May-Thurner syndrome

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Has anyone come across this?

I am a student doing my peds rotation and cared for a teenage girl who was diagnosed with this syndrome. She was post-op from having angioplasty on both the R & L common iliac veins. She had a history of injury to her left foot and lost some sensation and it was always cold to the touch. Eventually the diagnosis was made and then the surgery was performed.

If you read the description of the syndrome, only the L vein should have been affected... So why did they do the angioplasty on both? The syndrome was new to the nurses on the floor and my instructor so no one had an answer.

"In medicine, May-Thurner syndrome is a rare condition in which blood clots, called deep venous thrombosis (DVT), occur in the iliofemoral vein due to compression of the common venous outflow tract of the left lower extremity. The specific problem is compression of the left common iliac vein by the overlying right common iliac artery.[1][2] This leads to pooling or stasis of blood, predisposing the individual to the formation of blood clots. Classically, May-Thurner syndrome can only occur in the left leg, since the artery does not acutely overlap the vein in the right leg. A broader disease profile known as nonthrombotic iliac vein lesions (NIVL) can involve both the right and left iliac veins as well as multiple other named venous segments."

http://en.wikipedia.org/wiki/May-Thurner_syndrome

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She had NIVL?

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Specializes in PICU, Sedation/Radiology, PACU.

They probably made the diagnosis of May-Thurner syndrome because it could be confirmed by the presence of a clot in the left iliofemoral vein. However, on the chance that she actually has NIVL and the right vein hasn't shown symptoms yet, they did both legs as a precaution.

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She had NIVL?

well that was my inclination but there was no mention of NIVL on her chart, the diagnosis was clearly May-Thurner Syndrome. You think the doctor made the wrong diagnosis?

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They probably made the diagnosis of May-Thurner syndrome because it could be confirmed by the presence of a clot in the left iliofemoral vein. However, on the chance that she actually has NIVL and the right vein hasn't shown symptoms yet, they did both legs as a precaution.

Ah okay. I guess that makes sense. Is that something that happens often... doing the other side as a precaution?

Just curious how painful do you think the recovery from this angioplasty would be? I had a lot of trouble assessing her pain.

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well that was my inclination but there was no mention of NIVL on her chart, the diagnosis was clearly May-Thurner Syndrome. You think the doctor made the wrong diagnosis?

I think the doc made the best possible diagnosis with the information she had and, as Ashley said, did the right prophylactically.

You wll discover that diagnoses are ephemeral things, often making experienced people say, "Huh?" It's especially prevalent with sick old people. There's no cause anyone can find for the fever so it's always sepsis.

:)

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Specializes in PICU, Sedation/Radiology, PACU.
Ah okay. I guess that makes sense. Is that something that happens often... doing the other side as a precaution?

Just curious how painful do you think the recovery from this angioplasty would be? I had a lot of trouble assessing her pain.

It would depend on the diagnosis. I've never seen anyone with May-Thurner, so I don't have any similar experiences. I do know that in some cancers it's done- such as a bilateral mastectomy when cancer is found in one breast. I'm sure there are other examples.

How were you assessing her pain? Was she awake and talking? Did you use a pain scale that she understood? Were you asking her the location, intensity, and quality? She's 17, so probably can give you an accurate statement about her pain level.

Pain is perceived differently in everyone, and one patient's pain from a procedure will not be the same as another patient who has the same procedure. If she isn't talking and rating her pain, you can assess for other things such as increase in BP, respirations or heart rate, grimacing, being tense, moaning, eyes closed tightly, and guarding of the incision area. If the patient is unable to rate their own pain, then they should be receiving some medication around the clock, whether it be morphine or toradol or another medication.

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Specializes in maternal child, public/community health.

My step-mom (age 73)was diagnosed with May-Thurner syndrome when she developed DVT on the left side from her foot into the pelvis. She did not notice any symptoms until she woke up and found her left leg very swollen.

Due to the extent of the DVT, thrombolysis was recommended to decrease the risk of chronic edema. It was a few years back so I do not remember all the details but I think the thrombolysis (which was done over 3 days) involved a catheter placed in the vein (I think it was left in place??) through which a thrombolytic was administered. I think the catheter had holes down its length like a soaker hose. This was done in some sort of procedure area - maybe a cath lab?? Like I said, I do not remember details. She had to be in intensive care during this period due to risk of hemmorhage. She was discharged a couple days after the thrombolysis was completed.

She was put on coumadin for 6 months. Then she had a stent placed where the artery crosses the vein in order to prevent reoccurence. She stayed on the coumadin for a short time to allow the vein to heal but then was able to discontinue it. She has not had any problems since then.

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It would depend on the diagnosis. I've never seen anyone with May-Thurner, so I don't have any similar experiences. I do know that in some cancers it's done- such as a bilateral mastectomy when cancer is found in one breast. I'm sure there are other examples.

How were you assessing her pain? Was she awake and talking? Did you use a pain scale that she understood? Were you asking her the location, intensity, and quality? She's 17, so probably can give you an accurate statement about her pain level.

Pain is perceived differently in everyone, and one patient's pain from a procedure will not be the same as another patient who has the same procedure. If she isn't talking and rating her pain, you can assess for other things such as increase in BP, respirations or heart rate, grimacing, being tense, moaning, eyes closed tightly, and guarding of the incision area. If the patient is unable to rate their own pain, then they should be receiving some medication around the clock, whether it be morphine or toradol or another medication.

She was awake and talking and she understood the numeric pain scale... She just wouldn't give up a number. She was either visibly in pain, grimacing or she was all dopey from morphine or hydrocodone. But her heart rate never fluctuated much. It was always like "I dunno, it hurts" or "I dunno I feel okay". I was just curious because the surgical wounds were small and I just have no idea what getting your veins basically stretched open would feel like, how sore that would make you.

She was constantly on her phone, texting or facebooking or whatever. Someone should make the "text smiley" scale for the young people, similar to the Wong-Baker scale for kids. Except use common emoticons... So I could say, if I sent you a text message asking how your pain is, and you were going to reply with only a emoticon... which one would you use? Better yet, just text your pain emoticon directly to the nurse's station... or would that get annoying? :p It'd go something like this:

0 - :D

1-2 - :)

3-4 - : |

5-6 - : /

7-8 - :(

9-10 - :'(

I'd appreciate that since I'm not a big fan of the numeric pain scale... After I had a c-section I had trouble giving a number as well, but the PCTs *must* get one so they just keep asking. It's annoying for both parties. When you're in pain, it's difficult and not pleasant to try to imagine "The worst pain ever" (like being burned alive or something), so you can use that as a reference point.

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Specializes in Pediatrics.

I learned about a new syndrome from this thread, which is always good. But I mostly wanted to reply to say that I LOVE your "emoticon/text messaging" pain scale (even if it was posted mostly as a joke) and think it would work really well with a lot of people- kids and adults!!

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When you're in pain, it's difficult and not pleasant to try to imagine "The worst pain ever" (like being burned alive or something), so you can use that as a reference point.

http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html

This'll make you laugh.

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Specializes in private duty/home health, med/surg.

I love your pain scale! I can see it being very useful for teens & young adults.

I found this free article from a search on pubmed that might explain why she would have had surgery on both sides...

http://radiology.rsna.org/content/233/2/361.long

Multiple surgical treatment options have been advocated. These include vein-patch angioplasty with excision of intraluminal bands, division of the right common iliac artery and relocation behind the left common iliac vein or inferior vena cava, and contralateral saphenous vein graft bypass to the ipsilateral common femoral vein with creation of a temporary arteriovenous fistula (Palma crossover) (5,7).
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