May-Thurner syndrome: High output cardiac failure as a result of iatrogenic iliac fistula

Abstract

May-Thurner syndrome (MTS) also termed iliocaval compression or Cockett-Thomas syndrome is a common, although rarely diagnosed, condition in which the patient has an anatomical variant wherein the right common iliac artery overlies and compresses the left common iliac vein against the fifth lumbar spine resulting in increased risk of iliofemoral deep venous thrombosis. This variant has been shown to be present in over 23% of the population but most go undetected. We present a patient with MTS who developed high output cardiac failure due to an iatrogenic iliac fistula. The patient underwent an extensive workup for a left to right shunt including MRI and arterial duplex in the vascular lab. He was ultimately found to have a 2.1 cm left common iliac artery aneurysm and history of common iliac stent. We took the patient to the operating room for aortogram with placement of an endovascular plug of the left internal iliac artery and aorto-bi-iliac stent graft placement with CO₂ and IV contrast. Subsequently the patient underwent successful stent placement in the area that was compressed followed by 6 mo of anticoagulation with warfarin. The flow from the fistula decreased significantly.

Keywords: May-Thurner syndrome, Cardiac failure, Echocardiogram, Cockett-Thomas syndrome, Iliocaval compression

Core tip: To our knowledge, we describe the first case of high output cardiac failure due to iatrogenic iliac fistula and its management in the setting of May-Thurner syndrome (MTS). In our case, an iatrogenic iliac fistula resulted because of prior stent placement in left iliac vein to prevent deep venous thrombosis (DVT) secondary to MTS. We favored aorto-bi-iliac stent graft placement to prevent the fistula from leaking. In our case, the prior vascular stent placement was a clue to search for the fistula. It is important to note that stent placement to prevent DVT in MTS may result in iatrogenic fistula formation.