Young healthy woman with a DVT

[pushthesux]

Thanks in advance for reading this and providing any advice. This is a friend of mine, and I would appreciate any insight on this case.

Ms. "M" is a 34yo G1P1 previously healthy woman who has had a history of a left iliac thrombosis (not sure of the exact size) about 1 year after her child was born. At that time, the DVT was blamed on her oral contraceptives. She underwent about 6 months of coumadin therapy and she was told to get off birth control pills. She went about 1 year and started having classic DVT symptoms again in her left leg....obviously a recurrence of her original DVT.

She has no pertinent family history. She is on an antidepressant and has no allergies.

She has recently gone to a Hem/Onc doctor...and the lab results are all inconclusive. (I can provide lab results if you guys need them). Her CT scan shows no intra-abdominal mass compressing any vessels. She has had no other imaging that I know of.

She has been heparinized and is now on coumadin therapy.

Question: Could this be May-Thurner syndrome (also known as iliac
compression syndrome...where the right iliac artery compresses the left iliac vein)?? More importantly, has anyone seen this? Is she a surgical candidate?

She is young and healthy and probably wants to have another child...obviously a problem being anticoagulated. Her leg is also constantly swollen/engorged, and she is obviously at risk for long-term complications like venous stasis ulcers, dermatitis, etc...

Thanks a lot guys.

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[Tenesma]

heparin can be safely used during pregnancy as it does not cross the placenta... however it is a bitch to administer...

 

[Samoa]

The story is classic for antiphospholipid antibody syndrome. But I assume that was tested for?

 

[fishmonger69]

The story is classic for antiphospholipid antibody syndrome. But I assume that was tested for?

except the 'previously healthy'. i would assume some signs related to SLE might have been present, at least minor ones, since in my experience/reading primary APS is fairly rare.

i'd be interested in knowing what the heme lab results were, especially since they were deemed 'inconclusive' by the blood docs. also, is she back on OCPs?

re: surgical candidacy, i might get dopplers and some veno/arteriograms, just to rule in/out vessel disease/aberrancy.

 

[toxic-megacolon]

An arteriogram would show if she was a surgical candidate. You might have better luck with this question in the Internal Medicine forum. This is really an IM issue until a surgical indication is found (usually by the med people).

 

[Samoa]

except the 'previously healthy'. i would assume some signs related to SLE might have been present, at least minor ones, since in my experience/reading primary APS is fairly rare.

We had a patient like that on my medicine rotation. (Ah, Charity! No place like it.) Previously healthy, but she was diagnosed with APS after developing a DVT post-pregnancy. No SLE symptoms.

But yeah, it's an IM issue. Post this there, and you'll probably get lots of discussion.

 

[chemamr]

i think it would be good if you write the lab results to rule out some possible causes. I think APS has some skin signs, right?. It can be a rheumathologic disease, too, maybe she is starting and of course doesn´t have all the criteria for a diagnosis but it can be. Or any neoplasm. Has she had any arthritis or arthralgias? family history of thrombosis?

 

[Jim Picotte]

Won't comment on the medical workup, but this may very well be May-Thurner syndrome. Seen only two cases, but sounds pretty suspicious to me. Have her see an interventional radiologist who has some experience in this. This can be missed on CT. A venogram should be able to provide the diagnosis and this can be treated through angioplasty and an iliac vein stent if confirmed. Good luck.

Thanks in advance for reading this and providing any advice. This is a friend of mine, and I would appreciate any insight on this case.

Ms. "M" is a 34yo G1P1 previously healthy woman who has had a history of a left iliac thrombosis (not sure of the exact size) about 1 year after her child was born. At that time, the DVT was blamed on her oral contraceptives. She underwent about 6 months of coumadin therapy and she was told to get off birth control pills. She went about 1 year and started having classic DVT symptoms again in her left leg....obviously a recurrence of her original DVT.

She has no pertinent family history. She is on an antidepressant and has no allergies.

She has recently gone to a Hem/Onc doctor...and the lab results are all inconclusive. (I can provide lab results if you guys need them). Her CT scan shows no intra-abdominal mass compressing any vessels. She has had no other imaging that I know of.

She has been heparinized and is now on coumadin therapy.

Question: Could this be May-Thurner syndrome (also known as iliac
compression syndrome...where the right iliac artery compresses the left iliac vein)?? More importantly, has anyone seen this? Is she a surgical candidate?

She is young and healthy and probably wants to have another child...obviously a problem being anticoagulated. Her leg is also constantly swollen/engorged, and she is obviously at risk for long-term complications like venous stasis ulcers, dermatitis, etc...

Thanks a lot guys.

 

[gerickson03m]

She needs a hypercoagulable workup. 10% of the people who get DVT's have a problem. This is much more common than the syndome.
1. Factor V leiden
2. homocystein
3. Prothrombin gene mutation
4. Anticardiolipin
5. Thrombin time
6. Protein C + S levels
7. Lupid Anticoagulant
8. PT/Inr/PTT
9. Factor 8 level

This is the 2nd time she had a DVT and so this is required work-up. She need s to be off all anticoagulation for 1 week befor the above labs can be drawn, her vein is permanently injured and she has a high chance of having chronic venus reflux and pain.

 

[womansurg]

If she's been seen by a hematologist - which she has - then she has already undergone a comprehensive rule out for hypercoaguable syndromes. You indicate that no causal etiology was identified.

Basically, a heme-onc is the pinnacle of IM specialty with regards to coagulopathies. Sending her back to IM isn't going to get you any further.

I think you're probably right on in thinking about May Thurner syndrome. The location of thrombus in the left iliac vein, the reccurence without identifiable contributing factors, and the lack of alternate etiology are all very supportive of this.

Defintive diagnosis can usually be obtained via venous phase contrasted pelvic CT. Gold standard would be venography. I'd leave it up to your local vascular radiologists to decide which study would be preferable in their hands.

Treatment is usually endovasular stenting, an outpatient procedure well tolerated. Surgical bypass is also possible.

In the early phase of diagnosis a symptomatic proximal DVT can often be treated with catheter directed thrombolysis. This decreases risk for post phlebitic syndromes such as you describe: chronic swelling, venous insufficiency. Likely the clot is too organized for consideration for this by this point.

Good luck.

 

[f_w]

Good story for May Thurner, but it seems like the cows have already left the barn.

CT abd/pelvis is not a terribly good test to show you the scarring, stenosis and webs of the iliac vein that make up part of the pathology. Masses and CFA aneurysms are an uncommon etiology for iliofemoral DVT in this age group, they are more important in an older patient.

Get her seen by a fairly aggressive interventional radiologist. Even though the clot by now is pretty organized, pharmacomechanical thrombolysis might still work to clear up the iliacs (~50% chance in chronic dvt). If the venogram shows the typical May-Thurner findings, she might benefit from a stent.
This is not standard therapy (yet), most of the research are small 30 patient series (e.g. this one: Bush RL, Lin PH, Bates JT, Mureebe L, Zhou W, Lumsden AB. Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study. J Vasc Surg. 2004 Nov;40(5):965-70.) It is a minimally invasive procedure, at times it requires overnight ICU admission if additional catheter directed thrombolysis is necessary. When it works, the results are impressive.

As for a list of people active in this arena, check out the author list of this paper :

Development of a Research Agenda for Endovascular Treatment of Venous Thromboembolism: Proceedings from a Multidisciplinary Consensus Panel Journal of Vascular and Interventional Radiology 16:1567-1573 (2005)



The hypercoagulable workup mentioned above sounds reasonable. One caveat is that some of the values can get screwed up by coumadin, however if they are near normal you can exclude most conditions.