Iliac Vein Compression: Causes, Diagnosis, and Treatment Options

Q: Iliac Vein Compression: Causes, Diagnosis, and Treatment Options

Hello： Iliac vein compression syndrome occurs when the left iliac vein is compressed between the iliac artery and the spine, leading to impaired venous return from the left lower limb, resulting in swelling or pain in the left leg. <br>Under normal physiological conditions, the l

How can the causes of iliac vein compression be identified?

Hello Dr.
Huang: I have been experiencing pain in my left leg for over a month.
My right leg does not hurt, and when I lie down and elevate my legs, it slightly alleviates the pain in my left leg.
The pain is located in the upper half of my calf behind the knee and the lower half of my thigh, and sometimes I feel soreness in the left side of my buttock.
I have a history of a car accident and have had a herniated disc for over 8 years.
Initially, I also injured my coccyx, and an MRI confirmed the herniated disc.
Over a month ago, I consulted Dr.
A, a vascular surgeon, who diagnosed me with [varicose veins] and [iliac vein compression].
Dr.
A arranged for a CT scan of my pelvis and legs in May (one with contrast and one without).
The CT report is as follows:
Summary: Pain and tension over the left lower limb for a period of time.
History of ACL injury in both knees and herniated intervertebral disc.
Allergic to some unknown anti-cold medication in childhood.
Engorged veins, left lower limb swelling, bilateral lower limb.
No pitting edema.
R/O iliac vein compression with pelvic congestion.
Plan for CTV.

Other treatment: Elastic stockings, treatment effect pending.

Imaging findings: CT for lower limbs with and without contrast shows:
- A 2.8 cm left ovarian cyst.
- Uterine myoma, size about 2.5 cm.
- No evident venous thrombosis.
- No evident abnormal enlarged lymph nodes.
- Good patency of main trunk arteries in both lower limbs.
IMPRESSION:
1.
A 2.8 cm left ovarian cyst.
2.
Uterine myoma, size about 2.5 cm.
3.
No evident DVT.
No obvious iliac vein compression.
I used an AI translation tool, which indicated the presence of a uterine myoma and cyst, with no significant iliac vein compression.
I previously inquired with you, Dr.
Huang, whether this report can confirm if the patient has [iliac vein compression syndrome].
I asked the vascular surgeon, who explained that LSS refers to the small saphenous vein, BLL refers to both legs, and LLL refers to the left lower limb.
Your response was as follows:
Hello: The CT results mainly indicate a left ovarian cyst and uterine myoma, confirming that there is no iliac vein compression syndrome.
LSS and BLL may describe symptoms of varicose veins (the abbreviations used by the physician are unclear to me), and not spinal stenosis or anemia.
I still recommend consulting your physician to make an accurate diagnosis and provide appropriate advice and treatment based on your symptoms and examination results.
Later, I returned to see Dr.
A, the vascular surgeon.
After reviewing the CT images, Dr.
A stated that I have iliac vein compression, with the iliac vein being compressed by the artery, reaching 30% to 40%.
Surgery is not yet necessary; I should first take medication to promote blood circulation and reassess in a few months.
The criteria for surgery include 50% compression, along with leg swelling, pain, or ulcers.
The surgery involves placing a stent, which seems to only expand the blood vessel, not resolve the issue of vein compression.
I inquired about the cause of the iliac vein compression, and Dr.
A mentioned it is due to congenital pelvic structure.
He also noted that herniated discs and scoliosis could affect treatment; however, correcting the herniated disc and scoliosis can only slightly relieve pressure but cannot cure iliac vein compression.
Currently, my leg is not very swollen, and surgery is not needed.
Later, I consulted Dr.
B, the radiologist who wrote the report.
Dr.
B stated that the iliac vein compression is not significant, with only a slight compression.
The left iliac vein still has a 0.76 cm gap, and the right has a 0.94 cm gap.
My blood test showed a dimmer clotting index of 0.34, and surgery is not yet required.
I asked Dr.
B about the cause of the iliac vein compression, and he also mentioned it is congenital.
However, I wondered why I did not experience leg pain before.
Dr.
B explained that if the leg swells significantly and the pain persists, I should go to the emergency room because iliac vein compression also carries a risk of pulmonary embolism.
Dr.
B noted that the determination of iliac vein compression is somewhat subjective, and his opinion is that there is only slight compression, with no lymph node compression, while Dr.
A stated it is already compressed by 30% to 40%.

Currently, I have leg pain but no significant swelling.
I experience daily leg pain, and while surgery is not needed now, I am very concerned about it worsening one day.
I fear the possibility of amputation or pulmonary embolism (educational materials online indicate that severe iliac vein compression carries a risk of amputation).
If it is confirmed that I have iliac vein compression, I hope to identify the cause and seek treatment to alleviate the pressure on the vein.
I am very worried.

Please, could you answer the following questions:
1.
Do I really have an issue with iliac vein compression?
2.
Besides a CT scan, what other tests should be conducted to confirm the presence of iliac vein compression?
3.
If it is confirmed that I have iliac vein compression, I would like to find out the cause and seek treatment to relieve the pressure on the vein.
What tests should be done to determine the cause of the arterial compression on the iliac vein? Which specialty should I consult? Thank you.

Niming, 40~49 year old female. Ask Date: 2023/06/01

Dr. Huang Yinghe reply Cardiology

Hello: Iliac vein compression syndrome occurs when the left iliac vein is compressed between the iliac artery and the spine, leading to impaired venous return from the left lower limb, resulting in swelling or pain in the left leg.
Under normal physiological conditions, the left iliac vein is situated between the artery and the spine, making it susceptible to compression.
A CT scan can reveal whether such compression is present.
The causes are mostly congenital, but can also be acquired, such as from spinal injuries, abdominal surgeries, or pregnancy, which can exacerbate the compression.

Modern imaging techniques have made it common to identify iliac vein compression, with reports indicating that 44% of asymptomatic individuals may have this condition.
I have encountered many patients who were found to have iliac vein compression incidentally during abdominal CT scans for other reasons, but most do not exhibit symptoms and do not require treatment.
Surgical intervention is only necessary if the compression exceeds 50% and is accompanied by severe swelling and pain in the left leg.
The standard treatment currently involves the use of anticoagulants and the placement of venous stents to maintain blood flow and alleviate symptoms.

In summary, surgical intervention is only warranted when there are symptoms of abnormal venous return, such as swelling and pain in the left leg, and this is typically performed by a vascular surgeon.
Your examination results indicate that the vascular compression is not severe, and the edema is not pronounced.
The pain may be more related to spinal or nerve issues.
Please do not worry; follow your physician's advice to observe for a period and attend follow-up appointments.
If the left leg pain is suspected to be related to a disc issue, you may consider consulting a neurosurgeon.

Reply Date: 2023/06/01

More Info

Iliac vein compression syndrome, also known as May-Thurner syndrome, occurs when the left iliac vein is compressed by the right iliac artery, leading to impaired venous return from the left leg. This condition can cause symptoms such as leg pain, swelling, and in some cases, can lead to more severe complications like deep vein thrombosis (DVT) or pulmonary embolism.
Based on your description, it seems you have been experiencing left leg pain for over a month, which is exacerbated by certain positions and relieved when you elevate your legs. Your medical history includes a previous car accident and a diagnosis of a herniated disc, which could contribute to your current symptoms. The imaging studies you underwent, including CT scans, did not show significant iliac vein compression, but your vascular surgeon indicated a 30-40% compression, which is noteworthy.

1. Do you really have iliac vein compression?
Your symptoms and the imaging results suggest that there may be some degree of compression, but it is not severe enough to warrant immediate surgical intervention. The vascular surgeon's assessment of 30-40% compression indicates that while there is some impact on venous return, it may not be the sole cause of your pain. Other factors, such as your history of disc herniation, could also be contributing to your discomfort.

2. What additional tests can confirm iliac vein compression?
Besides CT scans, other imaging modalities can be utilized to evaluate iliac vein compression. These include:
- Venography: This is a specialized X-ray that uses contrast dye to visualize veins and can provide a clear picture of any compression.

- Ultrasound: A Doppler ultrasound can assess blood flow in the veins and may help identify any abnormalities in venous return.

- Magnetic Resonance Venography (MRV): This is a non-invasive imaging technique that can visualize the venous system and may provide additional information about the iliac veins.

3. If iliac vein compression is confirmed, what treatments are available?
Treatment options depend on the severity of the compression and the symptoms experienced. If the compression is significant (usually over 50%) and accompanied by severe symptoms such as swelling, pain, or skin changes, surgical options may be considered. These include:
- Stenting: This procedure involves placing a stent in the iliac vein to keep it open and improve blood flow.

- Angioplasty: This involves inflating a balloon in the compressed vein to widen it.

- Medications: Anticoagulants may be prescribed to prevent blood clots, especially if there is a risk of DVT.

In your case, since the compression is not severe and you are not experiencing significant swelling or other alarming symptoms, conservative management may be appropriate. This could include:
- Compression stockings: These can help improve venous return and reduce swelling.

- Medications to improve circulation: As your doctor suggested, these can help alleviate symptoms.

- Regular follow-up: Monitoring your symptoms and any changes in your condition is crucial.

It's understandable to be concerned about the potential for complications like limb loss or pulmonary embolism, especially with a history of leg pain and compression. However, the current assessment indicates that while there is some compression, it is not at a level that typically leads to such severe outcomes.
If your symptoms worsen or if you develop new symptoms such as significant swelling, discoloration, or pain, it is essential to seek immediate medical attention. Additionally, consider consulting with a vascular specialist who can provide further insights and tailored treatment options based on your specific condition.
In summary, while you may have some degree of iliac vein compression, the current evidence does not suggest an urgent need for surgical intervention. Regular monitoring and conservative management are advisable, and further imaging may help clarify the situation if symptoms persist.

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