Goetz Ryan L, Yoo James Jae-Hyung, Hsu Joyce, Vakiti Anusha, Hardy David M, Tariq Khurram
Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA.
Department of Medicine at Augusta University, 1120 15th Street, Augusta, GA 30912, USA.
J Hematol. 2018 Sep;7(3):112-115. doi: 10.14740/jh381w. Epub 2018 Sep 1.
May-Thurner syndrome (MTS) is a rarely diagnosed vascular abnormality that typically presents in young adults. The anomaly arises from compression of the left common iliac vein between the right iliac artery anteriorly and the lumbar vertebral body posteriorly, resulting in lower extremity venous outflow obstruction and recurrent deep vein thromboses (DVTs). We report the case of a 24-year-old female with a long history of recurrent DVTs and pulmonary emboli (PE) despite full anticoagulation. A computed tomography (CT) scan revealed findings consistent with MTS, and a left common iliac vein stent was placed. However, the patient continued to have DVTs while trialing several anticoagulation therapies, including rivaroxaban, enoxaparin, and warfarin. Eventually, the patient developed arterial thrombi resulting in critical limb ischemia, necessitating a right below knee amputation (BKA). One month status-post BKA, the patient was admitted for severe BKA stump pain secondary to infection and necrosis. She underwent BKA revision, but continued to experience pain post-operatively and was found to have new right common iliac artery, external iliac artery, and common femoral artery thrombosis in the setting of continued inpatient anticoagulation therapy with enoxaparin and aspirin. The patient returned to the operating room for emergent Fogarty thrombectomy, however, this was complicated by rupture of the balloon catheter secondary to migration of the left common iliac vein stent into the right common iliac artery lumen. A stent was placed in the right common iliac artery to shift the rogue vein stent, but the patient continued to have poor distal circulation of the BKA stump and eventually underwent an above knee amputation. Dual anti-platelet therapy (DAPT) with aspirin and clopidogrel in combination with enoxaparin were used to prevent in-stent thrombosis and future formation of arterial and venous thrombi. After the initiation of DAPT and enoxaparin, her clinical course was free of any further thromboembolic events. Clinicians should consider MTS in the differential diagnosis of younger adults presenting with recurrent DVTs or other unprovoked thromboembolic events. A two-pronged strategy of DAPT and anticoagulation was employed for successful prevention of thrombotic events.
梅-图二氏综合征（MTS）是一种罕见的血管异常疾病，通常在年轻人中出现。这种异常是由于左髂总静脉受到前方右髂动脉和后方腰椎椎体的压迫，导致下肢静脉流出道梗阻和复发性深静脉血栓形成（DVT）。我们报告了一例24岁女性病例，尽管进行了充分的抗凝治疗，但她仍有复发性DVT和肺栓塞（PE）的长期病史。计算机断层扫描（CT）显示结果与MTS相符，并置入了左髂总静脉支架。然而，在试用包括利伐沙班、依诺肝素和华法林在内的多种抗凝治疗时，患者仍继续发生DVT。最终，患者出现动脉血栓形成，导致严重肢体缺血，需要进行右膝下截肢（BKA）。BKA术后一个月，患者因感染和坏死导致严重的BKA残端疼痛入院。她接受了BKA翻修手术，但术后仍持续疼痛，并且在继续接受依诺肝素和阿司匹林住院抗凝治疗的情况下，发现右髂总动脉、股外动脉和股总动脉出现新的血栓形成。患者返回手术室进行紧急Fogarty血栓切除术，但由于左髂总静脉支架迁移至右髂总动脉管腔导致球囊导管破裂，手术出现并发症。在右髂总动脉置入一个支架以移位错位的静脉支架，但患者BKA残端的远端循环仍然不佳，最终接受了膝上截肢。使用阿司匹林和氯吡格雷联合依诺肝素的双联抗血小板治疗（DAPT）来预防支架内血栓形成以及未来动脉和静脉血栓的形成。在开始DAPT和依诺肝素治疗后，她的临床病程未再出现任何进一步的血栓栓塞事件。临床医生在对出现复发性DVT或其他不明原因血栓栓塞事件的年轻成年人进行鉴别诊断时应考虑MTS。采用DAPT和抗凝的双管齐下策略成功预防了血栓形成事件。
