May-Thurner syndrome and iliac arteriovenous fistula in an elderly woman

Abstract

May-Thurner syndrome most commonly involves compression of the left common iliac vein by the right common iliac artery and can result in leg pain and swelling as well as potentially precipitate deep venous thrombosis. These symptoms can be exacerbated by additional vascular abnormalities. This is a case report of a 91-year-old woman with intractable massive left lower extremity edema that interfered with walking. She was diagnosed with concurrent May-Thurner syndrome and pelvic arteriovenous fistula. Treatment with embolization of the fistula and stenting of the left common iliac vein relieved her symptoms and allowed her to walk again.

Fig 1

A, Preoperatively, the patient had severe left lower extremity edema, two areas of skin ulceration on the anterior calf, and cyanosis in the toes. B, Three months postoperatively, the patient's swelling has significantly reduced, the ulcers have healed, and the toes are no longer cyanotic.

Fig 2

Venous duplex Doppler examination. Both the left common femoral vein (v) and artery (a) exhibit the same flow direction on color Doppler examination. There is complete reversal of flow toward the lower extremity in the vein as well as pulsatile waveforms (not shown) suggestive of an arteriovenous fistula (AVF).

Fig 3

Angiography. A, Arteriogram obtained through right common femoral artery access (black arrow) and injection of contrast material at the aortic bifurcation. The left external iliac artery (a) and vein (v) were visualized concomitantly because of early retrograde filling of the vein from an arteriovenous fistula (AVF, white arrow) at the level of the left internal iliac artery. B, Venogram obtained through left common femoral vein access (arrow) after coil embolization of AVF (c) and stenting (s) of left common iliac vein (CIV) shows normal flow through the venous system.