The British Journal of Radiology, 80 (2007), e176–e179
CASE REPORT
Spontaneous rupture of the left common iliac vein associated with May–Thurner syndrome: successful management with surgery and placement of an endovascular stent 1
Y H KIM,
MD,
1
S M KO,
MD
and 2H T KIM,
MD
Departments of 1Diagnostic Radiology and 2Vascular Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Republic of Korea
ABSTRACT. We report a case of spontaneous rupture of the left common iliac vein diagnosed pre-operatively with CT and successfully treated with surgery and placement of a stent. A 60-year-old woman was referred to our emergency room because of a sudden left lower abdominal pain and swelling of the left lower extremity. CT revealed a huge retroperitoneal haematoma and extrinsic compression of the left common iliac vein with acute thrombosis of deep veins of the left lower extremity. Venous patch angioplasty was performed at the site of spontaneous rupture. After thrombectomy with use of a Forgaty catheter, a stent was placed at the occluded segment of the left common iliac vein under the C-arm fluroscopic guidance. Follow-up CT 10 days and 8 months after initial examination demonstrated a venous stent with preserved luminal patency and striking resolution of deep vein thrombosis of the left lower extremity.
Spontaneous rupture of the iliac vein associated with May–Thurner syndrome is rarely reported [1–3]. This situation is life-threatening and must be diagnosed and treated correctly. In the past, the correct diagnosis was frequently not apparent pre-operatively and surgery was associated with substantial mortality and morbidity. Cho et al [4] reported successful conservative treatment of spontaneous rupture of the left common iliac vein. However, surgery or conservative treatment does not prevent the development of deep vein thrombosis and pulmonary embolism. Zieber et al [2] reported two cases, which were successfully managed by emergent endovascular repair with use of a covered stent. We report a case of spontaneous rupture of the left common iliac vein diagnosed pre-operatively with CT and successfully treated with surgery and placement of a stent.
Case report A previously healthy 60-year-old woman with no recent history of trauma was referred to our emergency room with the onset of sudden left lower abdominal pain after abrupt bending. Thereafter, she complained of swelling of the left lower extremity. On arrival, her blood pressure was 90/50 mmHg and her pulse rate was 110 beats min21. On physical examination, there was a tender mass in the left lower abdomen and diffuse swelling of the left lower extremity. Laboratory tests Address correspondence to: SungMin Ko, Department of Radiology, Dongsan Medical Center, Keimyung University College of Medicine, 194 Dongsan-dong, Jung-gu, Daegu 700-712, Republic of Korea. E-mail:
[email protected]
e176
Received 4 January 2006 Revised 7 April 2006 Accepted 15 May 2006 DOI: 10.1259/bjr/69371933 ’ 2007 The British Institute of Radiology
revealed a haemoglobin level of 10.8 g dl21 and a haematocrit level of 35.3%. Other blood chemistry parameters were within the normal range. CT was performed with 16-channel multidetector-row CT (Siemens, Forchheim, Germany). The protocol for CT was scanning with a 1.5 mm slice thickness and 1.5 mm reconstruction interval during venous phase (scan delay time: 3 min) after infusion of 130 ml of non-ionic contrast medium (Ultravist; Schering, Berlin, Germany). An abdominopelvic CT scan obtained 3 min after injection of contrast medium revealed a huge retroperitoneal haematoma in the left lower abdomen and pelvic cavity, measuring 4.6 cm66.2 cm610.0 cm. The retroperitoneal haematoma was contiguous to the haematoma around the acutely thrombosed left common iliac vein (Figure 1a). Extrinsic compression of the left common iliac vein between the body of L5 and the right common iliac artery with acute thrombosis of deep veins of the left lower extremity down to the level of the popliteal, anterior and posterior tibial, and peroneal veins were noted (Figure 1b). The compressed segment of proximal left common iliac vein contained lower density thrombus compared with thrombus in the distal common iliac vein; this was suggestive of underlying iliac vein compression syndrome. On the basis of CT findings, spontaneous rupture of the iliac vein associated with May–Thurner syndrome and spontaneous retroperitoneal haematoma causing deep vein thrombosis should be differentiated. However, considering the history of sudden lower abdominal pain after bending, spontaneous rupture and occlusion of the left common iliac vein due to May–Thurner syndrome with thrombosis of the deep venous system of the left lower extremity could be preferentially diagnosed. The British Journal of Radiology, August 2007
Case report: Rupture of the iliac vein associated with May–Thurner syndrome
Emergency laparotomy was performed by retroperitoneal approach through the skin incision in the left lower abdomen. A huge retroperitoneal haematoma was evacuated and the left common iliac vein was exposed. A tear of approximately 1.2 cm was noted at the anteromedial wall of the left common iliac vein, but there was no active bleeding at the site of rupture (Figure 1c). A recently formed thrombus was found to occlude the lumen of the left common iliac vein completely and extend to the left external iliac vein. Thrombus was removed through the site of rupture with a 6-Fr Fogarty arterial embolectomy catheter (Edwards Lifesciences, Irvine, CA). Venous patch angioplasty was performed at the site of spontaneous rupture with a branch of greater saphenous vein. The left femoral and greater saphenous veins were exposed by another skin incision in the left inguinal region. A transverse incision was made at the femoral vein and distal thrombus was removed with compression by an Esmarch band. Proximal thrombus was removed by Fogarty catheter. A 9-Fr introducer sheath (Radifocus Introducer II; Terumo, Tokyo, Japan) was inserted through the transverse incision at the left femoral vein. A venogram showed complete occlusion of the left common iliac vein, suggestive of May–Thurner syndrome. A 12 mm660 mm stent (Niti-S; Taewoong, Seoul, Korea) was placed at the occluded segment of the left common iliac vein. The left common iliac vein showed luminal patency after placement of the stent (Figure 1d). A temporary arteriovenous fistula was created between the left superficial femoral artery and greater saphenous vein to improve blood flow and the external wound was closed. Anticoagulation with low molecular weight heparin was started 12 h after surgery. The postoperative course was uneventful and the patient was discharged without complications. 3 months after initial surgery, repair of the temporary arteriovenous fistula was performed. Follow-up abdominal CT 10 days and 8 months after initial examination demonstrated a venous stent between the distal inferior vena cava and left common iliac vein with preserved luminal patency represented by proximal and distal venous flow, and striking resolution of the retroperitoneal haematoma and deep vein thrombosis of the left lower extremity (Figure 1e).
Discussion The rupture of an iliac vein is rare and primarily results from major trauma or injury during pelvic surgery. Spontaneous rupture of the iliac vein is even more unusual. There are only a small number of reported cases of spontaneous rupture of the iliac vein [1–6]; most of them are middle-aged or elderly women, with rupture predominately on the left side. Sudden onset of hypotension, lower abdominal pain and distension with a non-pulsatile mass in the iliac fossa, and oedema of the lower extremity of the affected side, without a history of recent trauma, are the symptoms found in cases of spontaneous rupture of the iliac vein. While the causes of spontaneous rupture of the iliac vein remain obscure, several hypotheses have been proposed. Venous hypertension triggered by an overlying thrombus or a The British Journal of Radiology, August 2007
Valsalva’s manoeuvre such as coughing, defecation, bending or similar efforts has been the most frequently suggested predisposing factor [3]. Proximal venous obstruction by the overlying right common iliac artery or the endothelial spur (May-Thurner syndrome) could be a contributing factor [7]. Thus the rupture occurs predominantly on the left side. In our case, the cause of spontaneous rupture of the left common iliac vein was believed to be related to May–Thurner syndrome. Venous obstruction alone, however, is unlikely to cause rupture, as veins can be used as an arterial substitute without problems. Thrombophlebitis can result in weakening of the intima and plays an important role in venous rupture. The predominant occurrence of spontaneous venous rupture in middle-aged or elderly women reflects occult thrombotic or phlebitic complications of pregnancy [3]. The other hypothesis is a hormonal effect [4]. Estrogen induces relaxation of smooth muscle and softening of collagen fibres in general, which in turn increases distensibility of veins [8]. With loss of this effect, distensibility of veins will be decreased. Considering that most reported cases were middle-aged or elderly women and the rupture occurred on the left side in most cases, loss of estrogenic effect or thrombophebitis combined with a sudden rise in intraluminal pressure in a segment of the vein between the inguinal ligament and the right common iliac artery may be one of the possible explanations for the spontaneous rupture of the iliac veins [4]. Because hypovolaemic shock is the chief symptom, emergency exploratory surgery is required in most cases of rupture of the iliac vein. However, most cases in the literature were operated under the misdiagnosis of a ruptured aortic aneurysm or an abdominal catastrophe due to a gynaecological problem. Thus, correct preoperative diagnosis is a prerequisite for resuscitation and surgical management. CT may play an important role in this regard. In our case, the diagnosis of the rupture of the left common iliac vein was made pre-operatively with CT. The ideal course of treatment consists of immediate cessation of bleeding and maintaining continuity in the deep-lying venous network. Depass [1] emphasized that prompt resuscitation and emergency surgical management are essential in the treatment of spontaneous rupture of the iliac vein. Primary repair with postoperative anticoagulation given prophylactically appears to decrease the risk of post-operative deep vein thrombosis. According to 17 previously reported cases summarized by Gaschignard et al [6], repair was achieved by direct suture in most cases, with insertion of a caval filter in three cases. However, post-operative thromboembolic complications were frequent: six cases of iliofemoral thrombosis, one of caval thrombosis and one of pulmonary embolism. Possible surgical alternatives to direct suture are venous patch angioplasty and ilioiliac crossover bypass reconstruction combined with a temporary arteriovenous fistula at the groin. Conservative treatment can be a therapeutic alternative to surgery in selected cases with no evidence of further bleeding, leg ischaemia or impending venous gangrene [4]. However, according to a report by Cho et al [4], deep vein thrombosis extending from the left common iliac e177
Y H Kim, S M Ko and H T Kim
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Case report: Rupture of the iliac vein associated with May–Thurner syndrome Figure 1. A 60-year-old woman with sudden onset of left lower abdominal pain. (a) Abdominal CT scan at the level of the common iliac vein reveals a large retroperitoneal haematoma (arrow) contiguous to the thrombosed left common iliac vein. (b) CT scan with curved planar reformation along the left common iliac vein course reveals extrinsic compression of the left common iliac vein between the fifth lumbar vertebra and right common iliac artery (short arrow) and acute thrombosis in the deep veins of the left lower extremity (long arrow). (c) Operative photogram shows a tear of approximately 1.2 cm at the anteromedial wall of the left common iliac vein (arrow). (d) Venogram obtained after placement of a stent reveals restoration of venous patency. (e) Follow-up CT scan with curved planar reformation obtained 8 months after treatment demonstrates a venous stent between the distal inferior vena cava and left common iliac vein with preserved luminal patency represented by proximal and distal venous flow.
vein to the distal superficial femoral vein developed 3 days after conservative treatment. Although left limb swelling was controlled with elevation and an elastic stocking without anticoagulation in his case, we presume that the risk of developing post-thrombotic syndrome may be increased during the follow-up period. O’Sullivan et al [9] reported that endovascular management of May-Thurner syndrome is safe and effective, and may replace surgical reconstruction or anticoagulation alone. They hoped that the ability to re-establish normal venous flow by stent placement would diminish the incidence of post-thrombotic syndrome and its longterm consequences. In our case, we performed surgical repair at the site of rupture to control bleeding, and thrombectomy to treat oedema of the left leg. We additionally placed a stent in the occluded segment of the left common iliac vein through the transverse incision at the left femoral vein under fluoroscopic guidance in the operating room to prevent postthrombotic syndrome. The left common iliac vein showed luminal patency after placement of the stent. Spontaneous rupture of the iliac vein is a vascular emergency that should be treated immediately. High clinical suspicion and CT play an important role in the correct pre-operative diagnosis. In middle-aged or elderly women presenting with left-sided retroperitoneal haematoma and deep vein thrombosis, the possibility of the rupture of the left common iliac vein should be considered. In cases with spontaneous rupture of the iliac vein associated with May–Thurner syndrome, endovascular prosthesis combined with surgery can be
The British Journal of Radiology, August 2007
another therapeutic option with an excellent result for immediate cessation of extravasation and restoration of the venous patency.
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