Amanda Phillips, RVT

Cockett Syndrome Iliac vein compression syndrome

http://www.ardms.org/volunteer-now/clearly-connected/pages/may-thurner-syndrome-what-sonographers-should-know.aspx

Compression of Lt CIV by the Rt CIA Trauma to vein due to vibration of artery Causes micro trauma = endothelial injury Body deposits elastin and collagen Creates webs and spurs inside the vein Increases risk of DVT formation

Women > Men 41% vs 27% 20 s-40 s

41 year old AA female Non smoker Started oral contraceptive pills for heavy periods

ED visit for SOB, right sided CP on inspiration that radiates to back and shoulders 1 day Pulmonary/Chest: Effort normal and breath sounds normal. Tenderness: slight R lower chest TTP. ECG rate assessment: tachycardic Rhythm: sinus rhythm Clinical evaluation unrevealing for cholelithiasis/cholecystitis by US. Sx resolved with Toradol and w/u otherwise also unrevealing. Will order outpt HIDA scan.

Nuc Med hepatobiliary scan: Abnormally low gallbladder ejection fraction of 11% with reproduction of intermittent intense pain after CCK, raising concern of biliary dyskinesia.

Spirometry shows mild obstruction. Has history of asthma. Will start Advair and Ventolin as needed. Refer to GI for eval

Presents with SHOB with minimal exertion and dry cough x 6 days. Subjective fever yesterday. Her left calf is sore and swollen as of today. States she has been at rest b/c too sob to move around. Pt admits she has concern for PE. Brother uncle and grandmother w/ h/o DVT.

Bilateral acute lower lobe pulmonary thromboemboli with the possibility of developing areas of lower lobe infarction as well. Total clot burden is considered mild to moderate. No evidence of right ventricular strain. No LE venous duplex performed Pt discharged home on ELIQUIS

Increasing dyspnea on exertion Patient states she was evaluated yesterday in the emergency department and diagnosed with a DVT in the left lower extremity and a PE. Patient states she has noticed increasing edema and pain in the left lower extremity and states the Lortab she was given is no longer improving her pain. Left leg is edematous when compared with the right. Patient reports increasing tenderness to palpation of the left leg. Range of motion decreased due to pain.

Tachycardic heart rate in the 100-110 range Repeat chest x-ray shows increased opacity with poor visualization of the diaphragms in the bilateral lung bases which is suspicious for bilateral effusions. Admitted for PE, Lt LE DVT, and pleural effusion

Continue Eliquis The patient was diagnosed with bilateral lower lobe pulmonary thromboemboli and a lower extremity DVT secondary to birth control usage Dyspnea on exertion likely for the next 1-2 weeks while her clot burden settles and starts to dissipate Lasix to help reduce her fluid burden from plural effusion and hopefully ease her work of breathing on exertion

Discontinued OCP Nurse Note: Patient with tenderness to left inner lower leg. Palpated small lump, leg is warm and swollen as well, with comparison to right lower extremity No Lt LE ultrasound performed

Eliquis Compression stockings 30-40 mm Hg

NEGATIVE hypercoagulable work-up

She reports DVT was assumed due to symptoms of leg swelling in setting of PE. US was never completed to know extent of thrombosis. With continued edema and discomfort, we will obtain US to further evaluate. Continue compression stockings. We will also refer to vascular medicine for further recommendations.

Lt Leg pain Venous Claudication Since she is symptomatic despite compression stockings and anticoagulation, will check CT scan to assess IVC and iliac veins. May be candidate for intervention/stenting if they are involved. If post-thrombotic changes limited to CFV & FV segments, then stronger stockings will be only option (for now).

CT: Chronic DVT left femoral through common iliac veins with no evidence of acute deep venous thrombosis

Occlusion of the left common and external iliac venous systems Collaterals

Pre-stenting Post-stenting

Rt CIA Lt CIV Lt CIA

Recognize the signs CFV waveforms matter! IVC and iliac imaging is possible (on some pts)

Barry A, Sonographer s Role in the Diagnosis of May-Thurner Syndrome. Journal of Diagnostic Medical Sonography. 2018; 34(1):65-69 Cardinale M, Montgomery R, Rossi C. May- Thurner Syndrome. Journal for Vascular Ultrasound. 2015; 39(2) 86-88