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October 3, 2022 11:46 PM
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Thurner Syndrome

May-Thurner Syndrome (SMTR) is related to the development of varicose veins and the formation of venous thrombosis in the left leg. It is a compression of the left iliac vein (VII) due to crossing the right iliac artery. The VII is compressed between the right iliac artery and the vertebral column, a situation that increases the venous pressure and makes it difficult to drain the left leg.

What Is May-Thurner Syndrome?

Veins and arteries intersect, sometimes giving rise to compressive phenomena. May Thurner Syndrome is believed to be one of the main reasons why 6 out of 7 cases of deep vein thrombosis occur in the left leg.

The exact origin of this compression is unknown, but it is very common in thin people, mainly women. One of the functions that fat fulfills in the body is to cushion some anatomical structures with others; Thin people, having less retroperitoneal fat, are more likely to suffer from SMTR.

What symptoms does it produce?

The compression of the VII produces an increase in venous pressure that makes it difficult to drain blood and generates varicose veins in lower areas such as the pelvis and legs, especially on the left. In some patients, pelvic and lower limb varicose veins may be secondary to compression of the left iliac vein. It can also generate venous thrombosis in the left leg, chronic edema, malleolar hyperpigmentation (darkening of the skin in the ankle area), and lumbar pain.

What studies are necessary to diagnose the disease?

First, non-invasive studies are requested from the vascular examination laboratory, whose most important tool is the Color Doppler echo, used in the diagnosis and follow-up of SMTR. It consists of performing a non-invasive ultrasound study that shows the structure, movement, and function of blood vessels in real-time.

To complete the diagnosis, it is necessary to perform ascending phlebography, which consists of puncturing a vein in the foot to inject a contrast medium that is distributed inside the veins and reaches the iliac vein, and thus perform a more precise assessment of the compressive syndrome. Once the veins have been channeled, a contrast agent is injected that fills them providing valuable information on the compressive syndrome and its impact on the rest of the vessels.

If the pelvic varicose veins have a therapeutic indication, it is possible to carry out the treatment in the same act.

What Is May-Thurner Syndrome?  The origin

May-Thurner syndrome is also known as Cockett syndrome or iliac vein compression syndrome. It is produced by extrinsic compression of the left common iliac vein between the right common iliac artery and the vertebral body (sacral promontory or L5).

And other simultaneous pathological situations can cause iliac vein compression syndrome. However, they are rare: due to masses (ovarian cysts, fibroids, tumors) or dilation of arteries (aneurysms) in the area through which the vein passes and ends compressing it.

Three alterations determine the appearance of symptoms:

  1. Alteration of the vein wall: due to repetitive microtrauma to which the vein is subjected in the area where it is compressed: this will develop the formation of fibers within the vein.
  2. Fibrotic change: As in any area of ​​the body subjected to pressure, a chafing occurs, and over time a “callus,” the same thing happens in the vein, producing a significant hardening of the vein wall at that point.
  3. Alterations in the return flow: This process was described at the beginning of the 20th century by different pathologists and forensic pathologists, including May and Thurner, from whom the name comes.

The symptoms go through different phases:

Slowing of the venous return flow and congestion at the level of the leg: pain, heaviness, change in color and increase in size, and a very limiting condition may appear for young people who suffer from this condition, which is “venous claudication”: an As we exercise more and more, the leg becomes congested until it starts to hurt and we have to stop because of the intense pain, then the pain disappears.

The appearance of symptoms of pelvic congestion is also frequent: abdominal distension at the end of the day, continuous discomfort similar to menstruation, radiating pain to the legs during the menstrual cycle, and even pain during sexual intercourse.

And finally, other factors are associated, such as prolonged immobilization, pregnancy, genetic predisposition to thrombosis, and a thrombus forms at that point, producing a deep vein thrombosis.

Visually we will see a more swollen leg, or even both, associating truncal varicose veins or varicose veins of atypical location: gluteal, vulvovaginal, or perineal. There may be increased pigmentation and atrophy of the skin (drier and more brittle).

How to treat May-Thurner Syndrome

May-Thurner Syndrome or Cockett Syndrome is a pathology in which the right common iliac artery compresses the left common iliac vein when it crosses the pelvis. This condition will generate a partial occlusion of the vein for two main reasons:

  1. Mechanical compression of the vein by the artery against the vertebral column;
  2. Hypertrophy or thickening of the inner layer of the vein that occurs progressively due to local chronic trauma generated by the pulsation of the artery at the top of this vein. The normal condition of the organism, artery, and vein intersect without interruptions in various parts of the body because genetic formation can lead to this compression in some people.

In all the registered cases, 72% are women between 20 and 50. However, it is rare (affects about 2% of people with chronic venous insufficiency).

Compression syndrome caused by May-Thurner syndrome may result in pelvic varicose and varicose veins in the lower left limb. A more serious consequence is deep vein thrombosis (DVT) of the left lower limb, which often occurs from the site of compression to the distal veins of the leg.

How is the diagnosis?

To diagnose May-Thurner Syndrome, a great clinical suspicion is necessary during the initial evaluation because it can be asymptomatic in the initial phases. Chronic Venous Insufficiency is much more accentuated in the left lower limb, raising suspicion and a history of deep venous thrombosis in this limb without other causes.

One or more complementary tests are necessary to elucidate the diagnosis. Exams that can be requested are:

  • Venous Doppler ultrasound of the cava and iliac veins: A non-invasive examination visualizes blood flow in the veins and identifies possible compression points. It also identifies deep venous thrombosis.
  • Pelvic angiography with venous phase: This examination is necessary for contrast injection to visualize the vessels and the compression point.
  • Pelvic Magnetic: Contrast injection was also performed to evaluate the pelvic veins and venous compression. 
  • Phlebography with Intravascular Ultrasound (IVUS): For phlebography, a puncture is performed to access the veins) and a contrast injection directly on the vein. This same procedure may require the use of Intravascular Ultrasound. This ultrasound navigates inside the vessel and can accurately visualize the degree of compression, even helping to choose the size of the stent used for the treatment.

Treat May-Thurner syndrome at the USA Vein ClinicsRequest for an appointment today. If you have any doubts, our trusted doctor will recommend the most suitable treatment for you.

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