0:01

Now this is a 40-year-old woman who presented

0:05

with acute onset

0:06

of left lower treaty swelling and throbbing pain.

0:08

She was previously completely healthy

0:10

and her only important past medical history was

0:14

that distorted oral contraceptive a month ago.

0:17

So of course the, the suspected DVT

0:22

and we, we did, uh, the DVT study.

0:25

And so if we look at the left common femoral vein, again,

0:29

you know that this is without compression,

0:31

this is with compression.

0:33

The vein is expanded, has a microgenic material

0:36

and is not compressing.

0:37

So the patient does have a left common femoral vein, DVT,

0:41

and she also had, I'm not showing this,

0:43

but she had extensive, uh,

0:46

DVT throughout the left lower extremity.

0:50

Now we were able to look very, very carefully.

0:53

That's not part of her routine, but

0:55

because of her history, we decided to,

0:58

to look a little bit more deeper in the pelvis.

1:01

So this is a longitudinal view of the iliac vein.

1:05

So more central above this, and this is completely occluded.

1:11

And then was, she was, you know, we were able to,

1:15

to see very deep and we, so we looked for the IVC

1:19

and the bifurcation of the iliac veins.

1:22

And you see here that the IBCs patent,

1:25

but the left iliac vein is completely occluded.

1:29

Even the left common iliac vein is, is occluded.

1:33

So now what is going on?

1:34

Yes, the patient has a DVT,

1:36

but it's probably not enough to just say that

1:40

because we need to understand why the patient has this

1:44

DVT otherwise healthy.

1:46

Okay? So what this patient has is,

1:49

and the right lower extremity venous doppler was normal.

1:52

She doesn't have, she didn't have any other risk factor like

1:56

hypercoagulable states.

1:58

But because her age

2:01

and the fact that she had extensive unilateral left low

2:05

extremity, DVT including involving the left common iliac

2:09

vein, we was the possibility of Mayer syndrome.

2:14

And that's important because the management

2:16

for this patient is not just anticoagulant,

2:18

but you need to address the root of the problem.

2:21

Okay, so what is maternal syndrome?

2:24

It is an compression of the iliac vein,

2:27

iliac vein compression syndrome.

2:29

It usually happens on the left side

2:31

because the pathogenesis, at least the thought is

2:33

that there's a obstruction

2:35

of the left iliac vein when it is caught

2:37

between the right iliac artery and the spine.

2:41

And because of the pulsation of the right iliac artery,

2:45

the one of the theories that their formation

2:47

of little mini trauma to the vein

2:49

and their formation internal webs, uh,

2:52

and the patient can either present acutely like this patient

2:56

with acute extensive DVT or they can have

2:58

Chronic symptoms of venous insufficiency,

3:01

which can be quite debilitating.

3:03

And remember, usually these are young

3:05

patients, usually young women.

3:08

So the typical patient is a woman in the second

3:10

or third decade of life, uh,

3:12

more commonly affect the left common iliac vein.

3:15

And this, this may turn a syndrome,

3:18

if you look at the literature is diagnosed in probably two

3:21

to 5% of patients with lower extremity venous disorder,

3:25

but maybe under reported

3:26

because we don't always think about this.

3:28

Of course, risk factors are oral contraceptive, pregnancy

3:32

and to confirm the diagnosis, CT or MR is very helpful.

3:37

And what you're going to see in this,

3:39

typically these patients are at risk.

3:41

This is a different patient.

3:43

There is a very narrow space between the iliac artery

3:48

and the right iliac artery and the, and the spine.

3:51

And you can nicely see here that the left

3:54

iliac vein is getting, complace is squished

3:57

between the iliac artery

3:58

and the, the, the vegetable body here.

4:01

So this patient also had extensive deep vein thrombosis, uh,

4:06

as you can see here with a vein expander.

4:09

Okay? So very important thing

4:10

to think about in the right, uh, patient.

4:14

Okay? So, uh, what, what we look at

4:16

for a very small diameter of the left commonly origin,

4:21

like I just showed you, just behind the right iliac artery.

4:25

And so the management, it's very important

4:27

to make the diagnosis, but

4:29

because in addition to to treating the DVT, um,

4:33

we can first of all try

4:34

to do thrombolysis in the acute phase to try to avoid, um,

4:39

the patient developing venous chronic venous insufficiency

4:43

and the treatment to prevent recurrences

4:46

to put an iliac vein stent placement.

4:48

So that's why making the specific diagnosis of meth

4:52

or syndrome can really be very,

4:54

very helpful to your patients.

5:00

So again, this is the challenge here is just

5:03

that even though you haven't, that's what I've hope hoped

5:05

to show you in these multiple cases.

5:07

Even you have classic finding or DVT. Just don't stop there.

5:11

Just think about why the patient has a DVT

5:15

and if there's a normal variant in this patient,

5:17

you may have, uh, ha, have specific therapeutic intervention

5:22

and improve the quality of life for these patients.