Case Presentation:
A 34‐year‐old woman presented with 6 weeks of worsening left calf pain, described as sharp, shooting, and increased on weight bearing. She had a 20 pack‐year smoking history and was taking oral contraceptive pills. She had an edematous, diffusely tender left lower extremity and a palpable cord in her left posterior thigh with overlying erythema. Sensation was intact throughout the limb, and motor function was limited secondary to pain. Dorsalis pedis and posterior tibial arterial pulses were not palpable but were detected with Doppler. Venous ultrasound revealed an occlusive thrombus in the left lower extremity from the common femoral vein to the popliteal vein. MRI pelvis showed a thrombus extending into the inferior vena cava (IVC) and focal narrowing of the left common iliac vein at the level of the crossing of the right common iliac artery. The patient had a negative laboratory workup for causes of inherited thrombophilia. Given the extensive clot burden, as detected on imaging, interventional radiology was consulted and performed mechanical and pharmacological thrombectomy with placement of an IVC filter. Severe anatomic stenosis was noted at the origin of the left common iliac vein, consistent with May– Thurner syndrome. Angioplasty and stenting of the vein were performed. The patient tolerated the procedure well, with improvement in her leg swelling and pain. She was discharged on warfarin and an enoxaparin bridge, with follow‐up in anticoagulation clinic.
Discussion:
Hospitalists frequently diagnose and treat deep vein thrombosis (DVT). A less‐recognized cause of left lower‐extremity DVT is anatomic compression of the left common iliac vein between the right common iliac artery and vertebral body, known as May–Thurner syndrome (MTS). If undiagnosed, MTS can prove to be limb‐ or even life threatening. It can be a difficult diagnosis for the physician to make, evidenced by the finding that our patient had been ruled out for DVT by her primary care physician 3 weeks prior with a negative calf ultrasound. May–Thurner syndrome presents most commonly in women between the third and sixth decades of life and should be suspected in cases of unprovoked, recurrent, or poorly responsive left lower‐extremity DVT. Given the pathophysiology of MTS, special consideration should be given to vascular intervention and/or stenting in addition to chronic anticoagulation as preferred therapeutic modalities. The hospitalist must remember that diagnosis of MTS carries with it implications for both patient lifestyle changes such as smoking cessation counseling as well as medication considerations such as discontinuation of oral contraceptive pills.
Conclusions:
May–Thurner syndrome is a documented cause of thrombophilia requiring a high index of suspicion by the hospitalist in the proper setting. It joins known genetic thrombophilias in predisposing affected patients to seemingly “unprovoked” DVT.
Disclosures:
R. Henderson ‐ none; S. Chudgar ‐ none