, et al. Sex differences in patients receiving anticoagulant therapy for venous thromboembolism. Medicine (Baltimore) 2014;93:309-17. Submitted Feb 12, 2017; accepted Nov 2, 2017.
Additional material for this article may be found online at www.jvsvenous.org.
Kaltenmeier et al
Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume
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Number
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Supplementary Table (online only). List of all articles included in the analysis with the corresponding year of publication Author 1. Cockett
Title
Date
Iliac vein compressiondits relation to iliofemoral thrombosis and the post-thrombotic syndrome
1967
2. Rigas
Iliac compression syndrome
1970
3. Sorensen
Silent iliac compression syndrome as a cause of renal thrombosis after transplantation
1972
4. Johnson
The iliac compression syndrome
1973
5. Jones
Common iliac vein compression syndrome occurring in siblingsdcase 1
1973
6. Jaszczak
Iliac vein compression syndrome
1977
7. Hans
Uncommon presentation of venous disease
1978
8. Moller
The iliac vein compression syndrome. A case report with a review of the literature
1980
9. Jacob
Iliac vein compression syndrome and lower limb vascular access for hemodialysis
1980
10. Marano
Aorto-iliac compression in iliac compression syndrome
1982
11. Ferris
May-Thurner syndrome
1983
12. Raesebeck
Iliac compression: a myth, a rarity, or a condition frequently missed?
1983
13. Hassel
Unilateral left leg edema: a variation of the May-Thurner syndrome
1987
14. Akers
Iliac vein bypass with autogenous saphenous vein for iliac compression syndrome
1987
15. Taheri
Iliocaval compression syndrome
1987
16. Steinberg
May-Thurner syndrome: a previously unreported variant
1993
17. Bomalaski
Iliac vein compression syndrome: an unusual cause of varicocele
1993
18. Robbins
Radiological cause of the month
1995
19. Berger
Iliac compression syndrome treated with stent placement
1995
20. Verhaeghe
Catheter-directed lysis of iliofemoral vein thrombosis with use of rt-PA
1996
21. Alimi
Iliac vein reconstruction to treat acute and chronic venous occlusive disease
1997
22. La Hei
Surgical thrombectomy and stent placement for iliac compression syndrome
1997
23. Heniford
May-Thurner syndrome: management by endovascular surgical techniques
1998
24. Binkert
Treatment of pelvic venous spur (May-Thurner syndrome) with self-expanding metallic endoprostheses
1998
25. Seidensticker
Treatment of May-Thurner syndrome with catheter-directed thrombolysis and stent placement complicated by heparin-induced thrombocytopenia
1998
26. Sakakibara
Iliac compression syndrome
1998
27. Simon
May-Thurner syndrome in an adolescent: persistence despite operative management
1999
28. Heijmen
Endovascular venous stenting in May-Thurner syndrome
1999
29. Liu
Feasibility of three-dimensional intravascular ultrasonography
1999
30. Patel
Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome
31. Ahmed
Intravascular ultrasonographic findings in May-Thurner syndrome
2000
32. O’Sullivan
Endovascular management of iliac vein compression (May-Thurner) syndrome
2000
33. Way
Paradoxical embolism to the basilar apex associated with May-Thurner syndrome
2000
34. Baron
Iliac vein compression syndrome: a new method of treatment
2000
35. Arrazola
May-Thurner syndrome in renal transplantation
2000
36. Oderich
Stent placement for treatment of central and peripheral venous obstructionda long-term multi-institutional experience
2000
37. Kasirajan
Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis
2001
38. Greer
Cerebral infarction in conjunction with patent foramen ovale and May-Thurner syndrome
2001
39. Hurst
Diagnosis and endovascular treatment of iliocaval compression syndrome
2001
40. Forauer
Intravascular ultrasound in the diagnosis and treatment of iliac vein compression (May-Thurner) syndrome
2002
41. Lamont
Prospective evaluation of endoluminal venous stents in the treatment of the May-Thurner syndrome
2002
42. Wolpert
Magnetic resonance venography in the diagnosis and management of May-Thurner syndrome
2002
43. Molloy
Arterial compression of the right common iliac vein; an unusual anatomic variant
2002
2000
(Continued on next page)
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2017
Supplementary Table (online only). Continued. Author
Title
Date
44. Kishi
Pulmonary emboli caused by iliac compression syndrome without leg symptoms
2002
45. Dheer
Retroperitoneal hematoma caused by a ruptured pelvic varix in a patient with iliac vein compression syndrome
2003
46. Cil
Case 76: May-Thurner syndrome
2004
47. Oguzkurt
Computed tomography findings in 10 cases of iliac vein compression (May-Thurner) syndrome
2004
48. Boyd
Unilateral lower extremity edema in May-Thurner syndrome
2004
49. Grunwald
Endovascular management of May-Thurner syndrome
2004
50. Cho
Endovascular management of iliofemoral deep venous thrombosis due to iliac vein compression syndrome in patients with protein C and/or S deficiency
2004
51. Illuminati
The surgical treatment of ilio-femoral venous obstruction
2004
52. Mullens
Migration of two venous stents into the right ventricle in a patient with May-Thurner syndrome
2005
53. Dogan
Three cases with May-Thurner syndrome
2005
54. Billakanty
May-Thurner syndrome: a vascular abnormality encountered during electrophysiologic study
2006
55. Burke
Unusual case of right-sided May-Thurner syndrome and review of its management
2006
56. Oguzkurt
Successful endovascular treatment of iliac vein compression (May-Thurner) syndrome in a pediatric patient
2006
57. Raffini
May-Thurner syndrome and thrombosis in adolescents
2006
58. Kim
Percutaneous treatment of deep vein thrombosis in May-Thurner syndrome
2006
59. Kim
Spontaneous rupture of the left common iliac vein associated with May-Thurner syndrome: successful management with surgery and placement of endovascular stent
2006
60. Ludwig
Postthrombotic syndrome complicating a case of May-Thurner syndrome despite endovascular therapy
2006
61. Oguzkurt
Ultrasonic diagnosis of iliac vein compression (May-Thurner) syndrome
2007
62. Husman
Stenting of common iliac vein obstruction combined with regional thrombolysis and thrombectomy in acute deep vein thrombosis
2007
63. Knipp
Factors associated with outcome after interventional treatment of symptomatic iliac vein compression syndrome
2007
64. De Bast
May-Thurner syndrome will be completed?
2008
65. Vyas
May-Thurner syndrome in a pediatric renal transplant recipientdcase report and literature review
2008
66. Sharma
A case of May-Thurner syndrome with antiphospholipid syndrome
2008
67. Zander
May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis in the postpartum period
2008
68. Elsharawy
Unusual case of left iliac vein compression secondary to May-Thurner syndrome and crossed fused renal ectopia
2008
69. Loukas
A case of May-Thurner syndrome
2008
70. Oguzkurt
Compression of the left common iliac vein in asymptomatic subjects and patients with left iliofemoral deep vein thrombosis
2008
71. Oguzkurt
Iliac vein compression syndrome: outcome of endovascular treatment with long-term follow-up
2008
72. Abboud
“Right-sided” May-Thurner syndrome
2009
73. Fretz
Compression of the inferior vena cava by the right iliac artery: a rare variant of May-Thurner syndrome
2009
74. Kiernan
May-Thurner syndrome in patient with cryptogenic stroke and patent foramen ovale
2009
75. Murphy
Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed May-Thurner syndrome
2009
76. Mougdill
May-Thurner syndrome: case report and review of the literature
2009
77. Lou
Endovascular treatment for iliac vein compression syndrome: a comparison between the presence and absence of secondary thrombosis
2009
78. Kim
Deep vein thrombosis associated with May-Thurner syndrome in an amyotrophic lateral sclerosis patientda case report
2010
79. Dhillon
Acute deep vein thrombus due to May-Thurner syndrome
2010
Kaltenmeier et al
Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume
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Number
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Supplementary Table (online only). Continued. Author
Title
Date
80. Canales
Intravascular ultrasound guidance in treating May-Thurner syndrome
2010
81. Lee
May-Thurner syndrome found incidentally after left femoral catherization in a pediatric patient
2010
82. Gurel
Direct contrast-enhanced MR venography in the diagnosis of May-Thurner syndrome
2010
83. Oguzkurt
Endovascular treatment of phlegmasia cerulea dolens with impending venous gangrene
2010
84. Campsen
May-Thurner syndrome complicating left-sided renal transplant
2010
85. Jeon
May-Thurner syndrome complicated by acute iliofemoral vein thrombosis
2010
86. Jeon
Catheter-directed thrombolysis with conventional aspiration thrombectomy for lower extremity deep vein thrombosis
2010
87. Jiang
Spontaneous retroperitoneal hematoma associated with iliac vein rupture
2010
88. Burnand
Varicosities in an adolescent girl on laparoscopy: an unusual presentation of May-Thurner syndrome
2011
89. Whitman
A case of lower extremity venous thrombosis in the pediatric emergency department: associations with May-Thurner syndrome and isotretinoin use
2011
90. Vink
Balloon-assisted retrieval of tilted OptEase IVC filter
2011
91. Cerquozzi
Iliac vein compression syndrome in an active and healthy young female
2011
92. Qing-you
Endovascular treatment of iliac vein compression syndrome
2011
93. Peters
May-Thurner syndrome: a not so uncommon cause of common condition
2012
94. Cheema
Congenital aplasia of the left iliac vein in a patient with concomitant Sturge-Weber syndrome and May-Thurner syndrome
2012
95. Nakajima
May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy
2012
96. Ibrahim
Endovascular management of May-Thurner syndrome
2012
97. Ito
Sharp recanalization of chronic left iliac vein occlusion
2012
98. Theodorus
Balloon-assisted retrieval of tilted OptEase IVC filter
2012
99. Budnur
Endovascular treatment of iliac vein compression syndrome (May-Thurner)
2012
100. Jones
Maximal venous outflow velocity: an index for iliac vein obstruction
2012
101. Narayan
Iliac vein compression as risk factor for left- versus right-sided deep venous thrombosis
2012
102. Carr
Correlation of the diameter of the left common iliac vein with the risk of lower extremity deep venous thrombosis
2012
103. Park
Extrinsic compression of left iliac vein does not predict the development of post thrombotic syndrome in left side deep venous thrombosis
2012
104. Kalu
May-Thurner syndrome: a case report and review of the literature
2013
105. Wang Yi
Endovascular treatment of acute proximal deep venous thrombosis secondary to iliac vein compression syndromeda novel technique for thrombus removal
2013
106. Spivack
Changing strategies to treat venous thrombotic occlusions of the upper and lower extremities secondary to compressive phenomena
2013
107. Rison
Acute paradoxical embolic cerebral ischemia secondary to possible May-Thurner syndrome and an atrial septal defectda case report
2013
108. Zhu
Iliac vein compression syndrome with secondary acute isolated iliofemoral deep vein thrombosis
2013
109. Alhalbouni
Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis
2013
110. Foit
Iliofemoral deep vein thrombosis after tibial plateau fracture fixation related to undiagnosed May-Thurner syndromeda case report
2013
111. Baran
Rectal bleeding and hypertensive colopathy in May-Thurner syndrome
2013
112. Cuerva
Delayed diagnosis of May-Thurner syndrome following staging surgery for ovarian cancer
2013
113. Hughes
A case of fatal iliac vein rupture associated with May-Thurner syndrome
2013
114. Hung
Prostatism and May-Thurner syndrome
2013
115. Fernando
May-Thurner syndrome in 68-year-old woman after remote abdominal surgery
2013
116. Vaidya
Successful salvage of a renal allograft after acute renal vein thrombosis due to May-Thurner syndrome
2013
117. DeRubertis
Endovascular management of nonmalignant iliocaval venous lesions
2013
118. Mousa
May-Thurner syndrome: update and review
2013
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Supplementary Table (online only). Continued. Author
Title
Date
119. Lu
May-Thurner syndrome associated with Klippel-Trenaunay syndrome
2013
120. Srisuwan
Case series of isolated primary persistent sciatic vein
2013
121. Igari
Surgical thrombectomy and simultaneous stenting for deep venous thrombosis caused by iliac vein compression syndrome May-Thurner syndrome
2013
122. Goldenberg
Percutaneous mechanical and pharmacomechanical thrombolysis for occlusive deep vein thrombosis of the proximal limb in adolescents
2013
123. Erdoes
Pharmacomechanical thrombolysis for phlegmasia cerulea dolens
2013
124. Park
Iliac vein stenting as a durable option for residual stenosis after catheter-directed thrombolysis and angioplasty of iliofemoral deep vein thrombosis secondary to May-Thurner syndrome
2013
125. Xue
Catheter-directed thrombolysis and stenting in the treatment of iliac vein compression syndrome
2013
126. DeStephano
Diagnosis and management of iliac vein thrombosis in pregnancy resulting from May-Thurner Syndrome
2014
127. Rege
May-Thurner syndrome complicating left-sided donor nephrectomy
2014
128. Pandit
Iatrogenic May-Thurner syndrome after EVAR
2014
129. Mathur
May-Thurner syndrome
2014
130. Alirhayim
Symptomatic ileofemoral deep vein thrombosis due to May-Thurner syndrome
2014
131. Smeds
Treatment of chronic venous stent occlusion with a Wildcat catheter
2014
132. Maldonado
Left lower extremity pain and swelling
2014
133. Vijayalakshmi
Unusual cases of right-sided and left-sided May-Thurner syndrome
2014
134. Sadaghianloo
Successful treatment of a spontaneous rupture of the left external iliac vein in a man
2014
135. Liu
Endovascular treatment for symptomatic iliac vein compression syndrome: a prospective consecutive series of 48 patients
2014
136. Matsuda
Early and long-term outcomes of venous stent implantation for iliac venous stenosis after catheter-directed thrombolysis for acute deep vein thrombosis
2014
137. Wax
May-Thurner syndrome complicating pregnancyda report of four cases
2014
Systematic review of May-Thurner syndrome with emphasis on gender differences Christof T. Kaltenmeier, MD, PhD,a Young Erben, MD,b Jeffrey Indes, MD,c Alfred Lee, MD, PhD,d Alan Dardik, MD, PhD,b Timur Sarac, MD,b and Cassius Iyad Ochoa Chaar, MD, MS, FACS,b Pittsburgh, Pa; and New Haven and Storrs, Conn
ABSTRACT Objective: May-Thurner syndrome (MTS) is increasingly recognized as a frequent source of leg swelling and a precipitating factor for venous thromboembolism. This paper is a systematic review of the English literature on MTS with an analysis focusing on gender differences in presentation and treatment. Methods: A systematic review of the English literature between April 1967 and December 2014 was performed using the following terms: “May-Thurner syndrome,” “Cockett syndrome,” and “iliac vein compression syndrome.” After review, there were 174 articles in the analysis. We first analyzed all presented cases, followed by a gender comparison if case reports and case series had detailed description. Asymptomatic patients with just anatomic compression without symptoms were excluded. Statistical differences between data sets were assessed using c2 test and Student t-test. Results: There were 1569 patients with MTS after exclusion of articles based on our criteria. The female to male ratio was 2:1 (976 [67.1%] vs 480 [32.9%]). Women presented at a younger age compared with men (38.7 6 14.0 years vs 46.2 6 16.9 years; P ¼ .02). Gender comparison at presentation, which was available for 254 patients, showed that men had significantly more reported leg swelling (92.7% vs 80.8%; P ¼ .037) and more leg pain (88% vs 74.3%; P ¼ .045) compared with women. There was no difference in the reported proportion of patients presenting with deep venous thrombosis between the two groups (88.9% vs 81.7%; P ¼ .14). However, women were significantly more likely to have a pulmonary embolus on presentation compared with men (9.9% vs 1.6%; P ¼ .035). Treatment modalities included endovascular interventions without thrombolysis (53%) or with thrombolysis (33.2%), open surgery (6.8%), and medical management (7%). Endovascular treatment was more common than surgical or medical treatment (P < .001). Because of lack of granularity in the data, it was not possible to distinguish treatment methods between female and male patients. There was no statistically significant difference in complication rate between men and women based on the articles that provided that information (P ¼ .34). However, open procedures had significantly higher complications compared with endovascular interventions (P ¼ .021). Conclusions: Based on the reported literature, MTS is more common in women and is at least twice as frequent in women as in men. Men tend to have more pain and swelling in the legs, whereas women tend to be younger and more likely to have a pulmonary embolus on presentation. MTS and iliac vein compression are sometimes used interchangeably in an inaccurate manner. (J Vasc Surg: Venous and Lym Dis 2017;-:1-8.)
May-Thurner syndrome (MTS), also known as Cockett syndrome or iliac vein compression syndrome, results typically from compression of the left common iliac vein (CIV) between the right common iliac artery (CIA) and the vertebrae. The resultant venous stasis from this compression can lead to venous congestion and the
development of deep venous thrombosis (DVT) in the left lower extremity. Virchow1 was the first to describe a left-sided predominance of iliofemoral DVT caused by venous stasis disease in 1851. Since Virchow made the observation, this has always been explained by an obstruction of the flow in the CIV caused by compression
From the Department of Surgery, University of Pittsburgh Medical Center, Pitts-
333 Cedar St, Boardman 204, PO Box 208062, New Haven, CT 06520-8039
burgha; the Section of Vascular Surgery, Department of Surgery,b and Section
(e-mail: [email protected]).
of Hematology, Department of Internal Medicine,d Yale University School of
The editors and reviewers of this article have no relevant financial rela-
Medicine, New Haven; and the Section of Vascular Surgery, Department of
tionships to disclose per the Journal policy that requires reviewers to
Surgery, University of Connecticut, Storrs.c Author conflict of interest: none. Poster and short oral presentation at the Twenty-eighth Annual Meeting of the American Venous Forum, Orlando, Fla, February 24-26, 2016. Additional material for this article may be found online at www.jvsvenous.org. Correspondence: Cassius Iyad Ochoa Chaar, MD, MS, FACS, Assistant Professor
decline review of any manuscript for which they may have a conflict of interest. 2213-333X Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvsv.2017.11.006
of Surgery, Section of Vascular Surgery, Yale University School of Medicine,
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of the crossing iliac artery.2 In 1950, Wanke further suggested that narrowing of the common and external iliac veins due to extrinsic compression can lead to sclerotic transformation and inflammation in the vessel. However, May and Thurner were the first to carry out a close investigation of this description reported in 1957. They performed a large autopsy study on 430 cadavers and observed compression of the left CIV by the overriding right CIA in 22% of cadavers.2 Cockett and Thomas3 coined the term iliac compression syndrome in 1965 and gave the first description of a large series of patients with the diagnosis, including clinical and angiographic findings in 29 patients. In addition to the detailed clinical reporting, their study was the first to recognize that symptoms can be right sided or even bilateral, depending on the anatomy and the configuration of the compressing structure.4 MTS is diagnosed in 2% to 5% of all patients being evaluated for chronic venous insufficiency of the lower extremity.5,6 Besides the classic presentation, there have been several variations described in the literature, such as right-sided disease4,7-13 and compression by other anatomic structures, including the bladder and kidney.12,14 Despite the increasing awareness of the syndrome, most of the literature written on the topic is based on case reports and case series. Even though MTS is more prevalent in women, gender differences with respect to presentation and treatment are not known. This paper presents a systematic review of the English literature on MTS and summarizes patients’ presentations, diagnostic modalities, and treatment strategies, focusing on the differences between men and women.
METHODS Search strategy. A systematic review of the English literature was performed between April 19674 and December 2014. The first article included in 1967 was the case series described by Cockett and had a detailed clinical description of 57 patients with the condition. A search of PubMed, OVID and Embase databases using the terms “May-Thurner syndrome,” “Cockett syndrome,” and “iliac vein compression syndrome” was performed. The abstracts of all papers were reviewed by two independent reviewers (C.T.K. and C.I.O.C.). All case reports and case series that had detailed description of cases with MTS were included. Papers that reported patients with DVT describing some patients with MTS and some without the syndrome were excluded when the characteristics of the group of patients with MTS could not be determined. The articles were reviewed, and patient demographics, presentation, risk factors, laterality, and anatomy of the compression were extracted. The methods of imaging as well as treatment modalities and complications were also noted. The length of follow-up and long-term results were recorded when available.
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Analysis. A descriptive analysis was performed of all cases of MTS looking at age, gender, laterality, presentation, and details of the anatomy of the compression when available. The general modalities of treatmentd medical, open surgical, and endovascularewere noted. Next, comparison of men and women with respect to presentation and association of MTS with DVT and pulmonary embolism (PE) was performed using a subset of articles. Papers that did not have detailed descriptions to allow differentiation based on gender were excluded. Statistical differences between men and women were assessed using c2 test and Student t-test.
RESULTS Search results The literature search resulted in 174 articles describing patients with MTS selected on the basis of review of the abstracts. After review of the manuscripts, 37 additional articles were excluded because of lack of detailed patient information or the description of mixed populations of patients (patients with DVT but no MTS) was presented and the characteristics of patients with MTS could not be extracted. Asymptomatic patients with just anatomic compression without symptoms were excluded. A general descriptive analysis based on 137 articles (n ¼ 1569 patients) was performed looking at presentation, anatomy, modalities of treatment, and complications. Subsequently, a comparison of men and women with MTS was performed. An additional 33 articles were excluded because of the inability to separate the characteristic of men and women. Gender comparison of patients with MTS was performed on the basis of 104 articles providing relevant information for 254 patients. The search strategy, including a flow chart and reasons for exclusion of articles, is presented in the Fig. All the papers are listed in the Supplementary Table (online only). General analysis Presentation. The mean age at presentation was 42.6 6 16.9 years. MTS was more common among women, with a female to male ratio of 2:1 (976 vs 480). Overall, 27 patients (1.9%; 18 female, 9 male) presented at young age up to 18 years. MTS most frequently presented as DVT with leg swelling and pain. There were 822 patients (52.4%) presenting with DVT. Leg swelling and leg pain were the most frequent symptoms on presentation and were reported in 52.2% (n ¼ 819/1569) and 38.5% (n ¼ 605/1569), respectively. The proportion of patients presenting with lower extremity ulcers was 5.9% (n ¼ 92/1569). With acute presentations, PE was reported in 122 of 1569 patients (7.8%). In addition, 2.2% (n ¼ 34/1569) of patients presented with an acute critical limb condition, such as phlegmasia (n ¼ 33) or compartment syndrome
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Fig. Flow chart: search results and reasons for exclusion.
(n ¼ 1). One patient had to undergo below-the-knee amputation15 (Table I). MTS was discovered after renal transplantation and manifested by deterioration of graft function in four patients.16-19 Salvage of the transplanted kidney using endovascular techniques and thrombolysis was possible in three patients.16,18,19 In one case, the patient had to undergo surgical removal of the kidney after loss of function.17 The patient developed left leg swelling and cyanosis in addition to anuria shortly after surgery. Open exploration with attempted thrombectomy was performed 24 hours after transplantation, but the kidney showed severe cyanosis and was not salvageable. MTS with acute left-sided DVT has been reported after laparoscopic donor nephrectomy as well.20 Jacob et al21 described a young patient on hemodialysis who developed left leg swelling only after an access was placed in the left leg. The patient was treated with an iliocaval bypass that resolved the symptoms. Several authors described patients suffering from embolic strokes due to MTS in the setting of a patent foramen ovale.22-25 Interestingly, stroke as initial presentation was found in 2.2% (35/1569) of the reported cases in this review. A few patients with MTS presented with bleeding. Most had acute bleeding into the retroperitoneum from ruptured pelvic varix,26-30 and one patient presented with chronic gastrointestinal bleeding from congested rectal varices.31 Male patients with MTS have been reported also to present with urologic conditions. Alhalbouni et al32 reported a case of a 42-year-old man suffering from venous-related priapism, and Bomalaski et al33 reported a case of a teenager with varicocele. In addition, MTS can sometimes be incidentally discovered during unrelated procedures. The presence of MTS during cardiac electrophysiologic catheterization can hinder access from the femoral vein, necessitating use of alternative access.9,34 Furthermore, Burnand et al35
Table I. Presentation of patients with May-Thurner syndrome (MTS) Presentation Age at presentation, years
42.6 6 16.9 (7-83)
Duration of symptoms, days
181.2 (<1 day-13 years)
Leg swelling
52.2 (819/1569)
Leg pain
38.5 (605/1569)
Leg ulcer DVT
5.9 (92/1569) 52.4 (822/1569)
PE
7.8 (122/1569)
Chest pain
0.3 (5/1569)
Shortness of breath
0.8 (12/1569)
Critical limb conditiona
2.2 (34/1569)
Stroke
2.2 (35/1569)
DVT, Deep venous thrombosis; PE, pulmonary embolism. Values are reported as mean 6 standard deviation, median (range), or % (n/N). a Critical limb condition includes phlegmasia and compartment syndrome.
noted a large left-sided abdominal varicocele during laparoscopy that triggered a workup for MTS. MTS has been reported in association with other vascular anomalies, such as Klippel-Trénaunay syndrome.36,37 Risk factors for venous thromboembolism (VTE). Recent surgery was present in 16.9% (139/822) and history of cancer was reported in 11.2% (92/822) of patients as the most common risk factors for patients with MTS who developed VTE. Immobilization was found in 9% (74/822) of presented cases. Trauma was the precipitating factor in 4.6% (38/822) of patients. Thirty-one patients presented during pregnancy (n ¼ 30) or in the postpartum period (n ¼ 1), accounting for 3.2% (31/976) of all women with MTS. Hypercoagulable disorders were found in 9.6% (79/822) of patients with VTE and 5.0% (79/1569) of the total
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Table II. Risk factors for venous thromboembolism (VTE) in patients with May-Thurner syndrome (MTS) Presentation Recent surgery
16.9 (139/822)
History of cancer
11.2 (92/822)
Immobilization
9.0 (74/822)
Hypercoagulable disorder
9.6 (79/822)
Factor V Leiden Antiphospholipid Protein C or S
39.2 (31/79) 2.5 (2/79) 29.1 (23/79)
Resistance of C activated protein
1.3 (1/79)
Prothrombin gene mutation
2.5 (2/79)
Increased anticardiolipin
3.8 (3/79)
Lupus anticoagulant
7.6 (6/79)
Antithrombin III
3.8 (3/79)
Hyperhomocysteinemia
1.3 (1/79)
Trauma
4.6 (38/822)
Hormone replacement therapy
6.3 (62/976)
Values are reported as % (n/N).
population. Factor V Leiden in 39.2% (31/79) and protein C or S deficiency in 29.1% (23/79) were the most common reported hypercoagulable disorders in all patients (Table II). Six percent (62/976) of women reported in the literature were taking hormone replacement therapy. Murphy et al38 reported DVT related to MTS in seven adolescent women after initiation of hormone replacement therapy. Only three patients were found to have an abnormality on hypercoagulable workup consistent with being heterozygous for factor V Leiden mutation. It is unclear whether there is a genetic predisposition to development of MTS. At least one case report described siblings with MTS and DVT.39 Imaging and anatomy. The most common diagnostic modalities were computed tomography venography (44.8%) and venography (38.7%), followed by magnetic resonance imaging (6.6%). Intravascular ultrasound was used in only 8.8% of cases. Gurel et al40 suggested that direct injection of contrast material by injector into the bilateral pedal veins would enhance visualization of the deep veins as well as the pattern of collaterals. The most common anatomic location of MTS is on the left side in 98.0% (1537/1569) due to compression by the right CIA in 91.9% (1442/1569). However, there were 34 cases that exhibited a different pattern, accounting for 2.2% (34/1569) of all reported cases of MTS. Right-sided MTS was reported in 1.4% (22/1569)7-9,11-13 and bilateral compression in 0.8% (12/1569).41 Other compressed structures reported were the right CIV and inferior vena cava (IVC). Alternative structures that could cause compression were a transplanted kidney, bladder in the setting of prostatism,12 arterial aneurysm,42 and left iliac artery stent graft.43
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A tortuous left CIA,44 left internal iliac artery,45 and right internal iliac artery10 could cause compression in certain cases. Ectopic kidneys have been reported to contribute to MTS by direct compression of the left CIV by a left pelvic kidney46 or by exacerbating the compression by the right CIA in a patient with a fused ectopic kidney.14 A case of reverse MTS, in which the left CIA compresses the right CIV, was reported in a patient with situs inversus.9 These cases are probably best referred to as iliac vein compression syndrome as there is no true anatomic compression similar to the seminal cases described by May and Thurner. Treatment. Multiple treatment modalities have been used to treat MTS, including endovascular interventions without thrombolysis (53%) or with thrombolysis (33.2%), open surgery (6.8%), and medical management (7%). Endovascular treatment was more common compared with surgical or medical treatment (Table III). Before the year 2000, 75% of procedures were performed by open surgery (39/52) and 25% were endovascular (13/52). In contrast, during the following period (2000-2014), 4.1% of treatment involved open surgery (45/1099) and 95.9% (1054/1099) were endovascular interventions. Medical management consisted of anticoagulation for patients presenting with VTE with compression therapy for patients with swelling, but no interventions were performed. Berger et al47 performed the first known venous stent placement to relieve iliac compression in 1995. Stents were placed in 1048 patients, with an average stent size of 12.5 mm (8-20 mm). Balloon angioplasty without stenting was performed in six patients (1%). The AngioJet (Boston Scientific, Natick, Mass; n ¼ 33) and Trellis (currently off the market; n ¼ 7) were used for pharmacomechanical thrombolysis (PMT) in patients with acute DVT. Treatment of acute iliofemoral thrombosis related to MTS has also been performed through hybrid procedures, such as open thrombectomy and on-table angiography and stenting.48 Open surgical procedures included venous patch angioplasty (n ¼ 18), venous bypasses with prosthetic (n ¼ 3), and saphenous vein (Palma procedure, n ¼ 6). Lysis of adhesions around the iliac vein was described in 7 cases and creation of a concomitant arteriovenous fistula in 13 patients. Because of lack of details of multiple articles, it was not possible to extract genderspecific information for treatment modalities. Several strategies have been reported for treatment of extensive DVT related to MTS during pregnancy. Treatment included anticoagulation and stent placement (n ¼ 1), venous thrombectomy (n ¼ 2), and PMT and definitive stent placement post partum (n ¼ 3). DeStephano et al49 suggested PMT with clot removal after suprarenal IVC filter placement in one session during pregnancy to minimize risks of irradiation and bleeding. Patients presented post partum for iliac vein stenting and removal of the IVC filter. The babies were born
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Table III. Treatment modalities and complications Treatment modality Medical
7.0 (86/1237)
Open surgery
6.8 (84/1237)
Endovascular
86.2 (1067/1237)
Endovascular without lysis
53.0 (656/1237)
Endovascular with lysis
33.2 (411/1237)
Open (n ¼ 84)
Endovascular (n ¼ 1067)
Bleeding/transfusion required
3.5 (3/84)
1.3 (11/1067)
.04
Thrombosis
3.5 (3/84)
1.0 (11/1067)
.04
Prolonged pain
1.2 (1/84)
0.6 (6/1067)
.49
Complications
P value
Perforation
d
0.09 (1/1067)
.78
HIT
d
0.09 (1/1067)
.78
PE
d
0.2 (2/1067)
.69
Total
8.1
3.3
.021
HIT, Heparin-induced thrombocytopenia; PE, pulmonary embolism. Values are reported as % (n/N).
with no complications; however, no long-term follow-up was reported. Complications. The overall complication rate for patients with MTS managed surgically was 2.1% with associated mortality rate of 0.07%. The most common perioperative complications reported were bleeding (n ¼ 14) and thrombosis (n ¼ 14); heparin-induced thrombocytopenia (n ¼ 1), intraoperative perforation of external iliac vein (n ¼ 1), and one death occurred. Complications were more common after open compared with endovascular procedures (8.1% vs 3.3%; P ¼ .021; Table III). The death occurred in a 49-year-old perimenopausal women with factor V Leiden and extensive left iliofemoral DVT. She was heterozygous for factor V Leiden. The patient was admitted for an IVC filter placement. After the procedure, the patient died of acute intra-abdominal hemorrhage related to spontaneous rupture of the left CIV. Autopsy revealed a 0.5-cm transmural defect of the left CIV; there was no evidence of laceration or mural dissection.50 Long-term follow up. The mean reported follow-up time was 25.8 6 16.4 months, and 20 patients had to undergo reinterventions after open (3.2%; n ¼ 3/94) or endovascular (1.6%; n ¼ 17/1067) treatment. The patency of the treated vein after 12 months was superior for endovascular treatment (96% [576/599]) compared with open surgery (64.2% [20/31]; P < .01). Information on follow-up could be extracted from 79 articles, most of them being single case reports or large case series if detailed information was provided. Follow-up imaging was performed using venography or computed tomography. Gender comparison The differences in gender are based on a subgroup analysis of 254 patients who had details of presentation.
Women presented at a younger age compared with men (38.7 6 14.0 years vs 46.2 6 16.9 years; P ¼ .02). On presentation, men had significantly more reported leg swelling (92.7% vs 80.8%; P ¼ .037) and more leg pain (88% vs 74.3%; P ¼ .045) compared with women. However, there was no difference in the reported proportion of patients presenting with DVT between the two groups (88.9% vs 81.7%; P ¼ .14). Women were significantly more likely to have PE on presentation compared with men (9.9% vs 1.6%; P ¼ .035). There was no difference in reported leg ulcers (P ¼ .17), shortness of breath (P ¼ .82), or chest pain (P ¼ .63). There were no significant differences in risk factors between the two groups (Table IV). Because of lack of granularity of the data, it was not possible to distinguish treatment methods between female and male patients.
DISCUSSION MTS is increasingly recognized as a cause of chronic venous insufficiency and a precipitating factor for VTE. Despite ongoing controversy about the exact definition of its pathologic process,51 endovascular treatment has been shown to be safe and effective for treatment of acute venous thrombosis or chronic compression.52 Furthermore, Raju53 has shown that iliac vein stenting is a safe and effective alternative to traditional open surgery to correct iliac vein compression. This systematic review provides a detailed description of the literature reporting on the syndrome since it was first clinically described in patients by Cockett et al4 in 1967. Our findings support the current paradigm of endovascular therapy as a modality of choice for MTS and iliac vein compression as well. In a limited comparison of a predominantly historical group of patients treated with a variety of open surgical procedures (venous bypass, patch angioplasty, lysis of adhesions, with creation of fistula/ thrombectomy), patients treated with endovascular stenting with lysis as needed developed significantly fewer perioperative complications and had superior patency after 1 year of follow-up. Even though the mortality from endovascular therapy is low, technical expertise is important to avoid serious complications. Mullens et al54 reported late migration of two stents after treatment of a patient with MTS who subsequently required open heart surgery and annular repair of the tricuspid valve. In pregnancy, VTE is an important cause of morbidity and mortality. PE remains a leading cause of maternal death in the United States, accounting for 9.3% of maternal mortality.55 The incidence of VTE events in pregnancy or the postpartum period is estimated at 1.72 to 2 per 1000 births, four to five times higher than the expected incidence for nonpregnant women at the same age.56,57 There are no current guidelines regarding treatment of pregnant patients presenting with DVT due to underlying MTS, and there is divergent opinion in the literature reviewed. Several authors in the current
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Table IV. Gender comparison: Differences in presentation Female Age at presentation, years Duration of symptoms, days
Male
38.7 6 14.0 (7-83)
46.2 6 16.9 (10-82 years)
183.9 (<1 day-13 years)
173.6 (<1 day-11 years)
P value .02 .3
Leg swelling
80.8 (130/161)
92.7 (51/55)
.037
Leg pain
74.3 (107/144)
88.0 (44/50)
.045
Leg ulcer DVT
1.0 (2/191) 88.9 (160/180)
3.7 (2/54)
.17
81.7 (49/60)
.14
PE
9.9 (19/192)
1.6 (1/62)
.035
Chest pain
1.9 (3/155)
4.3 (2/47)
.63
Shortness of breath
4.2 (7/167)
5 (2/40)
.82
DVT, Deep venous thrombosis; PE, pulmonary embolism. Values are reported as mean 6 standard deviation, median (range), or % (n/N).
literature have discussed the management of VTE during pregnancy, but there is no clear consensus.58-60 In contrast to May and Turner’s seminal report of leftsided MTS, several authors reported on cases with atypical patterns, including right-sided and bilateral disease.11,41 In fact, Raju and Neglen61,62 recognized the presence of those patterns in patients with severe chronic venous insufficiency and coined the term nonthrombotic iliac vein lesions as a broader term describing occult stenosis of the iliac veins typically by arterial bifurcations in the pelvis that are best diagnosed by intravascular ultrasound. Several articles described different anatomic structures causing compression, such as the right CIA and other pelvic organs, and more recently compression from an iliac artery stent has been reported.63,64 Even though these patterns are very discrepant from the initial description, they are referred to as iliac vein compression syndrome and were included in our analysis. The current literature on MTS was derived mostly from case reports or case series. Several larger studies provide information on larger cohorts of patients with heterogeneous populations that lack detailed patient information. This enabled us to have a detailed review of patients suffering from MTS who present with rare findings, including loss of renal graft function,16-19 cryptogenic stroke,24 priapism,32 and variceal bleeding.31 These presentations are less prevalent in real life, especially because the entity of MTS is known to be underdiagnosed.65,66 Interestingly, Kiernan et al24 analyzed 470 patients with cryptogenic stroke who underwent closure of a patent foramen ovale. They showed that 6.3% of the patients, predominantly women, had features consistent with MTS on magnetic resonance venography. The current review showed that 2.2% (35/1569) of all patients with MTS can present with an initial stroke; however, after removal of the case series of Kiernan et al,24 which included 30 patients, this number is then reduced to 0.3% (5/1569). It is interesting to state that on the basis of the reported literature, there are significant gender differences in
presentation of patients with MTS. The current review showed that female patients tend to be younger and are more likely to have PE on presentation.66 Chan et al67 have shown that patients with DVT due to MTS and high-grade stenosis (CIV <4 mm) have an 83% lower risk for development of PE compared with patients with a CIV luminal diameter >4 mm. This observation is most likely due to the protection of the iliocaval compression and thereby prevention of embolization. As such, patients with MTS and VTE were less likely to develop PE than the general population, in which it is estimated that 20% to 30% of patients with DVT would present with PE.68 The younger age at presentation of women compared with men could be partially attributed to increased chances for hypercoagulability with the use of hormone replacement therapy and pregnancy. Both conditions have been reported to be associated in women presenting with DVT due to MTS.38,49 Murphy et al38 therefore recommend screening for hypercoagulable disorders and underlying May-Thurner anatomy in women receiving hormone replacement presenting with leftsided iliofemoral DVT. Blanco-Molina et al69 analyzed sex differences in patients receiving anticoagulant therapy for VTE. In their study of 47,499 patients, they found that women presenting with acute VTE were older, more likely to present with PE or recent immobilization, but less likely to have cancer compared with men. This study is consistent with our findings; however, it analyzed VTE in general and does not specifically identify a diagnosis of MTS. This study is a comprehensive and unique review of the literature on MTS. The major limitation was the presence of many papers that described patients with and without MTS, with lack of granularity to be able to separate the information on patients with MTS. That led to significant decrease in sample of patients analyzed to derive specific characteristics and outcomes. The review is comprehensive and included a large number of case reports, introducing the chance of a bias toward complications and atypia. The gender analysis was particularly difficult
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as patients were described as heterogeneous groups regarding their gender for the most part, and that significantly decreased the number of patients.
CONCLUSIONS MTS, classically described as compression of the left CIV by the right CIA, is used sometimes inaccurately in the literature to describe iliac vein compression. It is more common in women, with a ratio of at least 2:1 compared with men. Women with MTS tend to present at a younger age and have increased risk of PE compared with men.
AUTHOR CONTRIBUTIONS Conception and design: CK, JI, TS, CC Analysis and interpretation: CK, YE, JI, AL, AD, TS, CC Data collection: CK, CC Writing the article: CK, CC Critical revision of the article: CK, YE, JI, AL, AD, TS, CC Final approval of the article: CK, YE, JI, AL, AD, TS, CC Statistical analysis: CK, YE, JI, AL, AD, TS, CC Obtained funding: TS, CC Overall responsibility: CC
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31. Baran M, Kanik A, Can E, Parildar M, Pala EE, Helvaci M. Rectal bleeding and hypertensive colopathy in May-Thurner syndrome. J Pediatr Gastroenterol Nutr 2013;56:e42-3. 32. Alhalbouni S, Deem S, Abu-Halimah S, Sadek BT, Mousa A. Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis secondary to May-Thurner syndrome. Vasc Endovascular Surg 2013;47:488-92. 33. Bomalaski MD, Mills JL, Argueso LR, Fujitani RM, Sago AL, Joseph AE. Iliac vein compression syndrome: an unusual cause of varicocele. J Vasc Surg 1993;18:1064-8. 34. Billakanty S, Burket MW, Grubb BP. May-Thurner syndrome: a vascular abnormality encountered during electrophysiologic study. Pacing Clin Electrophysiol 2006;29:1310-1. 35. Burnand K, Lahiri R, Petridou E, Shoukry M, Minocha A. Varicosities in an adolescent girl on laparoscopy: an unusual presentation of May-Thurner syndrome. Pediatr Surg Int 2011;27:1371-3. 36. Lu T, de Grandis E, Gloviczki P, Glockner J, Shepherd RF. May-Thurner syndrome associated with Klippel-Trenaunay syndrome. Perspect Vasc Surg Endovasc Ther 2012;24:155-60. 37. Srisuwan T, Arworn S, Rerkasem K. Case series of isolated primary persistent sciatic vein. Int J Low Extrem Wounds 2013;12:219-22. 38. Murphy EH, Davis CM, Journeycake JM, DeMuth RP, Arko FR. Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed MayThurner syndrome. J Vasc Surg 2009;49:697-703. 39. Jones WM, Taylor I, Stoddard CJ. Common iliac vein compression syndrome occurring in siblings. Br J Surg 1973;60:663-4. 40. Gurel K, Gurel S, Karavas E, Buharalioglu Y, Daglar B. Direct contrast-enhanced MR venography in the diagnosis of MayThurner syndrome. Eur J Radiol 2011;80:533-6. 41. Knipp BS, Ferguson E, Williams DM, Dasika NJ, Cwikiel W, Henke PK, et al. Factors associated with outcome after interventional treatment of symptomatic iliac vein compression syndrome. J Vasc Surg 2007;46:743-9. 42. Marano GD, Horton JA, Savrin RA. Aorto-iliac aneurysm in iliac compression syndrome. W V Med J 1982;78:87-9. 43. Pandit AS, Hayes M, Guiney-Borgelt S, Dietzek AM. Iatrogenic May-Thurner syndrome after EVAR. Ann Vasc Surg 2014;28:739.e17-20. 44. Hassell DR, Reifsteck JE, Harshfield DL, Ferris EJ. Unilateral left leg edema: a variation of the May-Thurner syndrome. Cardiovasc Intervent Radiol 1987;10:89-91. 45. Steinberg JB, Jacocks MA. May-Thurner syndrome: a previously unreported variant. Ann Vasc Surg 1993;7:577-81. 46. Eng JM, Walor DM, Michaels LA, Weiss AR. An unusual presentation of May-Thurner syndrome in a pediatric patient with a pelvic kidney. J Pediatr Urol 2013;9:e72-5. 47. Berger A, Jaffe JW, York TN. Iliac compression syndrome treated with stent placement. J Vasc Surg 1995;21:510-4. 48. La Hei ER, Appleberg M, Roche J. Surgical thrombectomy and stent placement for iliac compression syndrome. Australas Radiol 1997;41:243-6. 49. DeStephano CC, Werner EF, Holly BP, Lessne ML. Diagnosis and management of iliac vein thrombosis in pregnancy resulting from May-Thurner Syndrome. J Perinatol 2014;34:566-8. 50. Hughes RL, Collins KA, Sullivan KE. A case of fatal iliac vein rupture associated with May-Thurner syndrome. Am J Forensic Med Pathol 2013;34:222-4. 51. Hameed M, Onida S, Davies AH. What is pathological MayThurner syndrome? Phlebology 2017;32:440-2. 52. Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med 2015;20:74-83.
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53. Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg 2013;57:1163-9. 54. Mullens W, De Keyser J, Van Dorpe A, Meuris B, Flameng W, Herregods MC, et al. Migration of two venous stents into the right ventricle in a patient with May-Thurner syndrome. Int J Cardiol 2006;110:114-5. 55. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015;125:5-12. 56. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006;194:1311-5. 57. Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005;143:697-706. 58. Kawamata K, Chiba Y, Tanaka R, Higashi M, Nishigami K. Experience of temporary inferior vena cava filters inserted in the perinatal period to prevent pulmonary embolism in pregnant women with deep vein thrombosis. J Vasc Surg 2005;41:652-6. 59. Nakajima Y, Masaoka N, Tsuzuki Y, Morooka M, Sakai M. MayThurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy. J Obstet Gynaecol Res 2012;38:1106-10. 60. McConville RM, Kennedy PT, Collins AJ, Ellis PK. Failed retrieval of an inferior vena cava filter during pregnancy because of filter tilt: report of two cases. Cardiovasc Intervent Radiol 2009;32:174-7. 61. Raju S, Neglen P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg 2006;44:136-43; discussion: 144. 62. Neglen P, Raju S. Intravascular ultrasound scan evaluation of the obstructed vein. J Vasc Surg 2002;35:694-700. 63. Im S, Lim SH, Chun HJ, Ko YJ, Yang BW, Kim HW. Leg edema with deep venous thrombosis-like symptoms as an unusual complication of occult bladder distension and right MayThurner syndrome in a stroke patient: a case report. Arch Phys Med Rehabil 2009;90:886-90. 64. Hermany PL, Badheka AO, Mena-Hurtado CI, Attaran RR. A unique case of May-Thurner syndrome: extrinsic compression of the common iliac vein after iliac artery stenting. JACC Cardiovasc Interv 2016;9:e39-41. 65. Dogan OF, Boke E. Three cases with May-Thurner syndrome: a possibly under-reported disorder. Vasa 2005;34:147-51. 66. Donatella N, Marcello BU, Gaetano V, Massimo P, Massimo M, Giancarlo B. What the young physician should know about May-Thurner Syndrome. Transl Med UniSa 2015;12:19-28. 67. Chan KT, Popat RA, Sze DY, Kuo WT, Kothary N, Louie JD, et al. Common iliac vein stenosis and risk of symptomatic pulmonary embolism: an inverse correlation. J Vasc Interv Radiol 2011;22:133-41. 68. White RH. The epidemiology of venous thromboembolism. Circulation 2003;107(Suppl 1):I4-8. 69. Blanco-Molina A, Enea I, Gadelha T, Tufano A, Bura-Riviere A, Di Micco P, et al. Sex differences in patients receiving anticoagulant therapy for venous thromboembolism. Medicine (Baltimore) 2014;93:309-17. Submitted Feb 12, 2017; accepted Nov 2, 2017.
Additional material for this article may be found online at www.jvsvenous.org.
Kaltenmeier et al
Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume
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Number
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Supplementary Table (online only). List of all articles included in the analysis with the corresponding year of publication Author 1. Cockett
Title
Date
Iliac vein compressiondits relation to iliofemoral thrombosis and the post-thrombotic syndrome
1967
2. Rigas
Iliac compression syndrome
1970
3. Sorensen
Silent iliac compression syndrome as a cause of renal thrombosis after transplantation
1972
4. Johnson
The iliac compression syndrome
1973
5. Jones
Common iliac vein compression syndrome occurring in siblingsdcase 1
1973
6. Jaszczak
Iliac vein compression syndrome
1977
7. Hans
Uncommon presentation of venous disease
1978
8. Moller
The iliac vein compression syndrome. A case report with a review of the literature
1980
9. Jacob
Iliac vein compression syndrome and lower limb vascular access for hemodialysis
1980
10. Marano
Aorto-iliac compression in iliac compression syndrome
1982
11. Ferris
May-Thurner syndrome
1983
12. Raesebeck
Iliac compression: a myth, a rarity, or a condition frequently missed?
1983
13. Hassel
Unilateral left leg edema: a variation of the May-Thurner syndrome
1987
14. Akers
Iliac vein bypass with autogenous saphenous vein for iliac compression syndrome
1987
15. Taheri
Iliocaval compression syndrome
1987
16. Steinberg
May-Thurner syndrome: a previously unreported variant
1993
17. Bomalaski
Iliac vein compression syndrome: an unusual cause of varicocele
1993
18. Robbins
Radiological cause of the month
1995
19. Berger
Iliac compression syndrome treated with stent placement
1995
20. Verhaeghe
Catheter-directed lysis of iliofemoral vein thrombosis with use of rt-PA
1996
21. Alimi
Iliac vein reconstruction to treat acute and chronic venous occlusive disease
1997
22. La Hei
Surgical thrombectomy and stent placement for iliac compression syndrome
1997
23. Heniford
May-Thurner syndrome: management by endovascular surgical techniques
1998
24. Binkert
Treatment of pelvic venous spur (May-Thurner syndrome) with self-expanding metallic endoprostheses
1998
25. Seidensticker
Treatment of May-Thurner syndrome with catheter-directed thrombolysis and stent placement complicated by heparin-induced thrombocytopenia
1998
26. Sakakibara
Iliac compression syndrome
1998
27. Simon
May-Thurner syndrome in an adolescent: persistence despite operative management
1999
28. Heijmen
Endovascular venous stenting in May-Thurner syndrome
1999
29. Liu
Feasibility of three-dimensional intravascular ultrasonography
1999
30. Patel
Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome
31. Ahmed
Intravascular ultrasonographic findings in May-Thurner syndrome
2000
32. O’Sullivan
Endovascular management of iliac vein compression (May-Thurner) syndrome
2000
33. Way
Paradoxical embolism to the basilar apex associated with May-Thurner syndrome
2000
34. Baron
Iliac vein compression syndrome: a new method of treatment
2000
35. Arrazola
May-Thurner syndrome in renal transplantation
2000
36. Oderich
Stent placement for treatment of central and peripheral venous obstructionda long-term multi-institutional experience
2000
37. Kasirajan
Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis
2001
38. Greer
Cerebral infarction in conjunction with patent foramen ovale and May-Thurner syndrome
2001
39. Hurst
Diagnosis and endovascular treatment of iliocaval compression syndrome
2001
40. Forauer
Intravascular ultrasound in the diagnosis and treatment of iliac vein compression (May-Thurner) syndrome
2002
41. Lamont
Prospective evaluation of endoluminal venous stents in the treatment of the May-Thurner syndrome
2002
42. Wolpert
Magnetic resonance venography in the diagnosis and management of May-Thurner syndrome
2002
43. Molloy
Arterial compression of the right common iliac vein; an unusual anatomic variant
2002
2000
(Continued on next page)
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Journal of Vascular Surgery: Venous and Lymphatic Disorders ---
2017
Supplementary Table (online only). Continued. Author
Title
Date
44. Kishi
Pulmonary emboli caused by iliac compression syndrome without leg symptoms
2002
45. Dheer
Retroperitoneal hematoma caused by a ruptured pelvic varix in a patient with iliac vein compression syndrome
2003
46. Cil
Case 76: May-Thurner syndrome
2004
47. Oguzkurt
Computed tomography findings in 10 cases of iliac vein compression (May-Thurner) syndrome
2004
48. Boyd
Unilateral lower extremity edema in May-Thurner syndrome
2004
49. Grunwald
Endovascular management of May-Thurner syndrome
2004
50. Cho
Endovascular management of iliofemoral deep venous thrombosis due to iliac vein compression syndrome in patients with protein C and/or S deficiency
2004
51. Illuminati
The surgical treatment of ilio-femoral venous obstruction
2004
52. Mullens
Migration of two venous stents into the right ventricle in a patient with May-Thurner syndrome
2005
53. Dogan
Three cases with May-Thurner syndrome
2005
54. Billakanty
May-Thurner syndrome: a vascular abnormality encountered during electrophysiologic study
2006
55. Burke
Unusual case of right-sided May-Thurner syndrome and review of its management
2006
56. Oguzkurt
Successful endovascular treatment of iliac vein compression (May-Thurner) syndrome in a pediatric patient
2006
57. Raffini
May-Thurner syndrome and thrombosis in adolescents
2006
58. Kim
Percutaneous treatment of deep vein thrombosis in May-Thurner syndrome
2006
59. Kim
Spontaneous rupture of the left common iliac vein associated with May-Thurner syndrome: successful management with surgery and placement of endovascular stent
2006
60. Ludwig
Postthrombotic syndrome complicating a case of May-Thurner syndrome despite endovascular therapy
2006
61. Oguzkurt
Ultrasonic diagnosis of iliac vein compression (May-Thurner) syndrome
2007
62. Husman
Stenting of common iliac vein obstruction combined with regional thrombolysis and thrombectomy in acute deep vein thrombosis
2007
63. Knipp
Factors associated with outcome after interventional treatment of symptomatic iliac vein compression syndrome
2007
64. De Bast
May-Thurner syndrome will be completed?
2008
65. Vyas
May-Thurner syndrome in a pediatric renal transplant recipientdcase report and literature review
2008
66. Sharma
A case of May-Thurner syndrome with antiphospholipid syndrome
2008
67. Zander
May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis in the postpartum period
2008
68. Elsharawy
Unusual case of left iliac vein compression secondary to May-Thurner syndrome and crossed fused renal ectopia
2008
69. Loukas
A case of May-Thurner syndrome
2008
70. Oguzkurt
Compression of the left common iliac vein in asymptomatic subjects and patients with left iliofemoral deep vein thrombosis
2008
71. Oguzkurt
Iliac vein compression syndrome: outcome of endovascular treatment with long-term follow-up
2008
72. Abboud
“Right-sided” May-Thurner syndrome
2009
73. Fretz
Compression of the inferior vena cava by the right iliac artery: a rare variant of May-Thurner syndrome
2009
74. Kiernan
May-Thurner syndrome in patient with cryptogenic stroke and patent foramen ovale
2009
75. Murphy
Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed May-Thurner syndrome
2009
76. Mougdill
May-Thurner syndrome: case report and review of the literature
2009
77. Lou
Endovascular treatment for iliac vein compression syndrome: a comparison between the presence and absence of secondary thrombosis
2009
78. Kim
Deep vein thrombosis associated with May-Thurner syndrome in an amyotrophic lateral sclerosis patientda case report
2010
79. Dhillon
Acute deep vein thrombus due to May-Thurner syndrome
2010
Kaltenmeier et al
Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume
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Number
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Supplementary Table (online only). Continued. Author
Title
Date
80. Canales
Intravascular ultrasound guidance in treating May-Thurner syndrome
2010
81. Lee
May-Thurner syndrome found incidentally after left femoral catherization in a pediatric patient
2010
82. Gurel
Direct contrast-enhanced MR venography in the diagnosis of May-Thurner syndrome
2010
83. Oguzkurt
Endovascular treatment of phlegmasia cerulea dolens with impending venous gangrene
2010
84. Campsen
May-Thurner syndrome complicating left-sided renal transplant
2010
85. Jeon
May-Thurner syndrome complicated by acute iliofemoral vein thrombosis
2010
86. Jeon
Catheter-directed thrombolysis with conventional aspiration thrombectomy for lower extremity deep vein thrombosis
2010
87. Jiang
Spontaneous retroperitoneal hematoma associated with iliac vein rupture
2010
88. Burnand
Varicosities in an adolescent girl on laparoscopy: an unusual presentation of May-Thurner syndrome
2011
89. Whitman
A case of lower extremity venous thrombosis in the pediatric emergency department: associations with May-Thurner syndrome and isotretinoin use
2011
90. Vink
Balloon-assisted retrieval of tilted OptEase IVC filter
2011
91. Cerquozzi
Iliac vein compression syndrome in an active and healthy young female
2011
92. Qing-you
Endovascular treatment of iliac vein compression syndrome
2011
93. Peters
May-Thurner syndrome: a not so uncommon cause of common condition
2012
94. Cheema
Congenital aplasia of the left iliac vein in a patient with concomitant Sturge-Weber syndrome and May-Thurner syndrome
2012
95. Nakajima
May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy
2012
96. Ibrahim
Endovascular management of May-Thurner syndrome
2012
97. Ito
Sharp recanalization of chronic left iliac vein occlusion
2012
98. Theodorus
Balloon-assisted retrieval of tilted OptEase IVC filter
2012
99. Budnur
Endovascular treatment of iliac vein compression syndrome (May-Thurner)
2012
100. Jones
Maximal venous outflow velocity: an index for iliac vein obstruction
2012
101. Narayan
Iliac vein compression as risk factor for left- versus right-sided deep venous thrombosis
2012
102. Carr
Correlation of the diameter of the left common iliac vein with the risk of lower extremity deep venous thrombosis
2012
103. Park
Extrinsic compression of left iliac vein does not predict the development of post thrombotic syndrome in left side deep venous thrombosis
2012
104. Kalu
May-Thurner syndrome: a case report and review of the literature
2013
105. Wang Yi
Endovascular treatment of acute proximal deep venous thrombosis secondary to iliac vein compression syndromeda novel technique for thrombus removal
2013
106. Spivack
Changing strategies to treat venous thrombotic occlusions of the upper and lower extremities secondary to compressive phenomena
2013
107. Rison
Acute paradoxical embolic cerebral ischemia secondary to possible May-Thurner syndrome and an atrial septal defectda case report
2013
108. Zhu
Iliac vein compression syndrome with secondary acute isolated iliofemoral deep vein thrombosis
2013
109. Alhalbouni
Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis
2013
110. Foit
Iliofemoral deep vein thrombosis after tibial plateau fracture fixation related to undiagnosed May-Thurner syndromeda case report
2013
111. Baran
Rectal bleeding and hypertensive colopathy in May-Thurner syndrome
2013
112. Cuerva
Delayed diagnosis of May-Thurner syndrome following staging surgery for ovarian cancer
2013
113. Hughes
A case of fatal iliac vein rupture associated with May-Thurner syndrome
2013
114. Hung
Prostatism and May-Thurner syndrome
2013
115. Fernando
May-Thurner syndrome in 68-year-old woman after remote abdominal surgery
2013
116. Vaidya
Successful salvage of a renal allograft after acute renal vein thrombosis due to May-Thurner syndrome
2013
117. DeRubertis
Endovascular management of nonmalignant iliocaval venous lesions
2013
118. Mousa
May-Thurner syndrome: update and review
2013
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Supplementary Table (online only). Continued. Author
Title
Date
119. Lu
May-Thurner syndrome associated with Klippel-Trenaunay syndrome
2013
120. Srisuwan
Case series of isolated primary persistent sciatic vein
2013
121. Igari
Surgical thrombectomy and simultaneous stenting for deep venous thrombosis caused by iliac vein compression syndrome May-Thurner syndrome
2013
122. Goldenberg
Percutaneous mechanical and pharmacomechanical thrombolysis for occlusive deep vein thrombosis of the proximal limb in adolescents
2013
123. Erdoes
Pharmacomechanical thrombolysis for phlegmasia cerulea dolens
2013
124. Park
Iliac vein stenting as a durable option for residual stenosis after catheter-directed thrombolysis and angioplasty of iliofemoral deep vein thrombosis secondary to May-Thurner syndrome
2013
125. Xue
Catheter-directed thrombolysis and stenting in the treatment of iliac vein compression syndrome
2013
126. DeStephano
Diagnosis and management of iliac vein thrombosis in pregnancy resulting from May-Thurner Syndrome
2014
127. Rege
May-Thurner syndrome complicating left-sided donor nephrectomy
2014
128. Pandit
Iatrogenic May-Thurner syndrome after EVAR
2014
129. Mathur
May-Thurner syndrome
2014
130. Alirhayim
Symptomatic ileofemoral deep vein thrombosis due to May-Thurner syndrome
2014
131. Smeds
Treatment of chronic venous stent occlusion with a Wildcat catheter
2014
132. Maldonado
Left lower extremity pain and swelling
2014
133. Vijayalakshmi
Unusual cases of right-sided and left-sided May-Thurner syndrome
2014
134. Sadaghianloo
Successful treatment of a spontaneous rupture of the left external iliac vein in a man
2014
135. Liu
Endovascular treatment for symptomatic iliac vein compression syndrome: a prospective consecutive series of 48 patients
2014
136. Matsuda
Early and long-term outcomes of venous stent implantation for iliac venous stenosis after catheter-directed thrombolysis for acute deep vein thrombosis
2014
137. Wax
May-Thurner syndrome complicating pregnancyda report of four cases
2014