Working Diagnosis:
May-Thurner Syndrome with Meralgia Paresthetica

Treatment:
The patient was diagnosed with May-Thurner syndrome with concomitant Meralgia Paresthetica.
Vascular surgery was consulted and patient was treated with stent placement in her left common iliac vein.

Outcome:
She achieved full resolution of her symptoms and has since returned to full activity and sport, nearing her original 5 minute mile pace.

Author's Comments:
May Thurner Syndrome (MTS) is a rarely diagnosed condition in which the right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine that can inhibit/cause turbulent venous flow that can lead to deep vein thrombosis.1 The incidence and prevalence of MTS are unknown and it is likely underestimated because most individuals with MTS anatomy do not show symptoms and need no treatment.4 Patients with MTS may live their lives with no signs or symptoms of venous disorders.3 Some scientists have considered the term “May Thurner anatomy” for these patients and considered MTS as a term for patients that do have the anatomical variant and that do suffer the complications of the said variant.3 Among those presenting with venous disorders in the lower extremities, 2 to 5% of those patients are diagnosed with MTS.2 Risk factors that may be directly associated with MTS or that increase the likelihood of asymptomatic MTS advancing to symptomatic MTS include female gender (particularly post partum, multiparous or using contraceptives), scoliosis (due to compression of lumbar spine), dehydration, hypercoagulable disorders, and cumulative radiation exposure.4

Editor's Comments:
This is a great case which highlights a rare diagnosis of pain or claudication type symptoms in a patient. The diagnosis can be made with MR Venography or CT with venous phase. The treatment is based on severity of symptoms and whether there is a concomitant deep vein thrombosis associated. If symptoms are mild, treatment is conservative with compression stockings. If there are moderate to severe symptoms then angioplasty with stent may be warranted.

References:
1. May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology. 1957;8:419‐427.
2. Brazeau NF, Harvey HB, Pinto EG, Deipolyi A, Hesketh RL, Oklu R. May‐Thurner syndrome: diagnosis and management. Vasa. 2013;42:96‐105.
3. Oguzkurt L, Tercan F, Pourbagher MA, Kizilkilic O, Turkoz R, Boyvat F Eur J Radiol. 2005 Sep; 55(3):421-5.
4. Marion, DW. May Thurner Syndrome. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2014.

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