Endovascular Management of Acute Extensive Iliofemoral Deep Venous Thrombosis Caused by May-Thurner Syndrome

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PURPOSE

The authors report their experience on the treatment of acute extensive iliofemoral deep venous thrombosis (DVT) due to May-Thurner syndrome using endovascular techniques.

MATERIALS AND METHODS

During a 1-year period, 10 symptomatic women (age range, 22–52 years; mean, 35.5 years) were referred for treatment. After ascending venography, an infusion catheter system was placed and urokinase was infused locally into the thrombus burden. After near complete clot dissolution (≥ 95%) or lytic stagnation, the residual left common iliac vein narrowing was treated by means of angioplasty and/or placement of Wallstent endoprosthesis. All patients continued to receive oral warfarin. Patients were followed-up by means of clinic visits, and stent patency was assessed by means of duplex Doppler sonography performed at 1, 3, 6, and 12 months, and then yearly thereafter.

RESULTS

The total dose of urokinase used and the duration of infusion were 5.87 ± 2.57 million units (range, 3.18–10.7) and 51.95 ± 21.57 hours (range, 26.5–89), respectively. After completion of thrombolytic therapy, the iliac vein narrowing was successfully treated by deployment of a Wallstent endoprosthesis in all 10 patients because of failure of angioplasty. No major bleeding complications occurred. Initial clinical success was 100%, with complete resolution of symptoms in all patients. One patient, who was hypercoagulable and was receiving chemotherapy for metastatic adenocarcinoma, had recurrent symptomatic acute DVT 1 month after therapy. She underwent successful repeated lysis. The remaining nine patients were asymptomatic, with a mean follow-up of 15.2 months (range, 6–36 months). One asymptomatic patient, at 36- month follow-up ultrasound, had iliac vein occlusion and well-developed venous collaterals. Serial ultrasonography in all 10 patients showed no evidence of valvular insufficiency in the femoral and popliteal veins.

CONCLUSION

Catheter-directed thrombolytic therapy for the treatment of acute extensive iliofemoral DVT due to May-Thurner syndrome is an effective method for restoring venous patency and provides relief of the acute symptoms. The underlying left common iliac vein lesion invariably needs to undergo stent placement.

Section snippets

MATERIALS AND METHODS

During a 1-year period, 10 women (age range, 22–52 years; mean, 35.5 years) were referred with symptoms of less than 10 days' duration and a diagnosis of acute left lower extremity DVT confirmed by duplex Doppler sonography. Diagnostic ascending venography was performed via an ipsilateral venous access (posterior tibial or popliteal vein) to establish the extent of the thrombosis (11). A multisidehole infusion system (single catheter or coaxial) was introduced through a vascular sheath and its

RESULTS

Infusion catheters were successfully embedded throughout the thrombus burden in all 10 patients. The total dose of urokinase used and duration of infusion were 5.87 ± 2.57 million units (range, 3.18−10.7) and 51.95 ± 21.57 hours (range, 26.5–89). After completion of thrombolytic therapy, all 10 patients had complete clot lysis and an irregular narrowing/scarring of their left common iliac vein (Fig 1). All 10 patients required placement of a Wallstent endoprosthesis in the left common iliac

DISCUSSION

The precise definition of the incidence of acute DVT is complicated by the silent nature of most thromboses, as well as the nonspecific signs and symptoms. The incidence depends on the population studied, the intensity of screening, and the accuracy of the diagnostic tests employed. Extrapolating data from a longitudinal community-based study, Coon and associates calculated an incidence of 250,000 cases of acute DVT per year in the United States (12). Unfortunately, many of these studies were

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