Ipsilateral Double May-Thurner Syndrome with Congenital Double Left Common Iliac Vein: A Case Report of an Unprecedented Anatomical Variant and Hemodynamic Interaction

Objective: The objective of this case report is to present and discuss a unique and atypical manifestation of May-Thurner syndrome, characterized by the congenital split of the left common iliac vein (LCIV) resulting in simultaneous occlusion of both the outer left common iliac vein (OLCIV) and the inner left common iliac vein (ILCIV), due to compression by the right common iliac artery (RCIA) and the lumbar spine. The report aims to highlight the significance of comprehensive anatomical assessments, including venogram and intravascular ultrasound (IVUS), in both the diagnosis and management of complex venous pathologies, and to illustrate the successful utilization of stent placement as an effective intervention to relieve the venous compression in this rare "double May-Thurner syndrome" case. 

Methods: This case report details an exceptional presentation of May-Thurner syndrome in a 28-year-old woman. A 28-year-old woman presented with bilateral spider veins, lower extremity swelling, pelvic discomfort, and bilateral leg cramping. Initial assessment encompassed venous duplex scans, venograms (fig 1), and intravascular ultrasound (IVUS) (Fig 2) revealed not only chronic venous insufficiency involving the greater saphenous veins but, also the unique bifurcation of the LCIV into OLCIV and ILCIV. Intriguingly, both variant veins were subjected to compression by the RCIA, with the OLCIV compression occurring proximally and the ILCIV compression medially and this is primarily attributed to the anatomical configuration of the right iliac artery. 

Results: During the venogram procedure, a first stent was advanced over a 0.35” wire , centered across the lesion in the proximal OLCIV (16 mm x 90 mm stent). Afterwards, a second stent  was advanced and deployed (16 mm x 60 mm stent) after accurate positioning in the medial part of the ICLIV. The location of the stents were different due to arterial obstruction.  Successful repair of the venous compression was achieved. (Fig 1) (Fig 2)

Conclusions: The atypical and rare presentation of double May-Thurner syndrome, involving ipsilateral splitting of the left  iliac vein and an asymmetric arterial-venous interaction, highlights the importance of comprehensive anatomical assessments like venogram and IVUS in understanding and managing complex venous pathologies.