Quickshot: Anteriorization of the Left Common Iliac Vein: A Novel Approach to Treating Young Patients with May-Thurner Syndrome

May-Thurner Syndrome (MTS) occurs when the left common iliac vein is compressed by the anterior lying right common iliac artery leading to a lower extremity venous outflow obstruction. This outflow obstruction can progress to secondary venous hypertension causing lower extremity swelling, discoloration, pelvic congestion, and venous ulcerations. The diagnosis of MTS is based on careful history, physical exam, and multiple imaging modalities such as duplex ultrasound, CT/MR venography, catheter-based venography, and intravascular ultrasound. The accepted method for treating MTS is intravascular stent placement, which requires dual antiplatelet therapy post operatively. When treating younger patients with left iliac vein compression, short-term symptomatic improvements must be weighed against long-term implications of treatment. We report a surgical technique of left common iliac vein anteriorization, to treat symptomatic left common iliac vein compression in younger patients.

Methods:

This is a single center, retrospective chart review of 7 patients with symptomatic MTS treated with left common iliac vein anteriorization between July 2022 and January 2023. Baseline demographic data was obtained including patient age, past medical and surgical history, preoperative diagnoses, and clinical symptoms. Postoperatively clinical symptoms and vascular duplex imaging was examined through chart review.

Results:

All patients in this cohort were female with multiple vascular compression syndromes. The mean age was 23.7 ± 9.0 ranging from 17 to 43 years old. An ovarian vein patch angioplasty was used for one patient, a right great saphenous vein patch angioplasty was used for another patient, and bovine pericardial panel grafts were used for two patients. Three patients did not require patching. There were no post operative complications due to the procedure.

All patients reported abdominal pain prior to their surgeries. Two patients reported pelvic pain, three reported back pain, and one reported lower extremity pain and swelling. All patients were followed up within one week of being discharged from the hospital and reported either an improvement or resolution of compressive symptoms. Three patients reported nausea which eventually resolved as well.

All patients had venous duplex ultrasounds done within three months of discharge which demonstrated patency of the left common iliac vein repair. All patients were satisfied with the results of their surgeries at post-op appointments, and by 3 months post-operative, all pre-existing symptoms related to MTS were resolved.

Conclusions:

Anteriorization of the left common iliac vein is a safe and effective surgical treatment for young patients with symptomatic MTS. With the long-term outcomes of iliac vein stenting unknown, this is an alternative treatment which alleviates symptoms of the venous compression.