Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed May-Thurner Syndrome

• Published in: Journal of vascular surgery 2009-03, Vol.49 (3), p.697-703
• Main Authors: Murphy, Erin H., MD, Davis, Charles M., BS, Journeycake, Janna M., MD, DeMuth, R. Patrick, ThM, RVT, Arko, Frank R., MD
• Format: Article
• Language: English
• Subjects: Adolescent; Angioplasty - instrumentation; Anticoagulants - therapeutic use; Biological and medical sciences; Combined Modality Therapy; Constriction, Pathologic; Contraceptives, Oral, Hormonal - adverse effects; Diseases of the cardiovascular system; Female; Femoral Vein - pathology; Femoral Vein - surgery; Humans; Iliac Artery - pathology; Iliac Vein - pathology; Iliac Vein - surgery; Medical sciences; Peripheral Vascular Diseases - complications; Peripheral Vascular Diseases - diagnosis; Peripheral Vascular Diseases - therapy; Phlebography; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects); Retrospective Studies; Stents; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Syndrome; Thrombectomy; Thrombolytic Therapy; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Color; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Venous Thrombosis - chemically induced; Venous Thrombosis - etiology; Venous Thrombosis - pathology; Venous Thrombosis - therapy; Warfarin - therapeutic use; Young Adult
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2008.10.002

Objective May-Thurner syndrome is characterized by left common iliac obstruction secondary to compression of the left iliac vein by the right common iliac artery against the fifth-lumbar vertebra. This anatomic variant results in an increased incidence of left-sided deep venous thrombosis (DVT). Furthermore, while a preponderance of left-sided DVT has been demonstrated in women during pregnancy and oral contraceptive use, patients are not typically screened for this condition after developing a left-sided DVT. As anticoagulation alone is ineffective for DVT treatment in the setting of May-Thurner anatomy, more aggressive treatment is warranted. Failure to diagnosis this condition predisposes these women to the unnecessary risks of recurrent DVT and post-thrombotic syndrome. Methods We present the occurrence of 7 adolescent patients with previously undiagnosed May-Thurner syndrome who presented with DVT after the initiation of oral contraceptive steroids (OCP) use. All 7 patients elected to proceed with mechanical thrombolysis/catheter based thrombolysis followed by endovascular stenting and were postoperatively treated with 6 months of warfarin. Results Mean patient age was 18.3 ± 3.3 years (range, 16-24 years). Mean time to presentation after initiation of OCP was 5 weeks (range, 2-10 weeks). Mean time to intervention was 16.8 days (range, 10-24 days). All patients were treated with mechanical thrombectomy. Our rate of intraoperative clot resolution was 100%. All 7 patients were treated with self expanding nitinol stents after angioplasty of the iliac vein stenosis with resolution of the stenotic segment. Primary stent patency is 100% (7/7). Mean follow-up time is 13 ± 13.84 months (range, 6-42 months). There have been no long-term complications related to surgical treatment or anticoagulation. All 7 patients have experienced resolution of left leg swelling and pain and have no evidence of post-thrombotic syndrome or DVT recurrence to date. Conclusions Women on OCPs presenting with left-sided iliofemoral DVT should be screened for hypercoagulable disorders and underlying May-Thurner anatomy. Treatment of May-Thurner syndrome should include thrombolysis/thrombectomy and anticoagulation for current DVT in addition to angioplasty and stenting of the underlying obstruction.