ARRS 2022 Abstracts


E2032. May-Thurner and Pelvic Congestion Syndromes: A Case-Based Review and Recent Developments
  1. Brandon Rodgers; The Ohio State University Wexner Medical Center
  2. Marc Fromherz; Carilion Roanoke Memorial Hospital
  3. Robert Moranville; The Ohio State University Wexner Medical Center
  4. Michael Cline; The Ohio State University Wexner Medical Center
  5. Mina Makary; The Ohio State University Wexner Medical Center
May-Thurner Syndrome (MTS) is defined as extrinsic venous compression by the arterial system within the iliocaval region. MTS commonly presents as left common iliac vein compression by the right common iliac artery at the fifth lumbar vertebrae. Symptoms commonly include lower extremity swelling, venous claudication, thrombosis, and signs of venous insufficiency. Pelvic venous syndromes are divided into pelvic congestion syndrome (PCS) and vulvar varicosities. Clinical symptoms of PCS are often vague, but usually include > 6-month history of pelvic pain that can demonstrate activity-, ovulatory-, or gravity-related exacerbation, and can present with or without vulvovaginal varicosities. PCS is associated with valvular insufficiency and absence or compression of the left ovarian vein, and treatment has targeted embolization of the vein. It was previously believed that MTS was not a direct cause of PCS, but recently increasing amounts of cases have demonstrated their association. Treatment of MTS alone, or with associated PCS, by interventional radiologists depends on clinical presentation and imaging. If thrombotic disease is present, a thrombectomy is performed with subsequent intravascular ultrasound (IVUS) evaluation. If stenosis is visualized, angioplasty and stent placement is completed. Without thrombotic disease, symptomatic severity dictates subsequent imaging and treatment. MR or CT venography has a > 95% sensitivity and specificity for MTS. If the diagnosis is not clear with CT or MR and clinical suspicion remains high, IVUS can be employed to visualize and measure the degree of stenosis with a > 98% sensitivity and specificity, and angiography can be used to visualize reflux and collateral vessel engorgement. Based on stenotic severity and clinical symptoms, angioplasty and stent placement can be performed and lead to clinical improvement in > 75% of patients.

Educational Goals / Teaching Points
After viewing this exhibit, learners will be able to identify the common clinical presentations of MTS and PCS, understand the connection between them, and be able to identify common anatomical and physiological findings of both syndromes on CT, MR, IVUS, and angiography. Current evidence-based guidelines will be presented, and learners will be able to interpret clinical presentation and image data to describe appropriate treatment methods. Future innovations in diagnosis and treatment will be discussed.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Management of MTS and PCS requires knowledge regarding the clinical presentation, pertinent image findings, and various treatment options. Key imaging modalities used for diagnosis and treatment include CT, MR, IVUS, and angiography. Each of these modalities will be discussed in this review and key anatomic and physiologic features explained.

Reports describing the connection between MTS and PCS are becoming more common. As current or future interventional radiologists, understanding the clinical symptoms, pertinent anatomy, and diagnostic image findings of each syndrome are important for improving diagnostic rates and subsequent treatments.