Atypical Presentation of Bilateral May-Thurner Syndrome

Purpose: May-Thurner Syndrome is compression of the left common iliac vein by the right common iliac artery and is suspected to be the cause approximately 5% of acute deep vein thromboses (DVTs). It is rare for there to be compression of the bilateral common iliac veins, but this has been reported in the literature because of bilateral iliac artery aneurysms. Here we report a case of bilateral May-Thurner syndrome caused by tortuous nonaneurysmal iliac arteries.

Materials and Methods: A 65-year-old man without a prior history of DVT presented to his primary care physician with 2 to 3 days of left lower extremity swelling and pain that began after a prolonged car trip. Ultrasound showed acute occlusive clot from the left popliteal to femoral vein with extension into the iliac vein and no evidence of DVT on the right. The patient underwent CTV of the abdomen and pelvis. This showed compression of the bilateral common iliac veins by the bilateral common iliac arteries, which were tortuous, but nonaneurysmal.

Results: Intravenous ultrasound (IVUS) and fluoroscopic venography showed clot extending from the popliteal vein to the left common iliac vein. Mechanical thrombectomy with a 13-Fr ClotTriever (Inari) was performed from a popliteal approach with resolution of filling defects. However, there were persistent slow flow and narrowing at the site of the crossing common iliac artery. Given the bilateral common iliac vein compression on CTV, right popliteal access was obtained, and IVUS was performed showing compression of the right common iliac vein by the right common iliac artery. “Kissing” 16-mm Venovo stents (Bard) were deployed in the bilateral common iliac veins extending into the inferior vena cava followed by balloon angioplasty. Poststenting venography demonstrated patent femoral and iliac veins. At 1 week follow-up, the patient’s symptoms had resolved, and 2-month follow-up CTV showed patency of the stents.

Conclusions: Management of May-Thurner syndrome with DVT is predominantly with endovascular stent placement with or without thrombectomy. Bilateral May-Thurner syndrome is very rare but can occur even in the absence of common iliac artery aneurysms and recognition of this can lead to treatment.