Abstract

MACHADO, Miguel; MACHADO, Rui; MENDES, Daniel  and  ALMEIDA, Rui de. May-thurner syndrome associated with nutcracker syndrome: clinical case and literature review. Angiol Cir Vasc [online]. 2017, vol.13, n.2, pp.52-57. ISSN 1646-706X.

Introduction May Thurner syndrome (MTS), is a condition in which the left common iliac vein (LCIV) is compressed between the fifth lumbar vertebra, posteriorly, and the right common iliac artery (RCIA), anteriorly. This phenomenon can cause venous stasis in pelvis and in left lower limb. Nutcracker syndrome (NCS) is caused by compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta, called Anterior NCS, or more rarely by compression of the LRV between the aorta and the lumbar vertebra, when the vein passes behind the aorta, called posterior NCS. The association of the two anomalies can occur when a circunaortic renal vein exists. This phenomenon can cause stasis in the kidney and in the pelvis. The MTS and NCS are rare clinical entities and the association of the two pathologies is extremely rare. Clinical Case A 29-year-old female, complaints of bilateral leg pain, predominantly on the left side, left malleolar edema which increases in the end of the day, and dyspaneuria. This complaint leads to severe quality of life deterioration. Physical examination reveals collateral varices in the posterior aspect of the left tight, a right side vulvar varicose vein and mild left malleolar edema. Phlebography of the ilio-cava system and the ovarian vein was performed revealing a compression of the LCIV by RCIA with an extensive collateral pathway communicating the left and right iliac vein system, the origin of a right side vulvar varicose vein in the right internal iliac vein and compression of a posterior LRV by the aorta. A transluminal angioplasty with sequential dilatation with 12, 14 and 16 mm balloon was done and an Optimed® sinus vein stent 16/100 mm was implanted in the LCIV. At 3 months of follow up, the patient became pregnant, so she stopped the rivaroxabane treatment and maintained the elastic therapy with compression stockings. The pregnancy and the childbirth had no intercurrences. An abdomino-pelvic control CT at 12 months follow-up was done, confirming the correct position and patency of the. Posteriorly, the patient was submitted to stab avulsion of varicose veins in the left thigh. At 18 months follow-up, the patient was clinically asymptomatic. Discussion/Conclusion Insufficient knowledge about the natural history of NCS and MTS results from the uncertainty in the diagnostic criteria and treatment selection, particularly in the rare association of both. This association can be responsible for the amplification of the symptomatology of the venous obstruction. In our case, we have seen the resolution of the complaints by treating only one of the obstructive lesion (MTS) and we haven't seen any effect of the pregnancy in the structure and patency of the ilio-caval stent.

Keywords : Nutcracker Syndrome; May-Thurner Syndrome.

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