Iliofemoral deep vein Thrombosis. May-Thurner Syndrome
Comparación flebografía clásica vs IVUS
What is a Nutcracker Syndrome?
Varicose veins occurrence in the pelvis may be due to gonadal veins primary insufficiency (most commonly), or either because there is an unusual compression of retroperitoneal large venous vessels, such as the left renal vein (Nutcracker Syndrome). This is thus named because the lateral image of the compressed renal vein between the above artery (superior mesenteric) and the one which is found immediately below (aorta) looks like a nut inside a nutcracker.
As the blood from the left kidney is unable to drain properly by the renal vein towards the vena cava, a chronic disorder of the pelvic venous circulation is caused because the drainage is oriented in the opposite direction in the gonadal vein, descends to the pelvis and develops large pelvic varicose veins or left-sided pelvic varicocele. In women these varicose veins remain confined to the periuterine and left periovarian areas, and in men, varicocele settles in the left testicle.
Each case must be thoroughly studied, and the treatment performed independently. This pathology is not always treated. A simple finding in an imaging test, in a patient without varicose veins symptoms or repercussions which drain towards the legs, for example, possibly only require periodic clinical follow-up, without treatment at the outset.
However, in case of needing treatment, endovascular therapy is currently the first indication, by stent implantation inside the diseased veins and varicocele embolisation with coils or similar products. Classical surgery is not chosen from the beginning because it is too aggressive regarding endovascular treatment.
What is a May-Thurner Syndrome?
It is the iliac vein pathological compression, commonly in the left side, between the spine and the right iliac artery. This May-Thurner Syndrome is the cause of the enormous majority of the proximal deep vein thromboses of the left lower extremity. In these cases, when the thrombosis has already developed, sequelae and treatment are more complex than if this syndrome is achieved to be diagnosed before a vein thrombosis occurs. The symptoms a pathologic compression of the left iliac vein present (before thrombosis) are usually tension or congestive feeling of the extremity which increase with exercise and even compels the patient to stand still, and may cause pelvic venous disorders secondary to the known usual symptoms (pelvic congestion, chronic pain, etc.). Secondary varicose veins in the inguinal, genital or pelvic area may likewise occur.
May-Thurner Syndrome treatment before it maybe become complicated is the stent implantation inside the diseased vein, to dilate the narrow area. Classical surgery is not chosen from the beginning because it is too aggressive regarding endovascular treatment. If a venous thrombosis has already occurred, venous fibrinolysis may be performed, or endovascular recanalisation, although as always, making each case perfectly independent.
If it is a chronic case of iliofemoral (proximal) venous thrombosis developed years ago, with common edema sequelae (inflammation) of the extremity, heaviness, pain and tension during walking in the left leg, occurrence of ulcers in some cases, etc., in some patients does exist a real possibility of restoring patency of the blocked veins and placing a stent, relieving these sequelae significantly.
En algunas intervenciones aplicamos la ecografía intravascular (IVUS) (intravascular ultrasound) pues aporta la máxima calidad para conocer dónde están los puntos de máxima compresión, las referencias anatómicas y para saber con detalle la longitud y diámetro de los stents que hay que implantar. El prototipo de intervención donde habitualmente usamos el IVUS es en el Síndrome de May-Thurner.