Iliac vein compression syndrome: Clinical, imaging and pathologic findings

Abstract

May-Thurner syndrome (MTS) is the pathologic compression of the left common iliac vein by the right common iliac artery, resulting in left lower extremity pain, swelling, and deep venous thrombosis. Though this syndrome was first described in 1851, there are currently no standardized criteria to establish the diagnosis of MTS. Since MTS is treated by a wide array of specialties, including interventional radiology, vascular surgery, cardiology, and vascular medicine, the need for an established diagnostic criterion is imperative in order to reduce misdiagnosis and inappropriate treatment. Although MTS has historically been diagnosed by the presence of pathologic features, the use of dynamic imaging techniques has led to a more radiologic based diagnosis. Thus, imaging plays an integral part in screening patients for MTS, and the utility of a wide array of imaging modalities has been evaluated. Here, we summarize the historical aspects of the clinical features of this syndrome. We then provide a comprehensive assessment of the literature on the efficacy of imaging tools available to diagnose MTS. Lastly, we provide clinical pearls and recommendations to aid physicians in diagnosing the syndrome through the use of provocative measures.

May‐Thurner syndrome: History of understanding and need for defining population prevalence

“…Another potential reason for the underdiagnoses relates to the relative difficulty in diagnosing this condition. As detailed above and in Table , although contrast venography is the gold standard for diagnosing MTS, it is time and resource intensive, invasive, requires contrast, and can result with postprocedural complications . Because of these limitations, venography has never been used as a systematic screening tool, and is only implemented during situations in which follow‐up thrombolytics treatment is anticipated .…”

Female Runner With Painful Left Thigh Swelling: A Case of May‐Thurner Syndrome

“…CT venography, intravascular ultrasonography, and magnetic resonance imaging have utility in localizing the compression and also may identify the fibrous intraluminal spurs characteristic of the syndrome. Completing a hypercoagulable work‐up is essential [6‐8].…”

May‐Thurner syndrome and thrombosis: A systematic review of antithrombotic use after endovascular stent placement

“…Left iliac venous compression syndrome (IVCS), also known as May‐Thurner Syndrome (MTS), which denotes compression of the left common iliac vein by the right common iliac artery, can cause unilateral lower extremity swelling, discomfort, and is thought to be a risk factor for thrombosis . There are no standard diagnostic criteria for MTS diagnosis by imaging; the degree of measured venous compression may depend on more than one factor, including an individual's volume status . Diagnosis requires persistent narrowing of the left iliac vein regardless of positioning with MTS anatomy suggested by venous collateral development, hemodynamic flow >2 mmHg across the stenotic segment, or degree of left common iliac vein stenosis (e.g, >50% reduction in the luminal venous diameter) .…”

“…There are no standard diagnostic criteria for MTS diagnosis by imaging; the degree of measured venous compression may depend on more than one factor, including an individual's volume status . Diagnosis requires persistent narrowing of the left iliac vein regardless of positioning with MTS anatomy suggested by venous collateral development, hemodynamic flow >2 mmHg across the stenotic segment, or degree of left common iliac vein stenosis (e.g, >50% reduction in the luminal venous diameter) . The prevalence of MTS is currently unknown with a spectrum of estimates.…”