A 31–year–old Caucasian female, 2 months post–partum, on OCP for 4 weeks experienced left hip and buttock pain while working out at gym. She was prescribed NSAIDS and Medrol dose pack for sciatica. Pain worsened and she developed swelling of left thigh over next week. She went to ER where examination showed marked swelling and tenderness of left thigh and leg without venous or arterial compromise. Doppler of left lower extremity showed totally occluding deep venous thrombosis in common femoral, superficial & deep femoral, popliteal and peroneal veins of left leg. She had no personal or family history of DVT. She was asked to stop OCP’s and discharged to home on Enoxaparin and Coumadin from ER. Hypercoagulable panel was drawn prior to starting anticoagulation. Over next week, her pain and swelling continued to worsen. PCP discussed the case with Vascular surgeon and patient was admitted to hospital for thrombolysis. CT scan of abdomen showed DVT in left common iliac, external iliac and external femoral veins. Venography was performed, IVC filter was placed prophylactically, catheter–directed thrombectomy was performed and a stent was placed for the severe narrowing of left common iliac and external iliac veins. More than 90% clot burden reduction was achieved with no residual stenosis seen. Pt had significant improvement in swelling and pain and was discharged home on Coumadin. She was detected to have Lupus Anticoagulant. Plans were made to remove IVC filter in 4 weeks.
May–Thurner syndrome is a congenital anomaly of lower extremity vascular supply where left common iliac vein is compressed by right common iliac artery. It predisposes to extensive left lower extremity venous thrombosis. Its prevalence is 22% in autopsy specimens and about 50% in left iliac vein thrombosis, the diagnosis and management of which is challenging given our current practice of starting LMWH with Coumadin as Outpatient or in ER after drawing hypercoagulable profile for newly diagnosed DVT.
Our prevalent practice of starting LMWH and Coumadin in a newly diagnosed DVT in the clinic or ER may lead to underdiagnosis and mismanagement of younger individuals with massive limb thrombosis especially with left lower extremity (May–Thurner syndrome) or upper extremities (Paget–Schroetter Syndrome). These patients need to be admitted for further work–up and aggressive management as illustrated in above case.
Figure 1May–Thurner anomaly.