Foit Niels A, Chen Qing-Min, Cook Blaze, Hammerberg Eric Mark
Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, MC 0188, Denver, CO 80204, USA.
Patient Saf Surg. 2013 Apr 29;7(1):12. doi: 10.1186/1754-9493-7-12.
May-Thurner Syndrome (MTS) represents an anatomic variation of the iliac vessels, in which the left common iliac vein is compressed by an overriding iliac artery. Patients with this abnormality are predisposed to the formation of a left-sided iliofemoral deep venous thrombosis (DVT). While DVT is a familiar complication in the setting of lower extremity trauma, there are no previous reports of MTS complicating the care of patients requiring orthopaedic surgery.
We present the case of an extensive limb-threatening DVT in a patient with previously undiagnosed MTS, resulting after internal fixation of a left tibial plateau fracture. Four days after surgery, despite standard prophylactic anticoagulation, the patient developed an extensive occlusive DVT, extending from the common iliac vein to the popliteal vein. Successful diagnosis required a CT venogram in addition to standard lower extremity ultrasound exam. Severe lower extremity edema continued to worsen despite formal anticoagulation. Urgent mechanical thrombolysis was undertaken, followed by staged catheter-directed thrombolysis with recombinant tissue plasminogen activator (rTPA) and intraluminal stenting. Following this treatment, the patient was noted to have gradual but dramatic resolution of his lower extremity edema and swelling.
The present case demonstrates the potential danger that may accompany MTS in the setting of lower extremity trauma. When an extensive left lower extremity DVT complicates the care of a patient with extremity trauma, clinicians should have a low threshold to pursue the diagnosis of MTS with advanced imaging studies. Venography remains the gold standard in diagnosis, but CT and MRI venography are less invasive and should allow for accurate diagnosis. In this case, formal anticoagulation proved to be ineffective, and endovascular intervention was required.
梅-图二氏综合征（MTS）是一种髂血管的解剖变异，其中左髂总静脉被上方的髂动脉压迫。患有这种异常的患者易发生左侧髂股深静脉血栓形成（DVT）。虽然DVT是下肢创伤常见的并发症，但此前尚无MTS并发于需要骨科手术患者护理过程的报道。
我们报告一例先前未诊断出MTS的患者，在左胫骨平台骨折内固定术后发生广泛的威胁肢体的DVT。术后四天，尽管进行了标准的预防性抗凝治疗，患者仍发生了广泛的闭塞性DVT，从髂总静脉延伸至腘静脉。除了标准的下肢超声检查外，成功诊断还需要CT静脉造影。尽管进行了正规的抗凝治疗，严重的下肢水肿仍持续恶化。紧急进行了机械溶栓，随后用重组组织型纤溶酶原激活剂（rTPA）进行了分期导管定向溶栓和腔内支架置入术。经过该治疗后，注意到患者下肢水肿和肿胀逐渐但显著消退。
本病例表明在下肢创伤情况下MTS可能伴随的潜在危险。当广泛的左下肢DVT并发于肢体创伤患者的护理过程中时，临床医生应降低门槛，通过先进的影像学检查来诊断MTS。静脉造影仍是诊断的金标准，但CT和MRI静脉造影侵入性较小，应能实现准确诊断。在本病例中，正规的抗凝治疗被证明无效，需要进行血管内介入治疗。
