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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Introduction:
Introduction:
Named after Robert May and Karl Thurner (1), May Thurner Syndrome (MTS) is one of the vascular compression syndromes which refers to compression of the left common iliac vein (CIV) by the common iliac artery (CIA) over the 5th lumbar vertebra (1). The most common clinical presentation of MTS is left lower limb pain and swelling, varicosities, deep vein thrombosis or venous ulcers. Rarely, it can cause dilatation and reflux into the pelvic veins resulting in pelvic congestion syndrome(PCS).
Named after Robert May and Karl Thurner (1), May Thurner Syndrome (MTS) is one of the vascular compression syndromes which refers to compression of the left common iliac vein (CIV) by the common iliac artery (CIA) over the 5th lumbar vertebra (1). The most common clinical presentation of MTS is left lower limb pain and swelling, varicosities, deep vein thrombosis or venous ulcers. Rarely, it can cause dilatation and reflux into the pelvic veins resulting in pelvic congestion syndrome(PCS).
PCS is a common cause of chronic pelvic pain - defined as intermittent or constant pain, lasting for 3 to 6 months, present in the pelvic or abdominal region, occurring throughout the menstrual cycle, and without any association with pregnancy (2).
PCS is a common cause of chronic pelvic pain - defined as intermittent or constant pain, lasting for 3 to 6 months, present in the pelvic or abdominal region, occurring throughout the menstrual cycle, and without any association with pregnancy (2).
Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation (3).
Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation (3).
Here we present a patient with chronic pelvic pain with May Thurner Syndrome managed by endovascular stenting of the left CIV in the first sitting followed by ovarian vein embolisation planned at a second session.
Here we present a patient with chronic pelvic pain with May Thurner Syndrome managed by endovascular stenting of the left CIV in the first sitting followed by ovarian vein embolisation planned at a second session.
Case presentation:
Case presentation:
A 34 year old multiparous woman was referred to our department with chief complaints of vague intermittent pain in abdomen, non cyclic in nature since five months. She also complained of intermittent pain and swelling of left lower limb since one year. She denied history of current or prior DVT, pulmonary embolus, or anticoagulation therapy.She had past history of LSCS in 2019. There were no other co-mobidities. She had already undergone an Ultrasound examination of the abdomen and pelvis prior to visiting us. This was reported as having no significant abnormality. On CT venography, it was noticed that the left CIV is compressed by the right CIA with reformation of the internal and external iliac veins via collaterals due to chronic thrombosis of left CIV. (Fig 1 and 2). There were multiple pelvic and parametrial and ascending lumbar collaterals. Preprocedure colour Doppler screening of left lower limb revealed no abnormality. Thus a diagnosis of May Thurner Syndrome was made and the patient was planned for endovascular management.
A 34 year old multiparous woman was referred to our department with chief complaints of vague intermittent pain in abdomen, non cyclic in nature since five months. She also complained of intermittent pain and swelling of left lower limb since one year. She denied history of current or prior DVT, pulmonary embolus, or anticoagulation therapy.She had past history of LSCS in 2019. There were no other co-mobidities. She had already undergone an Ultrasound examination of the abdomen and pelvis prior to visiting us. This was reported as having no significant abnormality. On CT venography, it was noticed that the left CIV is compressed by the right CIA with reformation of the internal and external iliac veins via collaterals due to chronic thrombosis of left CIV. (Fig 1 and 2). There were multiple pelvic and parametrial and ascending lumbar collaterals. Preprocedure colour Doppler screening of left lower limb revealed no abnormality. Thus a diagnosis of May Thurner Syndrome was made and the patient was planned for endovascular management.
Figure 1, 2
Axial CT Venography showing compression of left CIV by right CIA.(left)
Axial CT Venography showing parauterine varices.(right)
Interventional technique:
Interventional technique:
Percutaneous left common femoral vein access was obtained with a 6 Fr sheath under ultrasound guidance, and iliocaval venography was performed (Video 1).
Percutaneous left common femoral vein access was obtained with a 6 Fr sheath under ultrasound guidance, and iliocaval venography was performed (Video 1).
Initial images revealed pelvic collateralization with crossover to the right iliac system as well as the ascending lumbar collaterals.
Initial images revealed pelvic collateralization with crossover to the right iliac system as well as the ascending lumbar collaterals.
These findings were consistent with high-grade outflow stenosis or occlusion of the left CIV. Intravascular ultrasound could not be performed due to technical issues. A attempt to navigate the iliac occlusion from the ipsilateral common femoral route was unsuccessful. Hence, MPA catheter was used to engage the confluence of left CIV with IVC from the right jugular route (Fig 3).
These findings were consistent with high-grade outflow stenosis or occlusion of the left CIV. Intravascular ultrasound could not be performed due to technical issues. A attempt to navigate the iliac occlusion from the ipsilateral common femoral route was unsuccessful. Hence, MPA catheter was used to engage the confluence of left CIV with IVC from the right jugular route (Fig 3).
VIDEO 1.mp4
Video 1 Iliocaval venography from left femoral access.
Fig. 3 DSA image showing contrast run through MPA catheter via right jugular access.
Using a MPA catheter tip as a guide under roadmap, a terumo glidewire wire was negotiated from the ipsilateral common femoral route into the IVC. ( Fig 4, Video 2). The length of the obstructed segment of the left common iliac vein was calibrated using a pigtail marker catheter by performing venograms from the femoral and jugular routes (Fig 5).
Using a MPA catheter tip as a guide under roadmap, a terumo glidewire wire was negotiated from the ipsilateral common femoral route into the IVC. ( Fig 4, Video 2). The length of the obstructed segment of the left common iliac vein was calibrated using a pigtail marker catheter by performing venograms from the femoral and jugular routes (Fig 5).
VIDEO 2.mp4Fig 4: (top left) Image showing glidewire with the H1 catheter having been successfully negotiated into the IVC from the left femoral access.
Fig 5: (top right) DSA image showing the use of a marker pigtail catheter to identify the length of the obstructed segment of the left CIV
Video 2 (bottom) : Iliocaval venography from right jugular access.
Predilatation was done with a 12mm x 40mm balloon (Video 3). A 14mm X 120mm ABRE self expanding stent was deployed across the left CIV (Video 4, Fig 6).
Predilatation was done with a 12mm x 40mm balloon (Video 3). A 14mm X 120mm ABRE self expanding stent was deployed across the left CIV (Video 4, Fig 6).
VIDEO 3.mp4VIDEO 4.mp4
Video 3 : Top left Predilatation with 12mm X 40mm balloon.
video 4 Top right Deployment of 14mm X 120mm ABRE self expanding stent across left CIV.
Fig 6 bottom Radiograph showing a stent in left CIV.
Completion venography demonstrated a widely patent iliac venous system with brisk antegrade flow into the IVC and significant reduction of pelvic venous collaterals (Video 5). Post procedure, Inj Heparin 5000IU TDS was administered for 24 hours. Thereafter, she was started with Warfarin 5mg OD and discharge was planned once her INR reached a value of 3.5. She was advised to continue warfarin for six months. Post procedure CT shows the stent in situ with a patent left CIV (Fig 7). There is significant reduction in the periuterine venous plexus (Fig 8).
Completion venography demonstrated a widely patent iliac venous system with brisk antegrade flow into the IVC and significant reduction of pelvic venous collaterals (Video 5). Post procedure, Inj Heparin 5000IU TDS was administered for 24 hours. Thereafter, she was started with Warfarin 5mg OD and discharge was planned once her INR reached a value of 3.5. She was advised to continue warfarin for six months. Post procedure CT shows the stent in situ with a patent left CIV (Fig 7). There is significant reduction in the periuterine venous plexus (Fig 8).
VIDEO 5.mp4
Video 5 Iliocaval venography post procedure showing patent left CIV with brisk antegrade flow in the IVC.
Fig 7 Axial CT Venography post procedure showing stent in left CIV with patent lumen.
Fig 8 Axial CT venography showing reduction in parauterine pelvic varices post procedure.
CFV access on both sides and right IJV access was achieved and a venogram from the left CFV showed slow antegrade flow across the left CIV stent with multiple large left to right internal iliac vein pelvic collaterals. (Video 6, Video 7). Through the Jugular route a 7 Fr x 90 cm long sheath was introduced into IVC. The pelvic collaterals were selectively cannulated using a 5F MPA catheter and embolised using multiple pushable and detachable coils (FIG 9). Post coiling there was significantly reduced flow across these collaterals. (Video 8),
CFV access on both sides and right IJV access was achieved and a venogram from the left CFV showed slow antegrade flow across the left CIV stent with multiple large left to right internal iliac vein pelvic collaterals. (Video 6, Video 7). Through the Jugular route a 7 Fr x 90 cm long sheath was introduced into IVC. The pelvic collaterals were selectively cannulated using a 5F MPA catheter and embolised using multiple pushable and detachable coils (FIG 9). Post coiling there was significantly reduced flow across these collaterals. (Video 8),
(VID 6).mp4(vid 7).mp4Video 6 Venogram from the left common femoral vein showing large left to right pelvic collaterals along the left internal iliac vein.
Video 7 Venogram from the left internal iliac vein showing large left to right pelvic collaterals.
Fig 9 Coils deployed in the left internal iliac vein collaterals.
(vid 8).mp4Video 8 Post coiling venogram showing significantly reduced flow across the pelvic collaterals.
The left ovarian vein venogram showed reflux into a large ovarian vein and collaterals as well as into the parametrial collaterals, as also into a dilated right ovarian vein (Video 9). Bernstein balloon occlusion catheter navigated into left ovarian vein. A Progreat (2.4 Fr) microcatheter was inserted coaxially through the occlusion catheter and the left ovarian vein was embolised using foam sclerosant (2 cc Setrol, 1 cc Lipiodol, 7 cc air), after inflating the balloon proximally. Controlled foam sclerosant injection was done from microcatheter as well as balloon occlusion catheter. (Video 10). A detachable coil was deployed in the proximal ovarian vein through the inflated balloon occlusion catheter after foam sclerotherapy.
The left ovarian vein venogram showed reflux into a large ovarian vein and collaterals as well as into the parametrial collaterals, as also into a dilated right ovarian vein (Video 9). Bernstein balloon occlusion catheter navigated into left ovarian vein. A Progreat (2.4 Fr) microcatheter was inserted coaxially through the occlusion catheter and the left ovarian vein was embolised using foam sclerosant (2 cc Setrol, 1 cc Lipiodol, 7 cc air), after inflating the balloon proximally. Controlled foam sclerosant injection was done from microcatheter as well as balloon occlusion catheter. (Video 10). A detachable coil was deployed in the proximal ovarian vein through the inflated balloon occlusion catheter after foam sclerotherapy.
(Video 9).mp4(vIDEO 10).mp4Video 9 : Left ovarian venogram showing a large left ovarian vein with collaterals, parametrial collaterals and reflux into the right ovarian vein.
Video 10 : Foam sclerotherapy of the left ovarian vein.
Post embolisation, there was no reflux in the left ovarian vein. (Video 11)
Post embolisation, there was no reflux in the left ovarian vein. (Video 11)
Venogram from the left CFV showed improved antegrade flow across the left CIV stent with significantly reduced flow in the pelvic collaterals. (Video 12)
Venogram from the left CFV showed improved antegrade flow across the left CIV stent with significantly reduced flow in the pelvic collaterals. (Video 12)
(Video 11).mp4(Video 12).mp4Video 11 : Post embolisation venogram showing no flow in the left ovarian vein.
Video 12 : Venogram from both common femoral veins showing significantly reduced collaterals and good antegrade flow in the left CIV stent.
Discussion:
Discussion:
Abnormal dilation of the interlinked venous channels of the internal iliac and ovarian veins is often implicated in pelvic congestion syndrome (3). Venous insufficiency can be primary or secondary. Primary is due to either the absence of the venous valves or incompetence of the valves. The inclination of multiparous women to develop pelvic congestion syndrome can be due to the 50% increased pelvic vein capacity due to physiological changes during pregnancy. These changes can lead to retrograde blood flow and incompetence of the valves. Secondary pelvic vein incompetence is often due to external compression of the vein, leading to venous outflow obstruction (4). Examples include May Thurner Syndrome, Nutcracker Syndrome (compression of the left renal vein between the superior mesenteric artery and the abdominal aorta), tumor thrombosis in the renal vein or IVC, retroaortic left renal vein, endometriosis and post- traumatic lesions (5). Conventionally, left CIV stenosis is considered hemodynamically significant if a reduction in lumen diameter is greater than 50%.
Abnormal dilation of the interlinked venous channels of the internal iliac and ovarian veins is often implicated in pelvic congestion syndrome (3). Venous insufficiency can be primary or secondary. Primary is due to either the absence of the venous valves or incompetence of the valves. The inclination of multiparous women to develop pelvic congestion syndrome can be due to the 50% increased pelvic vein capacity due to physiological changes during pregnancy. These changes can lead to retrograde blood flow and incompetence of the valves. Secondary pelvic vein incompetence is often due to external compression of the vein, leading to venous outflow obstruction (4). Examples include May Thurner Syndrome, Nutcracker Syndrome (compression of the left renal vein between the superior mesenteric artery and the abdominal aorta), tumor thrombosis in the renal vein or IVC, retroaortic left renal vein, endometriosis and post- traumatic lesions (5). Conventionally, left CIV stenosis is considered hemodynamically significant if a reduction in lumen diameter is greater than 50%.
Ultrasound is the first mode of investigation in patients with complaints of pelvic pain and can rule out any abnormal masses, detect deep vein thrombosis. Colour Doppler has the advantage of allowing dynamic examination with provocative Valsalva manoeuvres. It is a good practise to suspect pelvic DVT or MTS in a patient with chronic recurrent left lower limb swelling. Findings suggesting the diagnosis are tortuous pelvic veins with a diameter more than 4 mm, slow (≤ 3 cm/s) blood flow and dilated arcuate veins in the myometrium, communicating with the pelvic varicosities. Computed tomography venography (CTV) or magnetic resonance angiography (MRV) should be used to accurately visualize the pelvic region, which not only shows the offending overlying artery but can also confirm the presence of any other extrinsic compressions (6). An ovarian vein diameter greater than 8mm is significant. Magnetic Resonance Venography with Time Resolved Imaging provides accurate information, whether flow present in the ovarian vein is anterograde or retrograde (7).
Ultrasound is the first mode of investigation in patients with complaints of pelvic pain and can rule out any abnormal masses, detect deep vein thrombosis. Colour Doppler has the advantage of allowing dynamic examination with provocative Valsalva manoeuvres. It is a good practise to suspect pelvic DVT or MTS in a patient with chronic recurrent left lower limb swelling. Findings suggesting the diagnosis are tortuous pelvic veins with a diameter more than 4 mm, slow (≤ 3 cm/s) blood flow and dilated arcuate veins in the myometrium, communicating with the pelvic varicosities. Computed tomography venography (CTV) or magnetic resonance angiography (MRV) should be used to accurately visualize the pelvic region, which not only shows the offending overlying artery but can also confirm the presence of any other extrinsic compressions (6). An ovarian vein diameter greater than 8mm is significant. Magnetic Resonance Venography with Time Resolved Imaging provides accurate information, whether flow present in the ovarian vein is anterograde or retrograde (7).
Transcatheter venography is the gold standard for diagnosis. Signs of hemodynamically significant MTS are narrowing of the left CIV in combination with its prestenotic dilatation, substantial reflux of contrast media into the left IIV, visualization of pelvic collaterals and reflux of the contrast media into the dilated left iliolumbar vein. In addition, it is possible to measure the pressure in pre- and post-stenotic parts of the left CIV. A pressure gradient greater than 2-4 mm Hg is considered a sign of hemodynamically significant stenosis of the left CIV. Although intravenous ultrasonography (IVUS) is useful, few studies suggest that successful diagnosis and treatment of patients with a combination of MTS and PCS is possible without the use of IVUS (8).
Transcatheter venography is the gold standard for diagnosis. Signs of hemodynamically significant MTS are narrowing of the left CIV in combination with its prestenotic dilatation, substantial reflux of contrast media into the left IIV, visualization of pelvic collaterals and reflux of the contrast media into the dilated left iliolumbar vein. In addition, it is possible to measure the pressure in pre- and post-stenotic parts of the left CIV. A pressure gradient greater than 2-4 mm Hg is considered a sign of hemodynamically significant stenosis of the left CIV. Although intravenous ultrasonography (IVUS) is useful, few studies suggest that successful diagnosis and treatment of patients with a combination of MTS and PCS is possible without the use of IVUS (8).
Treatment of PCS ranges from conservative medical management like over-the-counter analgesics and medroxyprogesterone acetate hormone therapy to surgical intervention like pelvic vein ligation, hysterectomy and oophorectomy. Recent advances in technology have lead to endovascular management including ovarian vein embolisation using balloons, coils as well as sclerotherapy to occlude the periuterine venous plexus. Due to collaterals between ovarian and internal iliac veins, bilateral balloon occlusion venography and embolization of pelvic varices can be performed to prevent recurrence. Patients with secondary PCS due to MTS and nutcracker syndrome who present with symptoms of PCS can be treated with endovascular techniques including stenting (9). The effect of embolisation on fertility is not precisely known. It appears that embolisation may treat infertility caused by venous congestion (10). Stent occlusion is a major cause of failure of endovascular treatment (11).
Treatment of PCS ranges from conservative medical management like over-the-counter analgesics and medroxyprogesterone acetate hormone therapy to surgical intervention like pelvic vein ligation, hysterectomy and oophorectomy. Recent advances in technology have lead to endovascular management including ovarian vein embolisation using balloons, coils as well as sclerotherapy to occlude the periuterine venous plexus. Due to collaterals between ovarian and internal iliac veins, bilateral balloon occlusion venography and embolization of pelvic varices can be performed to prevent recurrence. Patients with secondary PCS due to MTS and nutcracker syndrome who present with symptoms of PCS can be treated with endovascular techniques including stenting (9). The effect of embolisation on fertility is not precisely known. It appears that embolisation may treat infertility caused by venous congestion (10). Stent occlusion is a major cause of failure of endovascular treatment (11).
Our patient is a 34 year old multiparous woman with PCS who had a structural etiology for MTS. Thus a 2-step treatment plan was devised - firstly to abolish the structural cause by stenting the left CIV and then to perform ovarian vein embolisation if the symptoms were not relieved after an observation period of one month. It is critical to understand that treating ovarian vein reflux before stenting the left CIV would only have made matters worse by increasing pressures in the pelvic venous system, thereby aggravating the congestion.
Our patient is a 34 year old multiparous woman with PCS who had a structural etiology for MTS. Thus a 2-step treatment plan was devised - firstly to abolish the structural cause by stenting the left CIV and then to perform ovarian vein embolisation if the symptoms were not relieved after an observation period of one month. It is critical to understand that treating ovarian vein reflux before stenting the left CIV would only have made matters worse by increasing pressures in the pelvic venous system, thereby aggravating the congestion.
As seen on follow up after six weeks, there was no symptomatic relief of pelvic pain. Embolization needs to be considered as a subsequent procedure to relieve symptoms of pelvic congestion syndrome.
As seen on follow up after six weeks, there was no symptomatic relief of pelvic pain. Embolization needs to be considered as a subsequent procedure to relieve symptoms of pelvic congestion syndrome.
One of the first documented cases of catheter embolization of incompetent ovarian veins was by Edwards et al. (12).
One of the first documented cases of catheter embolization of incompetent ovarian veins was by Edwards et al. (12).
More recently, a number of groups have started to treat the internal iliac veins also [13, 14] with the largest published series to date being reported by Kim et al. [15] who treated 131 patients aggressively; Laborda et al. [16] who treated 202 patients; and Monedero et al. [17] who treated 215 patients with recurrent varices after surgery, all using catheter venography as the basis of embolization.
More recently, a number of groups have started to treat the internal iliac veins also [13, 14] with the largest published series to date being reported by Kim et al. [15] who treated 131 patients aggressively; Laborda et al. [16] who treated 202 patients; and Monedero et al. [17] who treated 215 patients with recurrent varices after surgery, all using catheter venography as the basis of embolization.
The commonest embolic agents utilized are platinum embolization coils, foam, glue and liquid sclerosants [e.g. Polidocanol, 3 % sodium tetradecyl sulphate (STS)]. Platinum coils are used in isolation or as an adjunct to foam sclerotherapy. The use of embolising agents largely also depends on operator preference.
The commonest embolic agents utilized are platinum embolization coils, foam, glue and liquid sclerosants [e.g. Polidocanol, 3 % sodium tetradecyl sulphate (STS)]. Platinum coils are used in isolation or as an adjunct to foam sclerotherapy. The use of embolising agents largely also depends on operator preference.
Spirale platinum embolization coils measuring between 8 and 16 mm in unconstrained diameters (BALT Extrusion, Montmorency, France) are most commonly used. More recently, 8–12-mm diameter coils ‘fibred’ with synthetic dacron (Cook Inc, Bloomington, Indianapolis), rather than plain non-fibred coils have been utilized as they achieve more rapid occlusion with fewer coils required, offer easier retrievability if misplaced enabling a lower procedural time and reduced exposure to ionizing radiation.
Spirale platinum embolization coils measuring between 8 and 16 mm in unconstrained diameters (BALT Extrusion, Montmorency, France) are most commonly used. More recently, 8–12-mm diameter coils ‘fibred’ with synthetic dacron (Cook Inc, Bloomington, Indianapolis), rather than plain non-fibred coils have been utilized as they achieve more rapid occlusion with fewer coils required, offer easier retrievability if misplaced enabling a lower procedural time and reduced exposure to ionizing radiation.
Alternatively foam can be administered by free hand injection, or ‘controlled’ by using a balloon occlusion angiographic catheter by ‘pre-filling’ the catheter and target vein with iodinated contrast and injecting the foam under modest constant positive pressure to simply displace the contrast from the distal target vessel ensuring complete vessel coverage and minimal reflux. In this respect, it is best to use a O2/CO2 in the Trendelenburg position in a mixture with 3 % sodium tetradecyl sulphate in a 5:2 mixture avoiding room air (which contains 80 % nitrogen increasing the theoretical risk of stroke) (18).
Alternatively foam can be administered by free hand injection, or ‘controlled’ by using a balloon occlusion angiographic catheter by ‘pre-filling’ the catheter and target vein with iodinated contrast and injecting the foam under modest constant positive pressure to simply displace the contrast from the distal target vessel ensuring complete vessel coverage and minimal reflux. In this respect, it is best to use a O2/CO2 in the Trendelenburg position in a mixture with 3 % sodium tetradecyl sulphate in a 5:2 mixture avoiding room air (which contains 80 % nitrogen increasing the theoretical risk of stroke) (18).
Endovenous ablation of pelvic venous incompetence is a relatively simple, safe and efficacious technique for occluding and obliterating refluxing veins associated with pelvic venous congestion syndrome or implicated in the aetiology of de novo or recurrent lower limb venous varicosities with or without vulval or perivulvar veins. Conventional catheter techniques are used typically under conscious sedation employing commonly available occlusive agents including liquid sclerosants, glue, foam and most commonly platinum coils. The latter are highly visible and do not preclude patients undergoing future MRI imaging (although artefact is created on CT scanning). The procedure has a shallow learning curve and complications associated with therapeutic embolization are well defined, rare and easily managed percutaneously.(18)
Endovenous ablation of pelvic venous incompetence is a relatively simple, safe and efficacious technique for occluding and obliterating refluxing veins associated with pelvic venous congestion syndrome or implicated in the aetiology of de novo or recurrent lower limb venous varicosities with or without vulval or perivulvar veins. Conventional catheter techniques are used typically under conscious sedation employing commonly available occlusive agents including liquid sclerosants, glue, foam and most commonly platinum coils. The latter are highly visible and do not preclude patients undergoing future MRI imaging (although artefact is created on CT scanning). The procedure has a shallow learning curve and complications associated with therapeutic embolization are well defined, rare and easily managed percutaneously.(18)
References:
References:
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