Working Diagnosis:
DVT in setting of May-Thurner Syndrome

Treatment:
Oral Contraceptives were discontinued, and started aspirin therapy in office. Once ultrasound was done patient was started on rivaroxaban 15mg PO and was admitted to hospital. Venogram was done along with trombectomy Photo 3, infusion of tissue plasminogen activator, ballooning of common iliac stenosis Photo 4. Flow was restored after procedure Photo 5. No stent was placed due to improvement of stenosis. Anticoagulation was continued with rivaroxaban and continued for 3 months.

Outcome:
Completed 3 months of rivaroxaban. Follow up ultrasound at 12 weeks showed no evidence of thrombus along with normal flow. Able to return to competition. She has been advised to wear TED hoses and ambulate frequently during travel.

Author's Comments:
May-Thurner Syndrome related DVT accounts for only 2-3% of all lower limb DVTs. The iliac vein is compressed by the right iliac artery, usually against a lower lumbar vertebra. Contributing factors in this case include OCP use, recent travel, and possible dehydration. Stenting was not performed given the patient is young competitive athlete who would then have long-term foreign body in place requiring lifelong aspirin therapy. 3 months anticoagulation therapy as this was treated as provoked clot in the setting of OCPs and travel history although contribution of anatomic variant.

Editor's Comments:
May–Thurner syndrome (MTS), alternatively known as the iliac vein compression syndrome, is a rare condition in which compression of the common venous outflow tract of the left lower extremity illicits discomfort, swelling, and DVT's in the iliofemoral vein. It is thought to represent 2-5% of lower extremity venous disorders, being three times more common in females than males, and most often encountered in the 2nd through 4th decades of life.

The left common iliac vein takes a more transverse course, in which it travels below the right common iliac artery, causing compression against the lumbar spine. Iliac vein compression is a frequent anatomic variant. Compression becomes clinically significant only if hemodynamic changes in venous flow or venous pressure are induced and a DVT results.

References:
Depenbrock P. Thromboembolic Disorders: Guidance for Return-to-Play; Current Sports Medicine Reports Vol 10, Number 2, Mar/Apr 2011

Mousa A, AbuRahma A. May-Thurner Syndrome: Update and Review; Ann Vasc Surg 2013;27:984-995

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