Working Diagnosis:
May-Thurner Syndrome (MTS)

Treatment:
After discovery of MTS, the patient underwent a left common iliac vein balloon angioplasty and stent placement. Case Photo #6 Case Photo #7 A bilateral iliocaval ascending venogram was performed after the procedure that showed restored blood flow to the lower extremities. Case Photo #8

Outcome:
After the procedure, the patient was able to make a full recovery. She was started on a stepwise cardiovascular regimen and slowly began running again. As of the Fall NCAA season, she remains asymptomatic running 6 miles and is on track to compete in the Spring Track and Field season.

Author's Comments:
Lumbar radiculopathy or spinal stenosis was suspected on initial presentation, but workup was negative. Worsening symptoms hinted at exertional compartment syndrome. Orthopedics was consulted, but compartment testing was not performed. The COVID-19 pandemic halted training, and symptoms decreased. But when she returned, symptoms did as well. Pelvic congestion syndrome was seen on CT, but GYN did not suspect that caused her symptoms. Then, vascular surgery was consulted, US performed, and May-Thurner Syndrome (MTS) was diagnosed. MTS is difficult to diagnose. Patients are often seen by multiple specialists due to overlapping etiologies and waiting for a diagnosis becomes extremely frustrating.

Editor's Comments:
The typical patient with MTS is a female in the second or third decade of life presenting with symptoms including chronic left lower extremity swelling, pain, venous claudication and possible skin changes related to venous insufficiency. Pelvic congestion syndrome, as noted in this patient, may also be a feature of MTS. This case was notable for the fact that the patient never developed lower extremity swelling. Rather, the predominant symptom was venous claudication, defined as deep thigh/leg pain and tightness with exercise, which subsides with rest and/or elevation. MTS should be included in the differential for any painful leg disorder.

This patient also presented with ankle weakness after running, which is not typical for MTS. This symptom, presumably due to transient nerve compression or ischemia related to venous congestion, resolved after stent placement. Interestingly, the AMSSM case "Leg Pain in a Recreational Athlete" (Barton, et al) describes a patient with foot drop who was diagnosed with both MTS and chronic exertional compartment syndrome. The foot drop did not resolve after stent placement and the patient required subsequent compartment release.

References:
Barton E. Leg Pain in a Recreational Athlete. Ghuman M, ed. AMSSM/AOASM Case Study Teaching Tool. American Medical Society for Sports Medicine. https://www.amssm.org/leg_pain_in_a_recreational-csa-688.html?StartPos=160&Part=

Mousa AY. May-Thurner syndrome. In: UpToDate, Collins KA (Ed), UpToDate, Waltham, MA (Accessed on July 26, 2022).

Poyyamoli S, Mehta P, Cherian M, Anand RR, Patil SB, Kalva S, Salazar G. May-Thurner syndrome. Cardiovasc Diagn Ther. 2021 Oct;11(5):1104-1111.

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