Between a rock and a hard place: clinical and imaging features of vascular compression syndromes

Abdominal vascular compression syndromes: A pictorial review

Abdominal vascular compression syndromes (AVCS) refer to the entrapment of blood vessels between surfaces in a restricted space, a phenomenon that may cause clinical manifestations and can be identified using imaging methods. Although uncommon, their hemodynamic repercussions may lead to potential morbidity and should therefore be recognized by radiologists, who play a crucial role in diagnosing these conditions. Contrast-enhanced computed tomography (CECT) is the imaging modality of choice, primarily valued for its precision in identifying anatomical abnormalities, thereby facilitating appropriate management and reducing the risk of subsequent complications. Follow-up may range from conservative to invasive approaches, including surgical and endovascular procedures. This pictorial review focuses on the main imaging patterns of AVCS. Our objective is to enhance radiologists' ability to discern abdominal vascular anatomy, its interrelations with neighboring structures and its variants, and assist in the analysis of potential etiologies and pathophysiological mechanisms associated with these anomalies.

Under pressure: a head-to-toe review of vascular compression syndromes

Vascular compression syndromes are a group of conditions resulting from mechanical compression of blood vessels by adjacent structures leading to compromised blood flow and various associated symptoms. They frequently affect young, otherwise healthy individuals and are often underdiagnosed due to their rarity and vague clinical manifestations. Achieving an accurate diagnosis depends on the integration of clinical presentation and imaging findings. Imaging modalities including color doppler ultrasound, computed tomography angiography, magnetic resonance angiography, and catheter-directed digital subtraction angiography are essential for diagnosis and management. Dynamic imaging is crucial in eliciting findings due to the positional nature of many of these syndromes. In this paper, we will present a "head-to-toe" overview of vascular compression syndromes including Vascular Eagle Syndrome, Vascular Thoracic Outlet Syndrome, Quadrilateral Space Syndrome, Hypothenar Hammer Syndrome, Median Arcuate Ligament Syndrome, Renal Artery Entrapment Syndrome, Left Renal Vein Compression/Nutcracker Syndrome, May-Thurner Syndrome, Adductor Canal Syndrome, and Popliteal Artery Entrapment Syndrome. Treatment is variable but typically involves a combination of conservative and surgical management. Surgical approaches focus on decompression of affected neurovascular structures. Endovascular treatment alone is rarely recommended. We aim to equip general radiologists with the knowledge needed to accurately diagnose patients with vascular compression syndromes, allowing for timely treatment.

A radio-anatomical study of median arcuate ligament syndrome: unveiling the morphology and morphometry of median arcuate ligament, celiac trunk, and superior mesenteric artery

PURPOSE

In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL).

METHODS

Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done.

RESULTS

Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties.

CONCLUSION

This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions.

Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study

PURPOSE

To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables.

METHODS

Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software.

RESULTS

Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values.

CONCLUSION

This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.

Exertional calf pain at kilometer five - Finding the cause

A 23-year-old professional distance runner with several years of exertional calf pain was diagnosed with a unique mixed type III and functional popliteal artery entrapment syndrome (PAES). Surgical reduction of the obstructing tissue allowed her to return to professional running. This case highlights the importance of including PAES in the differential for chronic intermittent lower extremity claudication and outlines the work-up required to diagnose this vascular obstruction in younger athletes.

Morphological Changes of the Ovarian Vein in Pelvic Venous Disorders

OBJECTIVE

The management of pelvic venous disorders (PeVD) remains controversial. Open surgical and endovascular methods are currently used for treatment, but there are few data in the literature on the morphology and histology of the ectatic ovarian vein (OV). This study aimed to explore the histomorphological changes in a dilated OV in patients with PeVD and compare it with a normal OV obtained post-mortem and a normal great saphenous vein (GSV).

METHODS

Histology of the OV was studied in 16 patients who underwent surgery for PeVD, 10 control cadavers from whom fragments of the OV without visible gross changes were taken at autopsy, and nine control patients in whom the GSV was resected to be used for coronary artery bypass.

RESULTS

The OV wall in patients with PeVD consisted of three layers: intima, media, and adventitia. The OV looked very similar to the GSV wall because of a clearly developed layer of smooth muscle fibres. The thickness of the normal OV was significantly different to the OV wall in PeVD (475.3 μm, IQR 370.7, 607.6 vs. 776.3 μm, IQR 668.9, 879.6, p < .001) and did not differ significantly from the thickness of a normal GSV wall (784.3 μm, IQR 722.2, 898.2). The intima-media complex of the OV was significantly thinner than the GSV in PeVD (118.9 μm, IQR 75.6, 159.6 vs. 415 μm, IQR 399.5, 520.0, р < .001); however, the adventitia of the OV was significantly thicker than in normal OV and GSV (599.6 μm, IQR 444.3, 749.7 vs. 373.5 μm, IQR 323.8, 482.0 vs. 308.4 μm, IQR 275.9, 338.2, p < .001).

CONCLUSION

Dilatation of the OV in patients with PeVD was accompanied by a significant increase in the overall thickness of the vein wall, which brings it closer in structure to the GSV. This implies that the OV may be used safely for transposition into the inferior vena cava or iliac vein.

Atypical case of coexistent vascular compression syndromes: median arcuate ligament syndrome and nutcracker syndrome

Vascular compression syndromes, including median arcuate ligament syndrome (MALS) and nutcracker syndrome (NCS), are poorly understood and frequently delayed diagnoses. This case describes a young adult female presenting with chronic vomiting, abdominal pain and weight loss, with dependence on nasogastric feeding. Subsequent to her gastrointestinal symptoms, she developed haematuria and orthostatic intolerance. Investigations confirmed NCS and possible MALS, with superadded gastroparesis and bradygastria. Under the joint care of general and vascular surgeons, she underwent a gastrojejunostomy and panelled renocaval bypass which led to partial resolution of her symptoms. It is hypothesised that gastroparesis may have been caused by MALS via a neurogenic mechanism, or coexistent compression of the duodenum by the superior mesenteric artery. This case highlights the difficulty in diagnosis of vascular compression syndromes, the overlap between the conditions and the potential for multiple coexistent conditions which complicate diagnosis and lead to increased lead-time and morbidity for patients.

Body and Extremity MR Venography: Technique, Clinical Applications, and Advances

Magnetic resonance venography (MRV) represents a distinct imaging approach that may be used to evaluate a wide spectrum of venous pathology. Despite duplex ultrasound and computed tomography venography representing the dominant imaging modalities in investigating suspected venous disease, MRV is increasingly used due to its lack of ionizing radiation, unique ability to be performed without administration of intravenous contrast, and recent technical improvements resulting in improved sensitivity, image quality, and faster acquisition times. In this review, the authors discuss commonly used body and extremity MRV techniques, different clinical applications, and future directions.

Black-blood Venous Imaging (BBVI): A Contrast-Free and High-Resolution Magnetic Resonance Approach for Diagnosing IVCS - a Proof of Concept Study

Background

Iliac vein compression syndrome (IVCS) diagnosis heavily relies on an imaging test. However, non-invasive and contrast-free imaging test for the diagnosis of IVCS remains a big challenge. To address this issue, this prospective study aimed to assess the image quality and diagnostic performance of a magnetic resonance imaging technique, black-blood venous imaging (BBVI), in detecting IVCS by comparing it with contrast-enhanced computed tomography venography (CTV) and using invasive digital subtraction angiography (DSA) as the reference.

Methods

We enrolled 105 patients, and all patients underwent BBVI, CTV, and DSA examinations. We compared the consistency of CTV and BBVI image quality and their consistency in diagnosing the rate of iliac vein stenosis in IVCS patients. Using the consensus DSA as a reference, the sensitivity, specificity, positive and negative predictive values, and accuracy of BBVI and CTV and their diagnostic agreement with DSA were calculated.

Results

BBVI demonstrated high sensitivity, specificity, and accuracy for the diagnosis of IVCS, without contrast agents. BBVI and CTV are quite in diagnosis IVCS. Quite SE (67.8% vs 68.3%), SP (94.8% vs 94.8%), PPV (98.0% vs 98.0%), NPV (46.2% vs 46.9%) and ACC (75.3% vs 75.7%) were obtained by BBVI in comparison with CTV.

Conclusion

BBVI has comparable diagnostic performance with CTV. It may be a viable alternative to CTV techniques in screening the IVCS without contrast agents and free of ionizing radiation.

Current Status and Prospect of Stent Placement for May-Thurner Syndrome

Stent implantation has been proven to be safe and has become the first-line intervention for May-Thurner syndrome (MTS), with satisfactory mid-term patency rates and clinical outcomes. Recent research has demonstrated that catheter-directed thrombolysis is the preferred strategy when MTS is combined with deep vein thrombosis after self-expanding stent placement. However, the stent used for the venous system was developed based on the experience obtained in the treatment of arterial disease. Consequently, relatively common corresponding complications may come along later, which include stent displacement, deformation, and obstruction. Different measures such as adopting a stent with a larger diameter, improving stent flexibility, and increasing stent strength have been employed in order to prevent these complications. The ideal venous stent is presently being evaluated and will be introduced in detail in this review.

Popliteal Artery Entrapment Syndrome: A Diagnostic and Treatment Enigma for Orthopaedic Surgeons

Popliteal artery entrapment syndrome (PAES) is an uncommon condition that causes recurrent posterior leg pain and foot paresthesia in running athletes. This condition occurs most commonly due to an accessory or abnormal implant of the medial head of the gastrocnemius muscle. It may mimic or coincide with other chronic conditions of the lower extremity including chronic exertional compartment syndrome but is most consistent with vascular claudication. Clinical features that distinguish PAES from other causes of leg pain include a sensation of coolness of the posterior leg during exercise and associated paresthesia of the plantar aspect of the foot. Physical examination often reveals decreased intensity of the posterior tibial or dorsalis pedis pulses with passive dorsiflexion or active plantarflexion of the ankle. Diagnostic tests that confirm the presence of PAES include lower extremity angiography during active resisted plantarflexion or maximal passive dorsiflexion, and magnetic resonance angiography done after exercise provocation. Nonsurgical treatment with physical therapy and stretching of the gastrocnemius complex should be done as the first line of treatment. When conservative treatments are ineffective, referral to a vascular specialist for surgical intervention with a muscular band excision or transection, vascular bypass, or arterial reconstruction is necessary.

Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.

Imaging features of vascular compression in abdomen: Fantasy, phenomenon, or true syndrome

Vascular structures in the abdomen can compress or be compressed by adjacent structures. Classic imaging findings of vascular compressions, including median arcuate ligament syndrome, superior mesenteric artery syndrome, nutcracker syndrome, portal biliopathy, May-Thurner syndrome, and ureteropelvic junction obstruction will be discussed here. It is important to correlate imaging findings and clinical data to identify asymptomatic vascular compression which requires no treatment, intermittent vascular compression with nonspecific or vague clinical manifestation, and the subset of patients with true syndromes who will benefit from treatment.

Imaging of retroperitoneal haemorrhage revealing median arcuate ligament syndrome

Coeliac artery compression stenosis caused by the median arcuate ligament can lead to aneurysm formation in the pancreatico-duodenal arteries that can eventually result in a spontaneous rupture leading to retroperitoneal haemorrhage. In this case series, we describe the cases of three patients, all presenting with sudden epigastric pain, diagnosed as spontaneous haematoma, complicating a median arcuate ligament syndrome.

From Nutcracker Phenomenon to Nutcracker Syndrome: A Pictorial Review

Left renal vein (LRV) entrapment, also known as nutcracker phenomenon if it is asymptomatic, is characterized by abnormality of outflow from the LRV into the inferior vena cava (IVC) due to extrinsic LRV compression, often accompanied by demonstrable lateral (hilar) dilatation and medial (mesoaortic) stenosis. Nutcracker syndrome, on the other hand, includes a well-defined set of symptoms, and the severity of these clinical manifestations is related to the severity of anatomic and hemodynamic findings. With the aim of providing practical guidance for nephrologists and radiologists, we performed a review of the literature through the PubMed database, and we commented on the definition, the main clinical features, and imaging pattern of this syndrome; we also researched the main therapeutic approaches validated in the literature. Finally, from the electronic database of our institute, we have selected some characteristic cases and we have commented on the imaging pattern of this disease.

C-arm-based flat-panel detector cone-beam computed tomography venography in the diagnosis of iliac vein compression syndrome

Background:

C-arm-based flat-panel detector cone-beam computed tomography (CBCT) venography has never been used in the management of iliac vein compression syndrome (IVCS). This study aimed to determine the technical feasibility and safety of CBCT venography in the diagnosis of IVCS compared with conventional venography (CV).

Methods:

Twenty patients with clinical manifestations of lower extremity venous insufficiency were prospectively enrolled between May 2018 and December 2018. Each patient underwent both CV and CBCT venography. The feasibility and safety of CBCT venography were assessed by technical success rate and complication rate. The relationships between the clinical indexes and the results of CBCT venography and CV were analyzed with correlation analysis. The consistency of the diagnosis of IVCS using each modality was analyzed by the kappa test.

Results:

The technical success rate was 100% for CBCT venography and for CV, without any complications. Compared with CV, CBCT venography was able to show more details of adjacent tissues which might be helpful for making etiological diagnosis. The stenosis rate under CBCT venography had excellent consistency with that under CV (kappa = 0.78, Chi-square test). The stenosis rate under CBCT venography was positively correlated with the presence of collateral veins (odds ratio 1.12, 95% confidence interval: [1.00, 1.26], P = 0.049), while the stenosis rate under CV was not. Unexpectedly, only one patient had a venous pressure gradient of more than 2 mmHg (1 mmHg = 0.133 kPa).

Conclusions:

For the diagnosis of IVCS, C-arm-based CBCT venography was technically feasible, with good safety. The presence of collateral veins on CBCT was clinically significant. A C-arm fluoroscopy-based technique that combines CV and CBCT might be a promising protocol for the management of IVCS during a single session.

Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS) is often an underdiagnosed cause of chronic pelvic pain in female patients with radiology detection of gonadal vein dilatation and parauterine varices. It may occur either alone or in combination with vulvar varicosities and/or lower extremity venous insufficiency. Although transcatheter venography represent the gold standard for PCS diagnosis, it is performed after inconclusive noninvasive imaging such as Doppler Ultrasound, CT scan, and MRI. Once diagnosis has been confirmed, management of PCS include medical, surgical, and endovascular therapy. Medical and surgical treatments have been shown to be less effective than transcatheter pelvic vein embolization. This latter has been proven to be a safe, effective, and durable therapy for the treatment of PCS. Numerous studies have shown their results in PCS endovascular treatment, but neither of them has been subjected to an adequate randomized controlled trial. A well-designed randomized controlled trial is urgently needed to assess transcatheter embolization clinical success.

Magnetic Resonance Imaging Evaluation of Left Common Iliac Vein Compression in Patients With and Without Symptoms of Venous Disease

BACKGROUND

The goal of this study was to assess the degree of the left common iliac vein (LCIV) compression by the right common iliac artery (RCIA) on magnetic resonance imaging (MRI), and verify differences in compression measurements in end-inspiration, end-expiration, supine, and prone decubitus between patients with and without symptoms in the lower limbs.

METHODS AND RESULTS

A total of 82 consecutive participants provided informed consent and underwent pelvic MRI for different clinical indications other than vascular-related disorders. The participants answered a questionnaire about venous disease in the lower limbs and history of previous deep vein thrombosis. This study measured the area and diameter of the LCIV at the site of the crossing with the RCIA and in the uncompressed caudal LCIV segment. Statistical analysis was performed to compare the degree of LCIV compression by the RCIA and verify differences in compression measurements. A total of 71 participants were included; 46.6% were in group A and did not experience signs and symptoms in lower limbs and 53.6% were in group B and answered at least one question with a positive answer. It was observed that there was a statistically significant difference between groups for end-expiration. No statistically significant differences were observed for all other measurements.

CONCLUSIONS

A substantial percentage of the asymptomatic and symptomatic population showed compression of the LCIV, suggesting there are no clear relationships between stenosis and non-specific symptomatology in the general population.

CT imaging findings of abdominopelvic vascular compression syndromes: what the radiologist needs to know

Abdominopelvic vascular compression syndromes include a variety of uncommon conditions characterized by either extrinsic compression of blood vessels by adjacent anatomical structures (i.e., median arcuate ligament syndrome, nutcracker syndrome, May-Thurner syndrome) or compression of hollow viscera by adjacent vessels (i.e., superior mesenteric artery syndrome, ureteropelvic junction obstruction, ureteral vascular compression syndromes, portal biliopathy). These syndromes can be unexpectedly diagnosed even in asymptomatic patients and the predisposing anatomic conditions can be incidentally discovered on imaging examinations performed for other indications, or they can manifest with atypical abdominal symptoms and acute complications, which may lead to significant morbidity if unrecognized. Although computed tomography (CT) is an accurate noninvasive technique for their detection, the diagnosis remains challenging due to the uncommon clinical presentation and often overlooked imaging features. Dynamic imaging may be performed in order to evaluate patients with inconstant symptoms manifesting in a specific position. The purposes of this paper are to review the CT imaging findings of abdominopelvic vascular compression syndromes, correlating with anatomical variants and to provide key features for the noninvasive imaging diagnosis.

Síndrome do aprisionamento da artéria tibial anterior bilateral pelo retináculo extensor do tornozelo: relato de caso

Vascular entrapment is rare. In the lower limbs it is generally asymptomatic, but may cause atypical intermittent claudication in young people without risk factors for atherosclerosis and inflammatory diseases. The most common type of compression involves the popliteal artery, causing symptoms in the region of the infra-patellar muscles. When discomfort is more distal, other entrapment points should be considered, such as the anterior tibial artery. This article reports the case of a patient with intermittent claudication in both feet due to extrinsic compression of the anterior tibial artery bilaterally by the extensor retinaculum of the ankle, diagnosed by vascular ultrasonography and angiotomography during plantar flexion maneuvers. The patient was treated surgically, resulting in improvement of clinical symptoms.

Vertebroplasty-associated cement leak leading to iatrogenic venous compression and thrombosis

A 91-year-old woman presented with left lower extremity swelling and pain diagnosed as phlegmasia cerulea dolens. Doppler ultrasound and venography revealed extensive left lower extremity deep venous thrombosis. Review of prior images revealed cement leakage causing compression of the left common iliac vein. She underwent successful mechanical thrombectomy using the ClotTriever device (Inari Medical, Irvine, Calif) and subsequent stent placement. Phlegmasia cerulea dolens resolved on the following day, and the stent remained patent at the 1-month follow-up appointment. Cement leakage from L5 vertebroplasty can cause extrinsic compression on the left common iliac vein, resulting in iatrogenic venous compression syndrome and the development of deep venous thrombosis in the affected lower extremity.

Vascular magnetic resonance angiography techniques

Magnetic resonance angiography (MRA) denotes a unique option for the evaluation of peripheral vasculature due to its noninvasive nature, lack of ionizing radiation exposure, potential for non-contrast examination, and ability for generating volumetric representations that showcase vascular pathology. The constant evolution of the available MRA techniques, however, makes understanding and determining an optimal imaging protocol difficult. Here we present a brief overview of the major MRA sequence options, their major weaknesses and strengths, and related imaging considerations. Understanding the technical underpinnings of the various MRA methods helps with recognition of common imaging issues and artifacts and rendering clinically relevant interpretations.

It's Not All Deep Vein Thrombosis: Sonography of the Painful Lower Extremity With Multimodality Correlation

The purpose of this pictorial essay is to review different etiologies for lower extremity pain encountered on lower extremity venous sonography including acute deep venous thrombosis, chronic postthrombotic change, central venous disease, common arterial pathologies, and nonvascular abnormalities.

Case series of seven women with uterine fibroids associated with venous thromboembolism and chronic thromboembolic disease

Uterine fibroids have been described as an associate to acute venous thromboembolism (VTE), with case reports showing an association between large uterine fibroids, acute deep venous thrombosis (DVT), and acute pulmonary embolism (PE). However, there is little known about the association or causation between uterine fibroids, chronic thromboembolic disease (CTED), and chronic thromboembolic pulmonary hypertension (CTEPH). We report on six women with uterine fibroids and CTEPH, as well as one woman with CTED, all of whom presented with exertional dyspnea, lower extremity swelling, and in the cases of CTEPH, clinical, echocardiographic, and hemodynamic evidence of pulmonary hypertension and right heart failure. Compression of the pelvic veins by fibroids was directly observed with invasive venography or contrast-enhanced computed tomography in five cases. All seven women underwent pulmonary thromboendarterectomy (PTE) followed by marked improvement in functional, clinical, and hemodynamic status.

An Unusual Case of Inferior Vena Cava Thrombosis in a Healthy Male Bodybuilder

Inferior vena cava (IVC) thrombosis is very rare, particularly in the absence of an apparent congenital caval abnormality or hypercoagulable state. We herein report an unusual case of a healthy and active 62-year-old male bodybuilder with a mass-like IVC thrombus. We placed an IVC filter and began treatment with rivaroxaban. The patient recovered successfully, and the IVC thrombus completely disappeared three months later. This case suggested that extrinsic compression of IVC by a tightened weightlifting belt around the abdomen is a triggering factor of IVC thrombosis, and rivaroxaban, a new oral anticoagulant, may be a useful option for treatment.

Double venous compression due to duplicated inferior vena cava-induced right common iliac vein thrombosis

Venous compression syndromes are caused by extrinsic venous compression of anatomical structures, such as the adjacent arteries and bones. Chronic venous compression and pulsative vibratory arterial pressure accelerate the development of deep vein thrombosis. Herein, we report the first case of double venous compressions due to a duplicated inferior vena cava-induced right-sided common iliac vein thrombosis. The thrombus was induced by left-sided inferior vena cava entrapment and right-sided common iliac vein compression, resembling nutcracker syndrome and May-Thurner syndrome, respectively. Bypass flow of the right inferior vena cava rendered the right lower extremity asymptomatic. Once daily anticoagulation edoxaban was effective. Congenital venous anomalies and bypass formations should be considered when a common iliac vein thrombus without symptoms in the lower extremities is observed, and a lifelong periodical follow-up is mandatory, even after remission.

Venous Compression Syndromes

Venous compression syndromes occur due to extrinsic compression causing complications of venous hypertension or venous thrombosis. This review focuses on 4 venous compression syndromes involving the left common iliac vein, subclavian vein, left renal vein, and popliteal vein. Clinical presentation, diagnostic methods, and management options are reviewed. When properly diagnosed and treated, long-term consequences can be avoided.

Venous Compression Syndromes: a Review

OPINION STATEMENT

Venous compression syndromes present a diagnostic and therapeutic challenge as the clinical presentation can be vague, diagnostic criteria are often not present, and high quality standardization of when and how to treat is not available in part due to the limited number of cases reported and also due to the limited literature available. Significant venous compression should be considered when clinical symptoms correlate to location of compression and there is evidence of hemodynamic changes including venous hypertension, collateral/variceal formation, and/or thrombus formation. In general, treatment of venous compression should address the etiology of the compression as opposed to just treating symptoms associated with it such as significant varices or anticoagulation for thrombus to avoid recurrence of symptoms.

Intravascular ultrasound versus digital subtraction angiography: direct comparison of intraluminal diameter measurements in pediatric and adolescent imaging

BACKGROUND

Intravascular ultrasound (IVUS) allows intraluminal imaging of blood vessels rather than the one-dimensional luminal outline depicted by digital subtraction angiography (DSA). Despite extensive literature in multiple adult vascular diseases, IVUS has not been directly compared to DSA in pediatric and adolescent vascular pathologies.

OBJECTIVE

The purpose of this manuscript is to compare absolute luminal diameter measurements obtained via IVUS and DSA during a variety of pediatric endovascular procedures.

MATERIALS AND METHODS

We conducted a retrospective review of all pediatric and adolescent endovascular procedures from October 2014 to March 2016 in which IVUS and DSA were used. We compared the vessel diameter measurements and analyzed them using SAS software with a paired t-test.

RESULTS

There were 102 total measurements (DSA = 56; IVUS = 56; 22 procedures; 20 patients). On average, IVUS measured 0.6 ± 2.1 mm larger than DSA (95% confidence interval [CI] -0.01 to 1.12; P = 0.06; r = 0.90). When venous compression syndrome (May-Thurner, Nutcracker, superior vena cava syndrome) measurements were excluded, IVUS measured 0.7 ± 1.6 mm larger than DSA (95% CI 0.14 to 1.18; P = 0.01; r = 0.93). When venous compression syndrome measurements were evaluated separately, IVUS measured 0.3 ± 3.0 mm larger than DSA (95% CI -1.16 to 1.82; P = 0.65; r = 0.45).

CONCLUSION

Overall, IVUS measurements were slightly larger than DSA measurements in all data subsets. Absolute vessel diameter measurements obtained with IVUS in the pediatric and adolescent population are statistically significantly larger than those obtained using DSA when excluding venous compression syndromes. In venous compression syndromes, IVUS might provide a more accurate representation of vessel compression and diameter than DSA.

Minimally invasive treatments for venous compression syndromes

The management of venous compression syndromes has historically been reliant on surgical treatment when conservative measures fail. There are, however, several settings in which endovascular therapy can play a significant role as an adjunct or even a replacement to more invasive surgical methods. We explore the role of minimally invasive treatment options for three of the most well-studied venous compression syndromes. The clinical aspects and pathophysiology of Paget-Schroetter syndrome (PSS), nutcracker syndrome, and May-Thurner syndrome are discussed in detail, with particular emphasis on the role that interventionalists can play in minimally invasive treatment.

Imaging of venous compression syndromes

Venous compression syndromes are a unique group of disorders characterized by anatomical extrinsic venous compression, typically in young and otherwise healthy individuals. While uncommon, they may cause serious complications including pain, swelling, deep venous thrombosis (DVT), pulmonary embolism, and post-thrombotic syndrome. The major disease entities are May-Thurner syndrome (MTS), variant iliac vein compression syndrome (IVCS), venous thoracic outlet syndrome (VTOS)/Paget-Schroetter syndrome, nutcracker syndrome (NCS), and popliteal venous compression (PVC). In this article, we review the key clinical features, multimodality imaging findings, and treatment options of these disorders. Emphasis is placed on the growing role of noninvasive imaging options such as magnetic resonance venography (MRV) in facilitating early and accurate diagnosis and tailored intervention.

Left renal vein compression as cause for varicocele: prevalence and associated findings on contrast-enhanced CT

PURPOSE

The purpose of this study is to determine the prevalence of left renal vein compression in patients with varicoceles.

METHODS

Abdominal and pelvis contrast-enhanced CT images from 100 male patients with varicoceles (mean age 50.6 years) and 100 matched control patients (mean age 49.8 years) were retrospectively reviewed. The diameter of the left renal vein was measured as it crosses between the aorta and superior mesenteric artery and was classified as compressed if there was greater than 50% narrowing. The diameter of the left gonadal vein was measured at the origin. Comparison of the prevalence of left renal vein compression was made via a Chi-squared test and the gonadal vein diameter via a t test.

RESULTS

The distribution of varicoceles was 68 on the left, 24 bilateral, and 8 on the right. Compression of the left renal vein was significantly more common in the left varicocele (78%, 53/68) than in the bilateral varicocele (42%, 10/24, p = 0.002), right varicocele (13%, 1/8, p < 0.001), or control group (10%, 10/100, p < 0.001). In the subgroup analysis, the gonadal vein diameter was significantly greater in the left varicocele (mean 5.6 mm) than in the bilateral varicocele (mean 4.6 mm, p = 0.018), right varicocele (mean 3.2 mm, p < 0.001), and control group (mean 3.1 mm, p < 0.001).

CONCLUSION

Left renal vein compression by the superior mesenteric artery is a major contributor to left-sided varicoceles.

Nonhealing Venous Ulcers and Chronic Venous Outflow Obstruction A Case Report

The etiology of chronic venous insufficiency is typically neglected or misunderstood when treating lower-extremity edema and venous ulcerations. Despite the high prevalence of venous compression syndromes, it is rarely considered when treating venous ulcers and unresolved venous disease. We report a case of bilateral iliac vein outflow obstruction that prohibited venous ulcer healing until properly treated. This case highlights the importance of properly identifying and treating venous compression syndromes to enhance ulcer healing and decrease the risk of venous ulcer recurrence.

Paget-Schroetter syndrome: A review and Algorithm (WASPS-IR)

Venous compression syndromes are rare and occur due to the entrapment of vein(s) in confined anatomical spaces bounded by osseous and non-osseous structures. Here we present a review of Paget-Schroetter Syndrome, an important cause of upper extremity of deep vein thrombosis, its associated clinical and radiological findings as well as treatment options.

Imaging findings and clinical features of abdominal vascular compression syndromes

OBJECTIVE

This article describes the typical imaging findings and clinical features that are associated with four abdominal vascular compression syndromes. We explain the underlying pathophysiology that results in these clinical syndromes so that the patient subset who will benefit from treatment can be identified.

CONCLUSION

The abdominal vascular compression syndromes discussed here are uncommon and are potentially easily missed on a cursory review of radiologic examinations, particularly in a nonspecific and vague clinical setting. Hence, knowledge of the typical imaging findings and associated clinical symptoms is essential so that the they can be carefully sought and excluded. However, because these findings may also exist in healthy individuals as anatomic variants, it is important to correlate radiologic findings with clinical symptoms to identify the subset of patients who will benefit from treatment.

Venous compression syndromes: clinical features, imaging findings and management

Extrinsic venous compression is caused by compression of the veins in tight anatomic spaces by adjacent structures, and is seen in a number of locations. Venous compression syndromes, including Paget-Schroetter syndrome, Nutcracker syndrome, May-Thurner syndrome and popliteal venous compression will be discussed. These syndromes are usually seen in young, otherwise healthy individuals, and can lead to significant overall morbidity. Aside from clinical findings and physical examination, diagnosis can be made with ultrasound, CT, or MR conventional venography. Symptoms and haemodynamic significance of the compression determine the ideal treatment method.