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Diagnósticos da América
São Paulo – Brazil
A NOVEL APPROACH TO USING
MAGNETIC RESONACE
ANGIOGRAPHY IN THE STUDY
OF MAY THURNER SYNDROME:
A PICTORIAL ESSAY
NAKANO, E.M.; SHIGUEOKA, D.C.; SANTOS, J.E.M.; SALES, D.M.;
PINETTI, R.Z.; HERNANDEZ, S.F.; SOUZA, S.A.; LEME, L.M.;
UEMURA, L..
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
INTRODUCTION
Left iliac vein compression syndrome, also known as
May-Thurner syndrome or Cockett's syndrome, is a
result of extrinsic compression of the left common iliac
vein between the fifth vertebra and the right common
iliac artery. This compression leads to intimal fibrosis
and local obstruction of the vein. This syndrome causes
isolated left lower limb edema that was first reported by
McMurrich in 1908. In 1957 May and Thurner pointed
out the anatomy of this condition and in 1965 Cockett
and Thomas reported its clinical presentation.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
INTRODUCTION
Due to technical advances, Computed Tomography
Angiography
(CTA)
and
Magnetic
Resonance
Angiography (MRA) have come to replace Venography
in the study of this disease. Here we describe the use
of the new MRA sequence known as “time-resolved
imaging
of
contrast
kinetics”
(TRICKSTM)
in
combination with intravenous injection of gadolinium in
both lower limbs.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
PURPOSE
To show the MRA protocol employed in the study of
May-Thurner syndrome by the authors, in which
TRICKS sequence is used in combination with
intravenous injection of gadolinium in both lower limbs
in order to ensure better detection of the left common
iliac vein compression.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
DISCUSSION
Compression of the left common iliac vein by the right
common iliac artery leads to marked hemodynamic
modifications in the left lower limb. The principal
clinical manifestation is venous hypertension, which is
frequently accompanied by deep vein thrombosis.
Endovascular therapy with stent placement is a
minimally aggressive treatment that has yielded
favorable results. Early detection allows positive
treatment responses and better prognoses in severe
cases.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
DISCUSSION
The diagnosis has classically been made by ascending
venography using a femoral approach, allowing the
pressure gradient to be determined. The less invasive
techniques Doppler ultrasound, CTA and MRA also
reveal vascular injury with good diagnostic accuracy.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
DISCUSSION
The standard upper limb approach leads to poor or
less effective iliac vein visualization (Fig. 1 and 2).
Although our results are preliminary, the novel
combination of TRICKSTM and intravenous injection of
gadolinium in both lower limbs was found to provide
better coverage of the iliac vein compression (Fig. 3, 4,
5, and 6).
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
▪ Figure 1. TRICKSTM Sequence – Dynamic study of an exam done to rule out left common iliac vein
compression. It showed no signs of May-Thurner syndrome. The injection was performed in the left
upper limb making the paramagnetic IV contrast less visible during the venous phase.
INTRODUCTION
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DISCUSSION
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▪ Figure 2. TRICKSTM Sequence – Stationary pictures of the same patient above. The dotted red arrows
points out the vascular crossover during the best venous phase in upper limb IV injection.
INTRODUCTION
PURPOSE
DISCUSSION
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▪ Figure 3. TRICKSTM Sequence – The dynamic study of this exam showed a compression of the left
common iliac vein of a symptomatic patient diagnosed with May-Thurner Syndrome. Note the left
common iliac deep vein thrombosis with partial vein rechanneling and collateral pudendal vein
circulation. The injection was performed in both lower limbs, at the same time, making the
paramagnetic IV contrast more visible at the venous phase.
INTRODUCTION
PURPOSE
DISCUSSION
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▪ Figure 4. TRICKSTM Sequence – Stationary pictures of the same case above. The red arrows shows the
vascular vein compression at the best venous phase during both lower limb IV injection.
INTRODUCTION
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DISCUSSION
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▪ Figure 5. TRICKSTM Sequence – The dynamic study of this exam showed partial compression of the
left common iliac vein of a symptomatic patient diagnosed with May-Thurner Syndrome. Note the left
common iliac vein partial duplication. The injection was performed in both lower limbs, at the same
time, making the paramagnetic IV contrast more visible at the venous phase.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
▪ Figure 6. TRICKSTM Sequence – Same case above: The full red arrow points out the vascular vein
compression at the best venous phase during both lower limb IV injection. The dotted red arrow
shows the vein duplication.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
DISCUSSION
Our protocol also uses T1WI 3D Ultrafast Spoiled GRE
and Coherent
These
SSFP Sequences (Figures 7 and 8).
sequences
aid
to
display
the
venous
compression. The angiographic sequence used in this
protocol
is
“time-resolved imaging of
contrast
kinetics” (TRICKSTM), which prioritizes temporal
resolution, and intravenous injection of gadolinium in
both limbs. The Chart 1 shows the paramaters of our
protocol.
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
▪ Figure 7. T1WI 3D Ultrafast Spoiled GRE Sequence – Axial View – The red arrow points out the left
common iliac vein compression.
INTRODUCTION
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DISCUSSION
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▪ Figure 8. Coherent Steady-State Free Precession (SSFP) Sequence – Oblique View – The red arrow
shows the left common iliac vein compression by the right iliac common artery in this symptomatic
patient.
INTRODUCTION
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DISCUSSION
Chart 1 – MRI Sequence Parameters
Sequence
TR/TE
Flip Angle
Coherent SSFP
T1WI 3D Ultrafast
Spoiled GRE
TRICKSTM
4.3 / 2.2 ms
7.0 / 4.2 ms
3.2 / 1.2 ms
80o
12o
30o
Coil
Body / Phase array
FOV
400 mm
Anatomic
Coverage
Superior renal edge to inferior portion of symphisis
pubis
Slice Thickness /
Gap
6 mm / 0.6 mm
Volume
Volume
INTRODUCTION
PURPOSE
DISCUSSION
REFERENCES
REFERENCES
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Magnetic resonance venography in the diagnosis and
management of May-Thurner syndrome. Vasc Endovascular
Surg 2002;36(1):51-7.
2. Ludwig B, Han T, Amundson D. Postthrombotic syndrome
complicating a case of May-Thurner syndrome despite
endovascular therapy: case report and review. Chest
2006;129(5):1382-6.
3. Oğuzkurt L, Ozkan U, Tercan F, Koç Z. Ultrasonographic
diagnosis of iliac vein compression (May-Thurner) syndrome.
Diagn Interv Radiol 2007;13(3):152-5.
4. Kwak HS, Han YM, Lee YS, Jin GY, Chung GH. Stents in common
iliac vein obstruction with acute ipsilateral deep venous
thrombosis: early and late results. J Vasc Interv Radiol
2005;16(6):815-22.
INTRODUCTION
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DISCUSSION
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REFERENCES
5. Cil BE, Akpinar E, Karcaaltincaba M, Akinci D. May-Thurner
syndrome. Radiology 2004;233(2):361-5.
6. Oguzkurt L, Tercan F, Pourbagher MA, Kizilkilic O, Turkoz R,
Boyvat F. Computed tomography findings in 10 cases of iliac
vein compression (May-Thurner) syndrome. Eur J Radiol
2005;55(3):421-5.
7. Mell M, Tefera G, Thornton F, et al. Clinical utility of timeresolved imaging of contrast kinetics (TRICKS) magnetic
resonance angiography for infrageniculate arterial occlusive
disease. J Vasc Surg. 2007; 45(3):543-8.