Imaging of Deep Venous Pathology.

Imaging plays an important role in the identification and assessment of clinically suspected venous pathology. The purpose of this article is to review the spectrum of image-based diagnostic tools used in the investigation of suspected deep vein disease, both obstructive (deep vein thrombosis and post-thrombotic vein changes) as well as insufficiency (e.g., compression syndromes and pelvic venous insufficiency). Additionally, specific imaging modalities are used for the treatment and during clinical follow-up. The use of duplex ultrasound, magnetic resonance venography, computed tomography venography and intravascular ultrasound as well as conventional venography will be discussed in this pictorial review.

Acquired Immunodeficiency Syndrome (AIDS)-Related Kaposi's Sarcoma in Conjunction With Methicillin-Resistant Staphylococcus aureus (MRSA) and May-Thurner Syndrome.

A 34-year-old male with a history of peripheral vascular disease and multifactorial anemia presented with red blotches on his face, trunk, and extremities, multiple large bumps prominent on the lower extremities that burst at times with yellow pus and blood, swelling in the ankles, extremely dry feet, a chronic ulcer on the foot, and a dry, flaky, and irritated left middle finger. The patient was human immunodeficiency virus (HIV) positive, viral load undetectable. Endovenous laser ablation therapy was performed to correct venous insufficiency. A balloon was placed in the common iliac vein to treat May-Thurner syndrome. The bumps on the lower extremities were biopsied and found to be Kaposi's sarcoma (KS) and were removed by both wide excisions and shave removals, and further treatment with doxorubicin was performed successfully. The foot ulcer was found to be positive for methicillin-resistant Staphylococcus aureus (MRSA) and was treated with sulfamethoxazole-trimethoprim, metronidazole, and a chlorhexidine topical liquid. The patient noted that the treatments on his leg were working very well, and he was clearing up.

Indications, technical aspects, and outcomes of stent placement in chronic iliofemoral venous obstruction.

BACKGROUND: Iliofemoral venous stent placement (IVS) has evolved to a well-established endovascular treatment modality for chronic iliofemoral venous obstruction (CIVO). Dedicated venous stents gained approval from the US Food and Drug Administration in 2019 and solidified IVS as a defined intervention with clear indications, contraindications, risks, benefits, and procedural management principles. This review focuses on the indications, technical aspects and outcomes of stenting for CIVO. Other aspects pertaining to IVS are covered in other articles that are a part of this series. METHODS: This study conducted a literature search limited to English articles. Three search strategies were used, and references were managed in Covidence software. Four investigators screened and evaluated articles independently, excluding meta-analyses, clinical trial protocols, and nonrelevant studies. Eligible studies, focused on clinical outcomes and stent patencies, underwent thorough review. RESULTS: The literature search yielded 1704 studies, with 147 meeting eligibility criteria after screening and evaluation. Exclusions were based on duplicates, irrelevant content, and noniliac vein stent placement. CONCLUSIONS: Successful IVS for CIVO relies on meticulous patient selection, consistent use of intravascular ultrasound examination during procedures and attention to the technical details of IVS.

Surgical anteriorization of the left common iliac vein results in improved venous outflow and quality of life for May-Thurner syndrome.

May-Thurner syndrome or left iliac vein compression occurs when the left common iliac vein is compressed by the right common iliac artery, leading to venous outflow obstruction. This obstruction can cause venous hypertension, resulting in lower extremity swelling, discoloration, pelvic congestion, and venous ulcerations. The standard surgical treatment of May-Thurner syndrome is endovascular venous stent placement. In a small, single-center sample, surgical anteriorization of the left common iliac vein was used to treat symptomatic left common iliac vein compression in younger patients, alleviating their symptoms, and can be considered an alternative treatment.

Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review.

Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed. Salient imaging features of each entity are illustrated through imaging examples using multiple modalities including ultrasound, fluoroscopy, CT, and MRI.

Impact of native iliac vein aspect ratio on initial clinical presentation and outcomes following stenting for symptomatic chronic iliofemoral venous obstruction.

OBJECTIVE: Venous stenting has become the first line of treatment for patients with symptomatic chronic iliofemoral venous obstruction (CIVO) in whom conservative therapy has failed. Intravascular ultrasound (IVUS) interrogation with the use of normal minimal luminal diameters or areas has become the standard to confirm the diagnosis and determine the adequacy of stenting. However, the aspect ratio (ratio between the maximal and minimal luminal diameters) has also been put forth as a possible metric for determining stent adequacy. This study explores the utility of the native iliac vein and stent aspect ratios in determining the initial presentation and outcomes after stenting. METHODS: A retrospective analysis of contemporaneously entered data from patients who underwent stenting for quality of life (QoL)-impairing clinical manifestations of CIVO for whom conservative therapy had failed formed the study cohort. The limbs were grouped into three at the time of intervention using the IVUS-determined native vein aspect ratio: group I, those with a ratio of ≤1.4; group II, those with a ratio of 1.41 to 1.99; and group III, those with a ratio of ≥2. The characteristics appraised initially and after stenting included the venous clinical severity score, grade of swelling (GOS), visual analog scale (VAS) for pain score, and the CIVIQ-20 QoL score. Analysis of variance and paired and unpaired t tests were used for comparison of clinical and QoL variables, and Kaplan-Meier analysis was used to evaluate stent patency, with the log-rank test used to discriminate between different curves. RESULTS: There were a total of 236 limbs (236 patients). The median age for the entire cohort was 62 years (range, 16-92 years). There were 161 women in the study, and left laterality was more common (137 limbs). Post-thrombotic obstruction was noted in 201 limbs (86%). The median body mass index was 36 kg/m2. There were 54 (23%), 64 (27%), and 118 (50%) limbs in groups I, II, and III, respectively. The median follow-up was 65 months. For the entire cohort, after stenting, the venous clinical severity score improved from 6 to 4 (P < .0001) at 3 months and remained at 4 at 6 months (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). The GOS for the entire cohort improved from 3 to 1 (P < .0001) at 3 months and remained at 1 at 6 months (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). The VAS for pain score for the entire cohort improved from 7 to 0 (P < .0001) at 3 months, increased to 2 (P < .0001) at 6 months, and remained at 2 (P < .0001) at 12 months. At 24 months, the VAS for pain score worsened to 3 (P < .0001). For the entire cohort, the CIVIQ-20 score improved from 62 to 40 (P < .0001). There was no difference in the GOS, VAS for pain score, or CIVIQ-20 score between the groups at baseline or at 6, 12, and 24 months after intervention. At 60 months, the primary stent patency was 89% for group I, 80% for group II, and 75% for group III (P = .85). The primary assisted stent patency was 100% for group I, 98% for group II, and 98% for group III (P = .5). Secondary patency was 100% for groups II and III (P > .5). Reintervention was pursued for QoL-impairing clinical manifestations in 53 limbs (22%) without a significant difference between the three groups (P = .13). CONCLUSIONS: The native vein aspect ratio does not appear to determine the initial clinical presentation or QoL or impact the clinical or QoL outcomes after stenting for CIVO. Following stenting, no patient had an aspect ratio >2, with 97% of patients having an aspect ratio ≤1.4 and the remaining 3% having an aspect ratio of 1.41 to 1.99. IVUS-determined minimal cross-sectional luminal area and not the aspect ratios should be used for confirmation of the diagnosis of CIVO and to assess the adequacy of stenting.

Post-COVID-19 Vaccine Thromboembolic Complication in the Setting of Newly Diagnosed May-Thurner Syndrome.

May-Thurner syndrome (MTS) can lead to deep venous thrombosis (DVT) in the left lower extremity, and it is often triggered by factors such as surgery or pregnancy. We present a rare case where the risk factor for thromboembolism in MTS is a complication from COVID-19 vaccination. A 44-year-old female who presented with fatigue, fever, and myalgia had developed thromboembolism as a complication of the Johnson & Johnson COVID-19 vaccine. Diagnostic criteria for vaccine-induced immune thrombotic thrombocytopenia (VITT) should be considered in such cases that include symptoms within 5-30 days post vaccination, elevated D-dimer, and thrombosis. Treatment involved anticoagulants and intervention for MTS included thrombectomy and stent placement. Recognition of post-COVID-19 vaccination complications such as VITT is crucial for early intervention and patient awareness during vaccination decisions.

May-Thurner Syndrome: The Worst-Case Scenario.

May-Thurner syndrome (MTS) is caused by compression of the left common iliac vein by the right common iliac artery against the spinal column. It can range from asymptomatic or present with subtle and unspecific signs and symptoms and rarely exhibit severe complications such as pulmonary embolism (PE). The diagnosis is confirmed by typical imaging findings. Treatment may include conservative measures, anticoagulation, endovascular or even surgical options. We report the case of a 20-year-old female who presented with cardiac arrest caused by an acute massive PE. Further study showed partial thrombosis of the internal iliac veins resulting from MTS. She continued anticoagulation therapy with low-molecular-weight heparin and then switched to edoxaban with a good clinical outcome. She was also referred to Vascular Surgery to discuss the possibility of iliac vein stenting. Abdominopelvic vascular compression syndromes include a large spectrum of conditions, and they are rarely considered as an etiology for venous thromboembolism. The clinical presentation of PE varies with several triggering factors and atypical presentation is more common in nonmalignant causes. The combination of noninvasive and invasive imaging modalities might be beneficial to establish a definitive diagnosis. Nevertheless, invasive procedures are often restricted to doubtful cases or to guide endovascular procedures which is the current treatment of choice. There is little evidence using nonvitamin K oral anticoagulants, but there are some case reports detailing their successful use. This case aims to point out the need for a profound understanding of different causes of deep vein and pulmonary thromboembolism; common entities in our practice but with a variety of clinical presentations and potentially caused by rare underlying conditions. MTS can be the origin of serious and deadly complications, hence the importance of early recognition and treatment.

Iatrogenic Venous Compression Syndrome Following Bilateral Hip Arthroplasty: A Unique Case of Bilateral Femoral Vein Compression in a Patient With May-Thurner Syndrome.

Iatrogenic venous compression syndrome is defined by extrinsic vein compression due to medical hardware, particularly relevant after joint replacement surgeries. Inserting medical hardware can lead to immediate risks such as deep vein thrombosis and pulmonary embolisms due to local tissue inflammation. The long-term issues include venous insufficiency due to chronic vessel irritation, subsequently causing intimal proliferation and thickening. Despite the existing knowledge of venous compression syndromes, iatrogenic cases are severely underreported. Here, we present a unique case of bilateral common femoral vein compression in a patient with May-Thurner syndrome and prior bilateral hip arthroplasty. An 85-year-old man with a history of venous insufficiency and bilateral hip arthroplasty for osteoarthritis presented with bilateral leg edema. Unsuccessful sclerotherapy and radiofrequency ablation led to a referral to a vascular specialist for venous duplex scans, venograms, and intravascular ultrasound. May-Thurner syndrome was revealed in the left common iliac vein, prompting the deployment of an 18 mm × 16 mm stent. Subsequently, during a venogram, what initially appeared to be a vasospasm in the left common femoral vein was diagnosed as extrinsic iatrogenic venous compression due to acetabular hip screws. This was found after two IV injections of 400 mg nitrogen and one balloon angioplasty could not resolve the compression. After advancement over a 0.35" microwire and accurate positioning over the center of the left common femoral vein lesion, a 16 mm × 90 mm stent was deployed. The venogram and intravascular ultrasound also showed a similar compression in the right common femoral vein. Another 400 mg IV nitrogen did not expand the lesion, so it was concluded that there was similarly an iatrogenic venous compression of the right common femoral vein, also due to acetabular hip screws in the right femur. A follow-up was scheduled a couple of weeks later to address the issue in the right common femoral vein. The underreported issue of iatrogenic venous compression following joint replacements highlights the need for better recognition and management of vascular complications due to inflammation and intimal proliferation. This is especially the case in high-risk patients, such as those with May-Thurner syndrome.

Unmasking May-Thurner Syndrome: A Case Report of Massive Deep Vein Thrombosis.

Deep venous thrombosis is a significant medical condition that results in life-threatening complications such as pulmonary embolism. Various factors can contribute to the formation of deep venous thrombosis, including prolonged immobility, surgery, and specific health conditions. May-Thurner syndrome is an underrecognized cause of deep venous thrombosis due to the compression of the left common iliac vein by the right common iliac artery. It poses diagnostic challenges due to its varied clinical presentations. This report discusses a 42-year-old female with no notable medical history who presented with acute onset of left leg swelling, pain, and discoloration. Despite the absence of common risk factors for deep venous thrombosis, investigations revealed a massive left-sided deep venous thrombosis. Additional imaging studies revealed the diagnosis of May-Thurner syndrome, manifesting as significant compression of the left common iliac vein. The patient underwent anticoagulation therapy, catheter-directed thrombolysis, and stent placement, resulting in symptomatic improvement and no recurrence over a six-month follow-up period. This case underscores the necessity of considering anatomical variations like May-Thurner syndrome in patients with unexplained deep venous thrombosis, particularly without typical risk factors. It highlights the importance of a comprehensive diagnostic approach, including advanced imaging techniques, to uncover underlying causes of deep venous thrombosis.

Left Common Iliac Vein Stenting in a Case of Postural Orthostatic Tachycardia Syndrome/Pelvic Pain Overlap.

Postural orthostatic tachycardia syndrome (POTS) is mainly characterized by orthostatic intolerance and positional tachycardia although it frequently involves a myriad of non-specific symptoms that seem to overlap with existing medical conditions. Recent efforts have been made to further classify subtypes of POTS and associated conditions to better delineate underlying pathophysiology in an effort to guide diagnosis and tailor treatment. Here, we present a 22-year-old female with debilitating symptoms of POTS who reported pelvic pain on review of systems and underwent vascular ultrasound of the inferior vena cava, iliac veins, and bilateral lower extremities which revealed the characteristic left common iliac vein compression of May-Thurner syndrome prompting venous stenting which provided systemic symptomatic relief.

Initial experience with the ambulatory management of acute iliofemoral deep vein thrombosis with May-Thurner syndrome with percutaneous mechanical thrombectomy, angioplasty and stenting.

OBJECTIVE: Patients undergoing intervention for acute iliofemoral deep vein thrombosis (IFDVT) with May-Thurner syndrome (MTS) typically require inpatient (IP) hospitalization for initial treatment with anticoagulation and management with pharmacomechanical thrombectomy. Direct oral anticoagulants and percutaneous mechanical thrombectomy (PMT) devices offer the opportunity for outpatient (OP) management. We describe our approach with these patients. METHODS: Patients receiving intervention for acute IFDVT from January 2020 through October 2022 were retrospectively reviewed. Patients undergoing unilateral thrombectomy, venous angioplasty, and stenting for IFDVT with MTS comprised the study population and were divided into two groups: (1) patients admitted to the hospital and treated as IPs and (2) patients who underwent therapy as OPs. The two groups were compared regarding demographics, risk factors, procedural success, complications, and follow-up. RESULTS: A total of 92 patients were treated for IFDVT with thrombectomy, angioplasty, and stenting of whom 58 comprised the IP group and 34 the OP group. All 92 patients underwent PMT using the Inari ClotTriever (Inari Medical), intravascular ultrasound, angioplasty, and stenting with 100% technical success. Three patients in the IP group required adjuvant thrombolysis. There was no difference in primary patency of the treated IFDVT segment at 12 months between the two groups (IP, 73.5%; OP, 86.7%; P = .21, log-rank test). CONCLUSIONS: Patients with acute IFDVT and MTS deemed appropriate for thrombectomy and iliac revascularization can be managed with initiation of ambulatory direct oral anticoagulant therapy and subsequent return for ambulatory PMT, angioplasty, and stenting. This approach avoids the expense of IP care and allows for effective use of resources at a time when staffing and supply chain shortages have led to inefficiencies in the provision of IP care for nonemergent conditions.

The TOPOS study.

Background: We aimed to study the long-term safety and efficacy of oblique venous stents for post-thrombotic syndrome (PTS) with iliac vein compression. Patients and methods: In the multinational, prospective, single-arm TOPOS study, PTS patients scheduled for endovascular therapy with the sinus-Obliquus® stent and optional distal extension with the sinus-Venous® or sinus-XL Flex® stent were enrolled at eight European vascular centres between October 2016 and December 2020. The primary outcome was primary stent patency at 24 months, and secondary outcomes included the clinical course of PTS (Villalta score, revised Venous Clinical Severity Score [rVCSS], Visual Analog Scale [VAS] of pain), quality of life changes (Chronic Venous Insufficiency Quality of Life Questionnaire, CIVIQ-20), and device-related complications. Results: We enrolled 60 patients (mean age 46±15 years, 68% women, 13% active ulcers): 80% required stent extension (70% below the inguinal ligament). The primary patency rate at 24 months was 80.7% (95%CI 68.1-90.0%); it was higher in patients without vs. those with stent extension (90.9% vs. 78.3%, p=.01). Compared to baseline, the Villalta, rVCSS, pain VAS, and CIVIQ-20 decreased by a median of 8 (interquartile range (IQR): 4-11), 5 (IQR: 3-7), 3 (IQR: 2-5), and 17 (IQR: 6-22) points, respectively; p<.001 for all parameters. Overall, 9 events of acute stent occlusion, 4 symptomatic stent stenosis, and 1 pulmonary embolism occurred. We did not observe major bleeding events or contralateral thrombosis. Conclusions: Endovascular treatment with the oblique stent and optional stent extension was safe and resulted in high patency rates at 24 months. The reduction in PTS severity was substantial and persisted over 2-year follow-up.

Ilio-Iliac Arteriovenous Fistula with May-Thurner Syndrome: A Case Report.

An ilio-iliac arteriovenous fistula (AVF) is rare. Common factors leading to ilio-iliac AVF include congenital malformations, iatrogeny, and trauma. There is limited documentation in the literature of cases involving ilio-iliac AVF with May-Thurner syndrome. Here, we present a case of an ilio-iliac AVF with May-Thurner syndrome in an 80-year-old male. CT and angiography confirmed extensive ilio-iliac AVF. Successful endovascular procedures for ilio-iliac AVF were performed using several variable-sized coils and 1400-2000 µm gelatin particles. After embolization, follow-up abdominopelvic CT revealed an improvement in edema in the left leg.

A comparative study of altered hemodynamics in iliac vein compression syndrome.

Introduction: Iliac vein compression syndrome (IVCS) is present in over 20% of the population and is associated with left leg pain, swelling, and thrombosis. IVCS symptoms are thought to be induced by altered pelvic hemodynamics, however, there currently exists a knowledge gap on the hemodynamic differences between IVCS and healthy patients. To elucidate those differences, we carried out a patient-specific, computational modeling comparative study. Methods: Computed tomography and ultrasound velocity and area data were used to build and validate computational models for a cohort of IVCS (N = 4, Subject group) and control (N = 4, Control group) patients. Flow, cross-sectional area, and shear rate were compared between the right common iliac vein (RCIV) and left common iliac vein (LCIV) for each group and between the Subject and Control groups for the same vessel. Results: For the IVCS patients, LCIV mean shear rate was higher than RCIV mean shear rate (550 ± 103 s-1 vs. 113 ± 48 s-1, p = 0.0009). Furthermore, LCIV mean shear rate was higher in the Subject group than in the Control group (550 ± 103 s-1 vs. 75 ± 37 s-1, p = 0.0001). Lastly, the LCIV/RCIV shear rate ratio was 4.6 times greater in the Subject group than in the Control group (6.56 ± 0.9 vs. 1.43 ± 0.6, p = 0.00008). Discussion: Our analyses revealed that IVCS patients have elevated shear rates which may explain a higher thrombosis risk and suggest that their thrombus initiation process may share aspects of arterial thrombosis. We have identified hemodynamic metrics that revealed profound differences between IVCS patients and Controls, and between RCIV and LCIV in the IVCS patients. Based on these metrics, we propose that non-invasive measurement of shear rate may aid with stratification of patients with moderate compression in which treatment is highly variable. More investigation is needed to assess the prognostic value of shear rate and shear rate ratio as clinical metrics and to understand the mechanisms of thrombus formation in IVCS patients.

Familiar Disposition of May-Thurner Syndrome-A Case Series.

May-Thurner syndrome is a venous compression syndrome of the pelvic vessels that represents a relevant risk factor for thrombus formation. The standard procedure to secure a diagnosis is venography, followed by endovascular therapy as the preferred treatment choice if the patient is symptomatic. In our case series, there are three related patients with May-Thurner syndrome. A 16-year-old female was admitted with pulmonary embolism, dyspnoea and hip pain. The compression syndrome was diagnosed with interventional venography, and the patient received venous stent implantation. Due to her family history, we also suspected her mother to be affected by the syndrome and elucidated the diagnosis shortly afterwards by invasive venography. Subsequently, we examined the patient's 19-year-old brother, and magnetic resonance imaging confirmed May-Thurner syndrome. A similar case series has not been published before. In this case, the family relation indicates a possible hereditary aspect of May-Thurner syndrome. This hypothesis should be the subject of further research. In conclusion, it is essential to assess family history thoroughly when treating patients with May-Thurner syndrome.

Review of the literature supporting international clinical practice guidelines on iliac venous stenting and their applicability to Australia and New Zealand practice.

BACKGROUND: The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO). METHODS: A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts. RESULTS: The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib). CONCLUSIONS: Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments.

Is the May-Thurner Syndrome a Major Risk Factor for Deep Vein Thrombosis in Total Hip Arthroplasty?

Background: May-Thurner syndrome (MTS) is iliac vein compression syndrome associated with postoperative deep vein thrombosis (DVT) resulting from chronic compression of the left iliac vein against lumbar vertebrae by the overlying right or left common iliac artery. MTS is not well known as a risk factor for DVT after total hip arthroplasty (THA). We evaluated the incidence of DVT after THA and analyzed if the MTS is a risk factor for DVT after THA. We hypothesized that MTS would be associated with an increased risk of developing DVT after THA. Methods: All patients > 65 years of age who underwent THA between January 1, 2009, and January 12, 2017, were identified. Among them, the patients who presented for postoperative DVT of the lower extremity were reviewed with medical record data. MTS was diagnosed with computed tomography (CT) angiography of the lower extremity. We analyzed the demographic data, symptoms, diagnoses, and treatment of MTS patients. Results: A total of 492 consecutive patients aged > 65 years who underwent operation for THA were enrolled. Among them, 5 patients (1.0%) presented for postoperative DVT of the lower extremity. After reviewing the CT angiography of the lower extremity, 4 out of 5 DVT patients (80%) were identified as having MTS. All MTS patients were female and presented with pain and swelling of the left leg. All MTS patients were treated with systemic anticoagulation, aspiration thrombectomy, and percutaneous transluminal angioplasty. Complete resolution of thrombus was observed in all patients. Conclusions: If the diagnosis of MTS is delayed, the morbidity and mortality rates are significantly increased. Orthopedic surgeons should be aware of MTS as a risk factor for DVT after THA. Moreover, preoperative evaluation with duplex sonography or CT angiography to confirm MTS should be considered. In this regard, this study is considered to have sufficient clinical value for early diagnosis and appropriate treatment of MTS after THA.

Diagnosis of chronic iliac venous obstruction.

Stenting has become the first line of treatment for symptomatic chronic iliofemoral venous obstruction in patients with quality-of-life-impairing clinical manifestations who have failed conservative therapy. Patient selection for such intervention is, however, dependent on clear identification of relevant clinical manifestations and subsequent testing to confirm the diagnosis. In this regard, the physician engaged in management of such patients needs to be well-aware of symptoms and signs of chronic iliofemoral venous obstruction, and instruments used to grade chronic venous insufficiency and determine quality of life, in addition to diagnostic tests available and their individual roles. This review serves to provide an overview of the diagnosis of chronic iliofemoral venous obstruction and patient selection for stenting.