Prevalence and predictors of radiological left common iliac vein compression in asymptomatic patients.

OBJECTIVE: The aim of this study was to investigate the prevalence of radiological left common iliac vein (LCIV) compression among the asymptomatic population and identify possible predictors. METHODS: Contrast-enhanced abdominal and/or pelvic computed tomography scans of eligible asymptomatic patients were examined. The LCIV diameter was measured from different horizontal planes in the venous phase using PACSView. Degree of LCIV compression (Dc) was calculated by a predefined formula and graded as insignificant (Dc < 25%), mild (≥25% Dc < 50%), moderate (≥50% Dc <75%), and severe (Dc ≥ 75%). Venous stenosis was defined as a Dc of ≥50%. Comparison of variables, including gender, age, body mass index (BMI), and comorbidities was performed between the different grades of LCIV compression. RESULTS: Between November 2019 and July 2022, 1698 eligible asymptomatic patients (53.1% females; mean age, 39.3 ± 11.8 years; mean BMI, 22.9 ± 3.6 kg/m2) were reviewed. The mean Dc was 46.2% (range, 0.29%-90.4%). Insignificant, mild, moderate, and severe compression were distributed in 14.5%, 38.0%, 42.2%, and 5.2% of the cohort population, respectively. Prevalence of venous stenosis was higher in females than males (58.1% vs 42.2%; χ2 = 15.52; P < .001). Females aged ≥25 and <35 years accounted for the highest proportion of venous stenosis than other age groups and was a significant predictor (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.74-7.79; P < .001). In the Asian BMI classification group, being underweight is associated with venous stenosis (OR, 4.69; 95% CI, 2.70-8.14; P < .001) and obesity may be a protective factor (OR, 0.38; 95% CI, 0.23-0.64; P < .001). There is an inverse relationship between Dc and age and BMI. CONCLUSIONS: The prevalence of radiological LCIV compression on computed tomography scans was high, but all patients were asymptomatic. Female gender, especially those aged ≥25 and <35 years, and underweight were possible predictors for venous stenosis.

Traumatic Iliac Arteriovenous Fistula Treated With the Amplatzer Vascular Plug II: A Case Report and Literature Review.

Traumatic iliac arteriovenous fistula is a rare complication of vascular injury. Open surgical repair has an incidence of postoperative complications. In recent years, endovascular treatment has shown better efficacy. We report a 62-year-old female AVF patient with a stab injury history of more than 16 years. Computed tomography angiography (CTA) revealed a large arteriovenous fistula between the right internal iliac artery and the common iliac vein. After considering the patient's relevant conditions, an endovascular approach was satisfactorily performed with the implantation of an Amplatzer Vascular Plug II to interrupt the abnormal vascular communication and maintain arterial and venous patency. The final control images showed closure of the arteriovenous communication.

A Not So Common Iliac Vein Anomaly: A Case Report.

Arising from the external and internal iliac veins, the common iliac veins (CIVs) carry blood from the lower extremities and pelvic region into the inferior vena cava at the level of the fifth lumbar vertebra. It is sometimes common to observe slight anomalies in vascular anatomy in patients; however, anomalies of the CIVs are rare. We present a case of a patient with significant edema of the left lower extremity due to extrinsic compression (May-Thurner syndrome [MTS]) involving a duplicated left CIV found during vascular angiography. Anomalies in pelvic vasculature are well documented in the medical literature; however, documented cases of a duplicated CIV remain few and far between. These anomalies in pelvic vascular anatomy are essential to be aware of to avoid surgical complications and understand their implications in associated pathologies.

Enteric fistulization of a common iliac vein aneurysm.

Iliac vein aneurysm is rare. Its complications include rupture, thromboembolism, and enteric fistulization. If a patient with surgical history presents with gastrointestinal bleeding, the veno-enteric fistula should be part of the differential diagnoses. In presence of a veno-enteric fistula, surgical treatment consists of aneurysmectomy, venorraphy, and intestinal resection.

Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review.

Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.

Seizures, deep vein thrombosis, and pulmonary emboli in a severe case of May-Thurner syndrome: a case report.

BACKGROUND: May-Thurner syndrome is a vascular disorder caused by the right common iliac artery compressing the left common iliac vein against the lumbar spine, causing distal venous stasis and potentially leading to fibrous change in the venous wall structure. Although May-Thurner syndrome is most commonly discovered in females upon investigation of new-onset deep vein thrombosis, we present the case of an otherwise healthy 29-year-old male with severe May-Thurner syndrome who presented with seizures, bilateral deep vein thrombosis, and diffuse pulmonary emboli. Seizures constituted the earliest presenting symptoms for the patient. Although it is difficult to prove that the patient's seizures were related to the May-Thurner syndrome, this possible association renders this case extraordinary. CASE PRESENTATION: This report describes the case of a 29-year-old previously healthy white male with a severe case of left-sided May-Thurner syndrome that required extensive medical and interventional treatment. The patient experienced two seizures, one month apart, both of which occurred while residing at high altitude. The patient had no prior history of seizures, and epilepsy was ruled out. Three weeks after the second seizure, he presented to the emergency room with hemoptysis, dyspnea, and severe leg pain. Sites of thrombus were confirmed in both legs and diffusely in the lungs. Etiological work-up after treatment with intravenous tissue plasminogen activator revealed May-Thurner syndrome. Hematology workup including genetic testing showed no evidence of coagulopathy. Bilateral common iliac venous stents were placed to attempt definitive treatment. Despite stenting, the patient had another thrombotic event with associated sequelae after discontinuation of anticoagulation. The patient has not had another seizure since the stents were placed. Despite the negative testing, the patient remains on lifelong chemoprophylaxis in the event of an undiscovered hypercoagulopathy. CONCLUSIONS: The care team theorizes that the seizures resulted from hypoxia due to May-Thurner syndrome-induced hemostasis and associated thrombotic events, the high-altitude location of his residence at the time he experienced the seizures, and shallow breathing during sleep. For patients with lower limb venous thrombosis, May-Thurner syndrome should be considered in the differential diagnosis. Endovascular treatment followed by extended prophylactic anticoagulation therapy until the patient is determined to be no longer at risk for thrombosis is recommended. Post-venoplasty thrombosis is a common complication of endovascular treatment of May-Thurner syndrome and should be carefully monitored.

Acute Deep Vein Thrombosis in a Cyclist With Iliac Vein Compression From Psoas Muscle Hypertrophy.

A 22-year-old avid cyclist presented with 1 month of right lower extremity pain and associated swelling. Subsequent imaging demonstrated an extensive acute deep vein thrombosis (DVT) in the setting of right iliac vein compression from psoas muscle hypertrophy. We present an unusual risk factor for DVT among cyclists. (Level of Difficulty: Intermediate.).

Three-Dimensional in Vivo Anatomical Study of Female Iliac Vein Variations.

OBJECTIVE: To investigate female iliac vein variations by using the computed tomography angiography (CTA) three-dimensional (3 D) reconstruction technique. METHODS: We retrospectively studied 1623 patients undergoing abdominal and pelvic CTA scanning for gynecological diseases from December 2009 to December 2018. Accurate digital 3 D models of the iliac vein were constructed using Mimics 19.0 software and used to study the morphology and variations. Variations in the common iliac vein (CIV), external iliac vein (EIV) and internal iliac vein (IIV) were classified as type I, abnormal number of veins; type II, abnormal communicating branches; or type III, other variations. RESULTS: The overall variation rates of the iliac vein and CIV were 51.57% (837/1623) and 20.33% (330/1623), respectively. The main type of CIV variation was type II. The main type I CIV variation was the absence of the CIV (98.15%), which mostly occurred on the right side (64.81%, 35/54). Type II CIV variation was the most common, with abnormal communicating branches between the left CIV and right IIV (81.78%, 211/258). The overall variation rates of the EIV and IIV were 36.66% (595/1623) and 49.60% (805/1623), respectively, mainly on the right side. The main type of variation was type I. Among them, the division of the IIV into two branches plus convergence with the ipsilateral EIV was the most common (22.98%, 373/1623). CONCLUSION: In this study, approximately half of the patients had iliac vein variations. The preoperative identification of iliac vein variation may reduce vascular injury in pelvic surgery.

Deep vein thrombosis of the common iliac vein caused by neurogenic heterotopic ossification in the anterior lower lumbar spine of a patient with complete paraplegia due to radiation-induced myelopathy.

Context: Deep vein thrombosis (DVT), a frequent complication of spinal cord injury, is occasionally caused by neurogenic heterotopic ossification (NHO). In most cases of NHO, the hip joint is affected. Herein, we present a case of paraplegia following radiation-induced myelopathy that presented with left leg swelling due to DVT in the common iliac vein (CIV) caused by venous compression by NHO on the anterior lower lumbar spine.Findings: A 28-year-old man with complete paraplegia due to radiation-induced myelopathy presented with left lower extremity swelling 6 years after the onset of paraplegia. DVT in the left CIV was observed on computed tomography venography. The left CIV was significantly compressed between the NHO at the anterior longitudinal ligament of the lumbar spine and the right common iliac artery, suggestive of May-Thurner syndrome. Slightly distal to that compressed area, the left CIV was significantly compressed by the large NHO at the anterior longitudinal ligament of the lumbar spine.Conclusions: We believe that such compression of the left CIV would have contributed to the development of DVT. This case shows that DVT might be caused by NHO at the anterior aspect of the lumbar vertebral body, and this may help clinicians identify the main cause of DVT in the leg.

Variant formation of left common iliac vein by the confluence of four veins.

Common iliac vein variations are relatively rare compared to the variations of external and internal iliac veins. A rare pattern of formation of common iliac vein by the confluence of four veins is being reported here. The left common iliac vein was formed by the union of left external iliac vein, internal iliac vein, iliolumbar vein and a common trunk formed by the obturator and vesical veins. External iliac vein and obturator veins were connected by a communicating vein. Both external and common iliac veins were respectively medial to the external and common iliac arteries. Knowledge of this variant formation of common iliac vein could be useful to radiologists, gynecologists and orthopedic surgeons.

The association between iliac vein compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis.

Objective: This study aimed to investigate the association between the left common iliac vein (CIV) compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis (DVT). Patients and methods: This was a single-center retrospective observational study. Between January 2015 and June 2022, first diagnosed left lower extremity DVT patients with enhanced computed tomography of lower extremities were included. Patient demographics, comorbidities, risk factors, DVT characteristics, and CIV compression degree were collected and analyzed. Logistic regressions were performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI) of iliofemoral or mixed DVT vs. compression percentage. The association between compression percentage and iliofemoral or mixed DVT was evaluated on a continuous scale with restricted cubic splines (RCS). The association between compression percentage and thrombus burden was evaluated using the Spearman test. Results: A total of 196 (mean age, 61.8 ± 16.1 years; 86 males) patients were included. The median CIV compression percentage in iliofemoral or mixed DVT patients was significantly greater than in non-iliofemoral or non-mixed DVT, respectively (64.4 vs. 46.6%, p < 0.001; 67.8 vs. 54.8%, p = 0.004). CIV compression >50% was associated with significantly increased morbidity of iliofemoral DVT (adjusted OR, 2.96; 95% CI, 1.58-5.52; p = 0.001) or mixed DVT (adjusted OR, 2.39; 95% CI, 1.19-4.81; p = 0.014). RCS showed that a greater compression percentage was associated with a continuously increased OR of iliofemoral DVT (overall p = 0.003, non-linear p = 0.577) or mixed DVT (overall p = 0.020, non-linear p = 0.771). CIV compression percentage had a positive correlation with thrombus burden (rs = 0.284, p < 0.001). Conclusion: A greater left CIV compression percentage may be associated with increasing likelihood of more proximal location and severe clot extent in first diagnosed left lower extremity DVT.

Stent Migration Following Endovascular Intervention in May-Thurner Syndrome.

Developments in endovascular therapies have made stenting a common practice in the treatment of peripheral vascular diseases, including venous disorders such as May-Thurner syndrome. The placement of a stent in the venous system carries the risk of stent migration which although small occurs with a 3% incidence rate and can be life-threatening given the risk of pulmonary infarction, tricuspid regurgitation, and right-sided heart failure. Herein we report a case of stent embolization from the common iliac vein into the right side of the heart causing tricuspid regurgitation. After the failure of percutaneous approach to retrieve the stent, it was successfully removed using a minimally invasive right thoracotomy approach along with repair of the tricuspid valve.

Absence of right common iliac vein causing suprapubic and scrotal varices in a young athletic man.

We have described the case of a 26-year-old man who had presented to his primary care physician with persistent, painful varices across his lower abdomen and bilateral tender scrotal varicoceles, which intensified with exercise. Thorough investigations revealed a congenitally atretic right common iliac vein with right-to-left collateralization of the femoral and internal iliac veins. This shunting resulted in the development of suprapubic and pelvic and gonadal varicosities, which provided a critical venous outflow pathway for his right lower extremity. Heightened vigilance is, hence, paramount if our patient requires future abdominal and urologic procedures. Moreover, the present case has highlighted the importance of considering deep system venous anomalies when determining the differential diagnosis for venous diseases.

Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review.

PURPOSE: To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach. METHODS: PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance. RESULTS: Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases. CONCLUSIONS: Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.

Reduced External Iliac Venous Blood Flow Rate Is Associated with Asymptomatic Compression of the Common Iliac Veins.

Background and Objectives: Compression of the common iliac veins (CIV) is not always associated with lower extremity symptoms. This study analyzed this issue from the perspective of patient venous blood flow changes using quantitative flow magnetic resonance imaging. Materials and Methods: After we excluded patients with active deep vein thrombosis, the mean flux (MF) and mean velocity (MV) of the popliteal vein, femoral vein, and external iliac vein (EIV) were compared between the left and right sides. Results: Overall, 26 of the patients had unilateral CIV compression, of which 16 patients had symptoms. No significant differences were noted in the MF or MV of the veins between the two sides. However, for the 10 patients without symptoms, the EIV MF of the compression side was significantly lower than the EIV MF of the non-compression side (p = 0.04). The receiver operating characteristic curve and chi-squared analyses showed that when the percentage difference of EIV MF between the compression and non-compression sides was ≤-18.5%, the relative risk of associated lower extremity symptoms was 0.44 (p = 0.016). Conclusions: If a person has compression of the CIV, a decrease in EIV blood flow rate on the compression side reduces the rate of symptom occurrence.

An Unexpected Cause of Heart Failure in a Young Woman With Treated Lymphoma.

Arteriovenous fistula is a rare complication of lumbar surgery that may cause high-output cardiac failure. We describe the case of a patient with treated lymphoma and recent spinal surgery who presented with heart failure. Logical deduction from clinical and imaging findings helped us arrive at this unusual diagnosis. (Level of Difficulty: Intermediate.).

Nuances of oblique lumbar interbody fusion at L5-S1: Three case reports.

BACKGROUND: Oblique lumbar interbody fusion is a mini-open retroperitoneal approach that uses a wide corridor between the left psoas muscle and the aorta above L5. This approach avoids the limitations of lateral lumbar interbody fusion, is considered less invasive than anterior lumbar interbody fusion, and is similarly effective for indirect decompression and improving lordosis while maintaining a low complication profile. Including L5-S1, when required, adds to these advantages, as this allows single-position surgery. However, variations in vascular anatomy can affect the ease of access to the L5-S1 disc. The nuances of three different oblique anterolateral techniques to access L5-S1 for interbody fusion, namely, left-sided intra-bifurcation, left-sided pre-psoas, and right-sided pre-psoas approaches, are illustrated using three representative case studies. CASE SUMMARY: Cases of three patients who underwent multilevel oblique lumbar interbody fusion including L5-S1, using one of the three different techniques, are described. All patients presented with symptomatic degenerative lumbar pathology and failed conservative management prior to surgery. The anatomical considerations that affected the decisions to utilize each approach are discussed. The pros and cons of each approach are also discussed. A parasagittal facet line objectively assesses the relationship between the left common iliac vein and the L5-S1 disc and assists in choosing the approach to L5-S1. CONCLUSION: Oblique retroperitoneal access to L5-S1 in the lateral decubitus position is possible through three different approaches. The choice of approach to L5-S1 may be individualized based on a patient's vascular anatomy using preoperative imaging. While most surgeons will rely on their experience and comfort level in choosing the approach, this article elucidates the nuances of each technique.

May-Thurner syndrome, a diagnosis to consider in young males with no risk factors: a case report and review of the literature.

BACKGROUND: May-Thurner syndrome is an anatomical condition characterized by compression of the left common iliac vein by the right common iliac artery, causing venous outflow obstruction. It is an uncommon cause of deep vein thrombosis and is more prevalent among women. This paper highlights the importance of considering May-Thurner syndrome in young males without risk factors presenting with left lower limb pain, as endovascular treatment may be required. CASE PRESENTATION: A 23 year-old Caucasian male presented with a 1-week history of left lower limb pain, edema, and pallor. He was found to have an unprovoked deep vein thrombosis on Doppler ultrasound involving the left fibular, soleus, gastrocnemius, popliteal, femoral, common femoral, and external iliac veins. A heparin infusion was commenced as the initial treatment for deep vein thrombosis. Further investigation with computer tomography pulmonary angiogram and computer tomography venography of the abdomen and pelvis showed bilateral pulmonary emboli and left common iliac vein compression with left common, internal, and external iliac vein thrombosis. He was diagnosed with May-Thurner syndrome despite having no risk factors. A retrievable Cook Celect Platinum inferior vena cava filter was placed, and thrombus of the left common femoral, external, and common iliac veins was treated successfully with AngioJet thrombectomy, thrombolysis using 200,000 units of urokinase, angioplasty and stenting using two Cook Zilver Vena venous self-expanding stents. Therapeutic enoxaparin was commenced on discharge. His filter was removed after 10 weeks. Hematological follow-up 4 months later showed an overall negative thrombophilia screen, and anticoagulation was switched to apixaban. He has had no recurrent thrombosis. CONCLUSIONS: Clinicians should have a low threshold to investigate for May-Thurner syndrome in patients with left lower limb venous thrombotic events regardless of risk factors, as endovascular treatment may be required to minimize the long-term sequelae of deep vein thrombosis. Duplex ultrasound can be used initially for diagnosis, and computer tomography venography used subsequently if the common iliac vein is not visualized on ultrasound. Endovascular treatment is preferred over anticoagulation alone, especially in otherwise fit patients presenting early, the aim being to reduce the chances of chronic venous hypertension in the lower limb.

Endovascular and medical therapy of May-Thurner syndrome: Case series and scoping literature review.

INTRODUCTION: May-Thurner syndrome has been recognized as a cause of chronic venous insufficiency and a trigger for venous thromboembolism. There is no consensus about the definition, diagnosis, and therapeutic approach. We are aiming to describe its characteristics and a scoping literature review. METHODS: A retrospective review of patients with May-Thurner syndrome from March 2010 to May 2018 and scoping literature review were made. RESULTS: Seven patients were identified. All patients were female with a median age of 36 (20-60) years. The median time from the first symptom to diagnosis was 3.41 (0.01-9) years. The primary clinical presentation was post-thrombotic syndrome (4 patients). Six patients had at least one risk factor for deep venous thrombosis. All patients underwent angioplasty with stent; patients with acute deep venous thrombosis, furthermore mechanic thrombectomy with or without catheter-directed thrombolysis were done. There were three complications (one patient, lymphedema, and two venous stent thrombosis). Scoping review results were descriptively summarized. CONCLUSION: May-Thurner syndrome has a varied spectrum of clinical presentation, and clinical awareness is paramount for diagnosis. Its principal complication is the post-thrombotic syndrome, which is associated with high morbidity. There is no consensus on the antithrombotic treatment approach.

Treatment of common iliac vein aneurysms: case report and literature review.

In this study we report on a patient with a left common iliac vein aneurysm; a condition rarely seen in vascular surgery. A 49-year-old man with no history of trauma or surgery underwent computed tomography (CT) for the evaluation of lumbago. A subsequent 64-slice CT angiogram revealed a left common iliac vein aneurysm. Surgery was performed due to the possibility of rupture. The aneurysm was successfully treated with clipping and sutures and a pre-discharge CT showed the aneurysm had shrunk. We combine our experience treating this patient with a review of the characteristics of other reported cases and methods used to treat iliac vein aneurysms. A definitive diagnosis is recommended in patients in whom an iliac vein aneurysm is suspected, with a CT angiogram being a dependable diagnostic method. There is still no unified standard for the treatment of aneurysms. Conservative treatment can be chosen for some small aneurysms in early stage, but close follow-up is needed. Surgical treatment is still recommended for some large aneurysms. Because we know that if an aneurysm ruptures, it can be life-threatening. If appropriate artificial blood vessels or coated stents are available, aneurysms resection combined with artificial blood vessel reconstruction or directly coated stents are good choices for aneurysms isolation. For some very large aneurysms, I personally think that lateral wall resection and suture of our aneurysms is also a method. Early follow-up results also proved that the method was effective. Surgery should be performed as early as possible. Our method of surgery may be used as a selective surgical method if the aneurysm is large or saccular in morphology.