E1813. Balloon, Lyse, Stent, or Operate: A Review of the Diagnostic Imaging and Therapeutic Management for Vascular Compression Syndromes
  1. Karen Man; Morristown Medical Center
  2. Michael Prasad; Morristown Medical Center
  3. Akram Sadeghi; Morristown Medical Center
  4. Priya Mody; Morristown Medical Center
  5. Sean Calhoun; Morristown Medical Center
  6. Thaddeus Yablonsky; Morristown Medical Center
Vascular compression syndromes are characterized by the symptomatic extrinsic compression of vasculature by anomalous or prominent normal anatomy. Appropriate treatment depends on the acuity/severity of symptoms, the anatomic cause of compression, and the presence of possible coexisting vascular conditions. For example, in thoracic outlet syndrome, primary treatment via stenting of a vessel is generally contraindicated due to the high risk for crushing or occlusion of a stent in the setting of a persistent fixed compression (e.g. cervical rib). Instead, catheter-directed thrombolysis may be used for treatment of acute vascular occlusion, and definitive treatment depends on surgical release or repair of pathologic anatomy. In contrast, stent placement has shown acceptable risk and efficacy in the treatment of nutcracker syndrome and May-Thurner syndrome – except in cases of coexisting pelvic congestion syndrome, which may be indicative of venous insufficiency unrelated to the apparent anatomic compression. Thus, radiological findings are critical to the diagnosis and treatment planning for vascular compression syndromes, which may be managed with a variety of interventional or surgical therapies.

Educational Goals / Teaching Points
After completion of this educational review, the learner will be familiar with: imaging and clinical criteria for diagnosis of various vascular compression syndromes; clinical indications for treatment of the discussed syndromes; recommended first-line treatments and best practices according to current literature; and nuances, exceptions to the rule, or alternatives in management where applicable.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Diagnostic imaging findings and therapeutic management will be presented for the following vascular compression syndromes: thoracic outlet syndrome (including arterial compression, venous compression, and Paget-Schroetter syndrome), median arcuate ligament syndrome, nutcracker syndrome, May-Thurner syndrome, popliteal entrapment syndrome, and aortosternal venous compression. Although not strictly a vascular compression syndrome, pelvic congestion syndrome will also be discussed due to its close relationship to some of the compression syndromes and its impact on management. The appropriateness of various vascular management options including balloon angioplasty, catheter-directed thrombolysis, stent placement, and surgery will be reviewed for each syndrome.

Vascular compression syndromes are a unique set of vascular disorders in which radiology plays a critical role in the analysis of patient anatomy, diagnosis, and treatment planning. Interventional radiologists may serve as the primary treating physicians, and as such it is necessary to understand the appropriate therapeutic approach for each condition.