ABSTRACT
INTRODUCTION AND IMPORTANCE: May-Thurner Syndrome (MTS) is an uncommon etiology of left common iliac vein thrombosis due to arterial compression. In this report, we describe a case of MTS with severe occlusion of the left common iliac vein in the context of a previously undiagnosed pancreatic cancer. We detail the endovascular resolution of the iliac vein compression and show long-term patency. CASE PRESENTATION: A 33-year-old woman on oral contraceptive pills presented with extensive thrombosis of the left common iliac vein extending cephalad into the lower IVC and inferiorly to the femoral vein. The thrombus was refractory to therapeutic heparin. Mechanical thrombectomy removed the occluding thrombus. Intravenous ultrasound identified severe compression of the left common iliac vein by the right common iliac artery. Angioplasty and stenting provided complete resolution of the lesion. Imaging and hematologic workup revealed a pancreatic malignancy and concomitant hypercoagulable state that likely precipitated the patient's presentation. CLINICAL DISCUSSION: Endovascular intervention provided complete resolution of severe iliac vein compression. Patency was maintained at 6-month follow-up. Research suggests that the anatomical lesion predisposing individuals to MTS is relatively common despite infrequent occurrence of the syndrome. This case highlights the importance of a high clinical suspicion for associated hypercoagulable states when MTS is discovered. CONCLUSION: There is limited research exploring the relationship between severity of iliac vein compression and endovascular treatment outcome. This case documents endovascular resolution of a severe lesion with maintained patency.
ABSTRACT
BACKGROUND: Surpass Streamline (SS; Stryker©) is an over-the-wire first-generation flow diverter (FD). There is a scarcity of data on real-world outcomes and complications of this FD. METHODS: A retrospective review of consecutive cases between January 2019 and July 2021 at two high-volume comprehensive stroke centers, involving SS was conducted. RESULTS: Fifty-five patients harbored 69 treated aneurysms, of which 96% were in the internal carotid petrous to terminus segments and 88% were <10 mm in size, and 12% measuring 10-24 mm. Raymond Roy Grade 1 occlusion was noted in 55 aneurysms (79.7%) at 1 year. Median follow-up duration was 26 months (mean = 26.06). Major complications were seen in eight patients (14.5%; 95% CI 6.5-26.7) and mortality attributable to SS stenting complications occurred in two (4.3%) patients. Four (7.2%) had ophthalmologic thromboembolic complications and two had (3.6%) ischemic complications. Procedural complications occurred in 10 patients (18.18%; 95% CI 9.1-30.9). Technical complications during procedure (n = 3, 5.3%) were: "confirmed" distal middle cerebral artery (MCA) guidewire perforation; "suspected" distal MCA guidewire perforation causing post-procedural subarachnoid hemorrhage and internal carotid artery dissection causing ischemic stroke. Seizures were seen in 5 (9.09%) and carotid-cavernous fistula in 1 (1.8%). Multivariate regression analysis showed technical challenges significantly predicted occurrence of major complications (p = 0.001; R2 = 0.39, F(13,43) = 2.15, p = 0.029). Univariate analysis showed technical challenges significantly predicted ophthalmological complications (R2 = 0.06, F(1,55) = 4.04, p = 0.049) and major complications (R2 = 0.21, F(1,55) = 15.11, p = 0.0002). CONCLUSION: Large-scale future registry should focus on national data regarding SS safety, technical challenges, and procedural complications. We present one of the longest follow-ups for SS in literature.
ABSTRACT
PURPOSE: To describe a previously unreported anatomical variant of the hepatic arterial supply: a conjoined right hepatic artery, formed by branches of the common hepatic artery and gastroduodenal artery. METHOD: A 54-year-old female with oligometastatic colorectal cancer with metastases to the liver presented for planning stage arteriography in preparation for Y90 radioembolization. RESULTS: Arteriography of the common hepatic artery demonstrated bifurcation into a right hepatic artery and gastroduodenal artery. The gastroduodenal artery gave rise to a proximal branch, from which the left hepatic artery originated and then continued to anastomose in the hilum of the liver to the right hepatic artery originating from the common hepatic artery. It was initially identified on visceral artery arteriography and then retrospectively recognized on pre-procedural CT scan. CONCLUSION: Anatomical variants of the hepatic arterial supply are important to recognize during planning stage arteriography in preparation for Y90 radioembolization. Knowledge of these variants is also important for pre-operative planning.
