May-Thurner Syndrome in a Case of Severe Lipodermatosclerosi
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A 63-year-old female with a history of hypertension and diabetes complained about a 3-week history of severe left lower extremity swelling, tenderness, evolving erythema and hyperpigmentation. The patient had a 10-year history of venous insufficiency, left lower extremity swelling, and discomfort. On admission, physical exam of the left leg revealed significant hyperpigmentation, erythema, tenderness, and edema, along with intact strength and sensation and strong distal pulses.

Venous duplex studies demonstrated minimal deep venous reflux and some superficial varicose veins. The patient was treated for acute lipodermatosclerosis with a prednisone taper and completed a course of antibiotics for possible cellulitis, with improvement during her hospital stay.

At outpatient follow-up, the patient reported continued severe left lower extremity pain and swelling, and poor ambulatory function. She did not tolerate compression therapy due to pain. She started on pentoxifylline. She improved with leg elevation, antibiotics, and prednisone. Hydroxychloroquine was added to her regimen of pentoxifylline 400mg TD. MRI findings of the left lower extremity showed diffuse mild subcutaneous edema as well as fluid and skin thickening predominantly in the mid to lower calf, both concerning for possible cellulitis.

Lower extremity and inferior vena cava venography and intravascular ultrasound by IR demonstrated left iliac vein compression consistent with May-Thurner Syndrome. The patient underwent left common and external iliac vein angioplasty and stenting. Following this intervention, the patient reported significant improvement in her left lower extremity swelling and pain and was able to ambulate farther without the assistance of her walker.

In the year and a half since her intervention, she has not suffered any further acute inflammatory episodes requiring antibiotics or systemic steroids. She continues to have mild swelling of her left leg with improved hyperpigmentation and chronic sclerotic changes.