Background and Study Aims Tufted angiomas (TAs) are rare, benign vascular neoplasms of childhood mainly localized in the skin and subcutaneous tissues. TAs are progressive, slowly growing, and characteristically involve superficial or deep muscle fascia tissue. TAs are frequently seen before the age of 5 years (60 to 70%) and have no sex predominance. TA following pregnancy or TA among immunosuppressive drug users was rarely reported in literature. TA is extremely rare in patients older than 60 years.Patient A 73-year-old man presented with right eye pain, redness, burning sensation, swelling, and double vision. On physical examination, his right eye was protruding, hyperemic, and there was a supraorbital palpable mass extending to the lateral orbital wall. Cranial computed tomography and magnetic resonance imaging revealed a heterogeneously enhancing right intraorbital retrobulbar capsulated lesion with intracranial extension. The patient underwent surgery. TA was proven histopathologically.Conclusion We report the first TA of the orbit with orbital and cranial bone destruction, frontotemporal extension, and loss of vision due to optic nerve compression. The surgical treatment and orbitocranial mesh reconstruction following neurosurgical gross total removal of the lesion is discussed. TAs should be considered in the differential diagnosis of intraorbital tumors. TAs usually persist throughout life but cause no serious symptoms when they are located in the upper thorax, neck, and shoulders. TAs located in the orbit should be excised.

SESSION TYPE: Pleural Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Hemoptysis complicating paracentesis had been described with dry tap, we were able to find one case report of thoracentesis leading to fatal massive hemoptysis in the literature. The hemoptysis is usually caused by puncture of the lungs and puncture sites had been found on postmortem exam, it is unusual to get this complication with successful removal of pleural fluid when the lung is atelectatic.

CASE PRESENTATION:

79 YEAR OLD FEMALE WITH STAGE 4 LUNG CANCER NSCLCA WITH MALIGNANT PLEURAL EFFUSION, PRESENTED WITH DYSPNEA AND HYPOXEMIA AND ACCUMILATION OF RIGHT SIDED MASSIVE PLEURAL EFFUSION LEADING TO ATELECTASIS OF THE LEFT LUNG is 79-year-old female with stage IV non-small cell lung CA bronchogenic carcinoma with malignant pleural effusion, presented with dyspnea and hypoxemia, chest x-ray showed massive right-sided pleural effusion, with complete right lung atelectasis, the patient had mild episodes of hemoptysis which was attributed to the bronchogenic carcinoma, the patient was hemodynamically stable, nevertheless, her breathing was labored, and needed 60% oxygen supplement by Venturi mask, on a lateral decubitus chest x-ray film, the pleural fluid was freely floating in the pleural space, the patient underwent right thoracentesis with removal of 1000 cc of serous sanguinous pleural fluid, there was no blood through the needle upon entering the pleural space, the patient's dyspnea improved towards the end of the thoracentesis procedure, and the patient lied in bed comfortably, 5 minutes following the procedure the patient started coughing with large amounts of blood rushing through the airways, attempts to intubate the patient failed secondary to obscuring of the airways by the massive hemoptysis, the patient desaturated quickly, became bradycardic, and developed asystolic cardiac arrest, the family elected not to pursue CPR, patient expired.

DISCUSSION:

THIS UNEXPECTED COMPLICATION LEAD TO THE THINKING THAT LARGE VOLUME THORACENTESIS FOR MASSIVE PLEURAL EFFUSION MAY LEAD TO COMPLICATIONS RELATED TO THE REEXPANSION OF THE ATELECTATIC LUNG, WHICH IS NOT LIMITED TO REEXPANSION PULMONARY EDEMA . The mechanism of hemoptysis in this patient was thought not to be secondary to needle puncture of the lungs, rather, relieving a tympanotomy and pressure exerted by the malignant massive pleural effusion on the bronchogenic carcinoma, once the tympanotomy and pressure was relieved by thoracentesis, hemoptysis occurred. There had been a description of one case in the literature where the patient developed massive fatal hemoptysis. 3 minutes following a dry pleural tap. The cause of hemoptysis was described as direct puncture of the lungs, and puncture sites were found on the posterior surface of the lungs on the postmortem examination, in our case, there was massive pleural effusion, which provided a good distance between the needle and the lungs making the lung. Posterior much less likely, and our tap was not dry, on the contrary, large volume of fluid was removed with improvement of the patient's sense of dyspnea, since the patient did not get the postmortem exam is very difficult to determine whether the mechanism postulated of the sudden release of tympanotomy and pressure exerted by me pleural effusion had led to the decompression of the Brooklyn genic carcinoma, leading to the massive hemoptysis

CONCLUSIONS:

ALTHOUGH THIS IS AN UNUSUAL PRESENTATION AND COMPLICATION, ONME CAN LEARN TO BE CAREFUL WITH LARGE VOLUME THORACENTESIS IN A PATIENT WITH MALIGNANTPLEURAL EFFUSION AND HISTORY OF HEMOPTYSIS although this is an unusual presentation and complication of large-volume thoracentesis and malignant pleural effusions, one can learn to be more careful with the removal of pleural fluid and a patient with endobronchial extension of malignant neoplasms who had history of hemoptysis, insertion of the pigtail tube, and gradual removal of fluid may be preferred to large-volume thoracentesis in such patients, more research is needed to confirm this hypothesis.1) Seneff MG, Corwin RW, Gold LH, Irwin RS: Complications associated with thoracocentesis. Chest 1986; 90:97-1002) Virshup B, Coombs RH: Physicians' adjustment to retirement. West J Med 1993; 158: 142-1443) Collins TR, Sahn SA: Thoracocentesis: Clinical value, complications, technical problems, and patient experience. Chest 1987; 91:817-822DISCLOSURE: The following authors have nothing to disclose: Islam IbrahimNo Product/Research Disclosure InformationIMC, Jeddah, Saudi Arabia.

SESSION TYPE: Miscellaneous Case Report Posters IIPRESENTED ON: Tuesday, October 23, 201 at 01:30 PM - 02:30 PM

INTRODUCTION:

Patients with sarcoidosis are susceptible to the development of various manifestations of infiltrative disease including cardiac involvement. Cardiac manifestations range from conduction system aberrancies to myocardial infiltration. Pericardial manifestations are rarely described.

CASE PRESENTATION:

A 68 yo man with multi-organ sarcoidosis and diabetes mellitus presented with complaints of 4 days of worsening dyspnea and subjective fevers. The patient was on outpatient corticosteroid therapy and infliximab with recently negative fungal and tubercular studies. He was in his usual state of health 2 weeks before admission when his outpatient pulmonologist initiated a corticosteroid taper. Admission radiograph demonstrated increase in chronic interstitial changes. EKG was consistent with baseline studies including normal intervals and ST segments. Exam revealed mild hypoxemia, relative hypotension, coarse pulmonary crackles, distant heart sounds and 1+ bilateral lower extremity edema. VQ scan showed low probability of pulmonary embolism. Transthoracic echocardiogram showed normal systolic function, PA systolic pressure of 61mmHg, a moderate pericardial effusion composed primarily of peri-right ventricular fibrinous organized material and a small focal mass attached to the LV surface without evidence of collapse in any chamber. Right heart catheterization demonstrated CVP of 15 mmHg, PCWP of 8 mmHg, PA pressure of 40/20 mmHg and systemic BP of 185/101 mmHg. The patient was given corticosteroids, antibiotics and diuresis. On day 4, he became hypercapnic and altered, prompting initiation of mechanical ventilation. Bronchoalveolar lavage cultures grew Enterobacter cloacae. Therapy continued with significant clinical improvement. Cardiac MRI demonstrated an abnormal focus of enhancement within the inferior LV wall consistent with infiltrative disease. The previously noted effusion was not visualized. The patient continued on corticosteroids and was discharged at baseline level of cardiopulmonary functionality.

DISCUSSION:

The finding of a fibrinous pericardial mass may be an atypical cardiac manifestation of sarcoidosis but did not appear to have clinical significance in this patient's presentation.

CONCLUSIONS:

This case illustrates the importance of using the preponderance of data in clinical decision making. Although the patient had a fibrinous mass on echocardiogram, his symptomatology primarily stemmed from pneumonia and sepsis in the setting of immunosuppresion.1) Uma S. Ayyala, Ajith P Nair, Maria L Padilla. Cardiac Sarcoidosis. Clin Chest Med 29 (2008) 493-508.DISCLOSURE: The following authors have nothing to disclose: Patrick Aguilar, Karla Diaz, Diego Maselli, Adriel Malave, Marcos RestrepoNo Product/Research Disclosure InformationUniversity of Texas Health Science Center San Antonio, San Antonio, TX.

SESSION TYPE: Bronchology Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Thoracic tumors are a common cause of SVC syndrome. The mass can cause complete or partial obstruction of the vessel lumen. The most common malignancies known to cause this syndrome are of bronchogenic origin. Because of the distension and back pressure caused by the tumor occluding the superior vena cava, bleeding is a feared and known complication. There has been no publication that we are aware of looking at EBUS for diagnosis of this condition.

CASE PRESENTATION:

72 year old woman with a past medical history of hypertension presented with cough, facial edema, and dyspnea to our emergency department. Patient had an extensive smoking history, more than 100pkyrs, and quit 6months ago. She also reported anorexia and weight loss. Chest radiography revealed tracheal deviation to the left and mediastinal fullness. Computerized Tomography of the chest was positive for a mediastinal mass invading the proximal part of the superior vena cava ( Fig 1), and the clinical diagnosis of SVC syndrome was made. Patient was treated with steroids. An EBUS guided needle aspiration was performed along the right paratracheal and subcarinal lymph nodes region ( Fig 2). Rapid on site evaluation by a pathologist was diagnostic for non-small cell malignancy, later confirmed as adenocarcinoma of primary pulmonary origin. Radiation therapy was instituted and the patient was discharged to home with scheduled follow-up visits. No complications were noted with the procedure.

DISCUSSION:

We illustrate the safety of EBUS in a case of SVC syndrome. Prior studies were conducted on safety of blind transbronchial needle biopsies in the diagnosis of SVC syndrome with rapid on site evaluation of pathological specimen (Brundyn et al). The use of EBUS while performing the transbronchial biopsy has a dual benefit. The vessels can be identified and avoided during the biopsy procedure increasing safety, and a suitable area of the mass identified increasing yield.

CONCLUSIONS:

EBUS can be performed safely in a patient with SVC syndrome, and has the potential to increase safety and yield compared to other diagnostic procedures.1) Brundyn K, Koegelenberg CF, Diacon AH, et al.Transbronchial fine needle aspiration biopsy and rapid on-site evaluation in the setting of superior vena cava syndrome Diagn Cytopathol. 2011 Nov 18.DISCLOSURE: The following authors have nothing to disclose: Bala Prakash, Shweta Upadhyay, Veronica Brito, Shalinee Chawla, Jonathan IlowiteNo Product/Research Disclosure InformationWinthrop University Hospital, Mineola, NY.

SESSION TYPE: Cancer Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Leiomyosarcoma is a rare malignancy which responds poorly to systemic chemotherapy and radiation. Dew, et al. demonstrated a 5 year survival rate of 31% after surgical resection of the primary tumor. We present a 48 yo patient with leiomyosarcoma metastases to the lung treated with transpulmonary chemoembolization (TPCE).

CASE PRESENTATION:

A 48 year old man presented with lower extremity edema and was diagnosed with leiomyosarcoma of the IVC. After surgical resection of the primary tumor and systemic chemotherapy and radiation, the patient developed lung and liver metastasis not amenable to surgical resection. His liver metastases are well controlled with transarterial chemoembolization. His lung metastases continue to progress despite systemic chemotherapy. He has undergone two treatments of segmental TPCE using doxorubicin beads (image 1). He had minimal fatigue the week after the second procedure. He had no other systemic side effects such as nausea, vomitting, or mucositis. He has no worsening cough or chest pain related to embolization of the pulmonary artery. Image 2 demonsrates post-procedural appearance of his left lung. He will undergo further TPCE for continued treatment.

DISCUSSION:

Leiomyosarcoma of the IVC is a rare malignancy with less than 300 cases reported. Our patient in this study has disease recurrence to the lungs and liver after primary surgical resection and systemic chemotherapy administration. Given the poor response of leiomyosarcoma to chemotherapy and radiation, alternate therapies were considered to treat his nonresectable pulmonary disease. Vogl, et al. performed a study from 2001-2005 demonstrating the use of TPCE for pulmonary metastatic disease in 52 patients. 27 of the 52 cases demonstrated partial response or stable disease and all patients had minimal side effects from the procedure. Our patient has undergone 2 treatments of TPCE for his pulmonary disease. The patient has experienced no significant side effects from the embolization or local chemotherapy administration; he has had no complications since his initial treatment approximately 45 days ago.

CONCLUSIONS:

TPCE is a promising treatment option for patients with unresectable pulmonary metastatic disease. Our patient has had no significant complications or side effects after treatment. Although no conclusions can be drawn on one case, the lack of significant side effects after local doxorubicin administration suggests that further research is warranted using TPCE as a tolerable treatment for nonresectable pulmonary metastatic disease.1) J. Dew, K. Hansen, J. Hammon, T. McCoy, E. A. Levine, and P. Shen, "Leiomyosarcoma of the inferior vena cava: surgical management and clinical results," American Surgeon, vol. 71, no. 6, pp. 497-501, 2005.2) Vogl TJ, Lehnert T, Zangos S, Eichler K, Hammerstingl R, Korkusuz H, Lindemayr S. Transpulmonary chemoembolization (TPCE) as a treatment for unresectable lung metastases. Eur Radiol. 2008;18:2449-2455.DISCLOSURE: The following authors have nothing to disclose: Andrew West, Drew Sessions, Mollie MeekTranspulmonary Chemoembolization of pulmonary metastases is a procedure that has been rarely reported in literature. It is still likely considered a research procedure/technique. This will not discuss any products used.UAMS, Little Rock, AR.

SESSION TYPE: Therapeutic BronchoscopyPRESENTED ON: Sunday, October 21, 2012 at 01:15 PM - 02:45 PM

PURPOSE:

Recently flexible bronchoscope has been used for endobronchial obstructions commonly in some centres. Flexible bronchoscopic intervention needs skilled techniques, but it is more familiar than rigid bronchoscope, dose not require a general anesthesia, and provides access to more distal airways, so there is increasing the number of its use. However, data evaluating its outcomes and complications are lacking. This study aims to access outcomes and safety about flexible bronchoscopic intervention in acute airway obstructions.

METHODS:

The data from patients who had acute airway obstructions and underwent flexible bronchoscopic intervention from December 2009 to February 2012 were collected prospectively. Argon plasma coagulation(APC), Cryotheraphy, Endobronchial electrocautery were used depending on the situation, and procedures were perfomed by a skilled pulmonologist at single center.

RESULTS:

A total of 28 patients were enrolled in this study between ages 18 and 93. The majority of patients were men(24, 86%). Of all patients, 23(82%) had primary lung cancer, 5(18%) had benign lesions. Types of primary lung cancer included squamous cell carcinoma(14), adenocarcinoma(6), large cell carcinoma(2), and small cell carcinoma(1). Benign lesions included chronic inflammations(4), endobronchial lipoma(1). The anatomic locations of procedure were trachea(4), left main(3), right main(3), bronchous intermedius(4), left upper lobe(5), left lower lobe(2), right upper lobe(6), and right lower lobe(1). There was no severe complication including major bleeding, expire, except but, a case of bronchial edema occurred after the procedure.

CONCLUSIONS:

A flexible bronchoscopic intervention in acute airway obstruction is safe and useful procedure when done by a skilled pulmonologist. And it can resolve more easily distal airway obstruction without a general anesthesia.

CLINICAL IMPLICATIONS:

A flexible bronchoscopic intervention in acute airway obstruction is safe and useful procedure when done by a skilled pulmonologist.DISCLOSURE: The following authors have nothing to disclose: Ah Young Shin, Ju Sang Kim, Joong Hyun Ahn, Woo Ho BanNo Product/Research Disclosure Information.

IMPORTANCE Treatment of macular edema secondary to retinal vein occlusion with ranibizumab has been shown to improve visual acuity compared with macular laser or observation. It is important to determine whether these visual acuity improvements translate into measurable improvements in visual function.

OBJECTIVE

To examine the benefit of ranibizumab (Lucentis) on measured reading speed, a direct performance assessment, through 6 months in eyes of patients with macular edema after retinal vein occlusion (RVO). DESIGN Two multicenter, double-masked, phase 3 trials in which participants with macular edema after branch RVO or central RVO were randomized 1:1:1 to monthly sham, ranibizumab, 0.3 mg, or ranibizumab, 0.5 mg, for 6 months. SETTING Community- and academic-based ophthalmology practices specializing in retinal diseases. PARTICIPANTS Seven hundred eighty-nine eyes of 789 participants who were at least aged 18 years with macular edema secondary to retinal vein occlusion in the branch vein occlusion (BRAVO) and central vein occlusion (CRUISE) trials. INTERVENTIONS Eyes were randomized 1:1:1 to 1 of 3 groups for monthly injections for 6 months: sham (132 in BRAVO and 130 in CRUISE), intravitreal ranibizumab, 0.3 mg (134 in BRAVO and 132 in CRUISE), and intravitreal ranibizumab, 0.5 mg (131 in BRAVO and 130 in CRUISE). Patients were able to receive macular laser after 3 months if they met prespecified criteria. MAIN OUTCOMES AND MEASURES Reading speed in the study eye was measured with enlarged text (letter size equivalent to approximately 20/1500 at the test distance) at baseline and 1, 3, and 6 months. The number of correctly read words per minute (wpm) was reported. The reading speed test requires a sixth-grade reading level and does not account for literacy or cognitive state.

RESULTS

In patients with branch RVO, the mean gain for the 0.5-mg group was 31.3 wpm compared with 15.0 wpm in sham-treated eyes (difference, 16.3 wpm; P = .007) at 6 months. In patients with central RVO, the mean gain for the 0.5-mg group was 20.5 wpm compared with 8.1 wpm in sham-treated eyes (difference, 12.4 wpm; P = .01) at 6 months. A gain of 15 or more letters of best-corrected visual acuity letter score corresponded to an increase in reading speed of 12.3 wpm and 15.8 wpm in patients with branch and central RVO, respectively.

CONCLUSIONS

AND RELEVANCE These results suggest that patients with macular edema after RVO treated monthly with ranibizumab are more likely to have improvements in reading speed of the affected eyes through 6 months compared with sham treatment. These results demonstrate the relevance of the treatment benefit to functional visual gain. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00486018 and NCT00485836.

SESSION TYPE: Pleural Cases IIPRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION:

Chronic graft-versus-host disease (cGVHD) is a well-known complication following allogeneic hematopoietic stem cell transplantation (HSCT) that varies in time of onset, clinical course and organ involvement. The most commonly effected organ systems are the skin, mucous membranes, liver and eyes. We report a rare case of polyserositis secondary to cGVHD presenting with dyspnea on exertion, pericardial effusion and large bilateral pleural effusions that resolved following the institution of systemic steroids.

CASE PRESENTATION:

A 30-year-old male with pre-B-cell acute lymphoblastic leukemia, status post allogeneic HSCT who had been doing well until 6 months after transplant when he developed an erythematous rash. Shortly thereafter, the patient presented with increasing dyspnea on exertion and peripheral edema, unresponsive to diuretic therapy. Computed tomography of the chest revealed large bilateral pleural effusions without parenchymal abnormalities, and a significant pericardial effusion. Transthoracic echocardiogram confirmed the pericardial effusion and noted mild hemodynamic compromise with preserved ejection fraction. The patient underwent thoracentesis, consistent with transudative effusion. Pleural fluid contained 48% lymphocytes and cytology was consistent with reactive T lymphocytes without evidence of malignancy by cytology and immunostaining. Viral infection and nephrotic syndrome were excluded as other etiologies of serositis. The patient was started on prednisone with gradual, almost complete resolution of pleural and pericaridal effusions.

DISCUSSION:

Chronic GVHD is one of the most common problems affecting patients surviving allogeneic HSCT. It is the leading cause of non-relapse mortality in patients surviving more than 2 years after allogeneic HSCT. cGVHD can also impact functional status and quality of life. Development of serositis as a clinical manifestation of cGVHD has been reported but not well described. The pleural fluid is typically transudative as in this case. Pericardial involvement has been reported; however only one retrospective study has been done which showed the incidence of large pericardial effusion to be less than 1%.

CONCLUSIONS:

Polyserositis as a complication of cGVHD should be considered in patients post-HSCT presenting with dyspnea on exertion. Presence of pleural effusions should prompt an evaluation for other locations of serositis particularly pericardial effusions which may be massive and result in hemodynamic compromise. Early recognition and treatment with immunosuppressive therapy may prevent further morbidity and mortality.1) Lee, SJ et al. 2003; Chronic Graft-versus-Host Disease. Biology of Blood and Marrow Transplantation 9: 215-233.2) Norkin, M et al. 2011; Large pericardial effusion as a complication in adults undergoing SCT. Bone Marrow Transplantation 46: 1353-1356DISCLOSURE: The following authors have nothing to disclose: Jessica Boehmler, Kristin Miller, Harold ChungNo Product/Research Disclosure InformationVirginia Commonwealth University, Richmond, VA.

SESSION TYPE: DVT/PE/Pulmonary Hypertension Posters IIPRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE:

Computed tomography of the chest for pulmonary embolism (CTPE) is frequently used in emergency departments (ED) for patients with respiratory complaints. We theorized that the combination of formal screening scores, such as the Pulmonary Embolism Rule-out Criteria (PERC), the revised Geneva score (RGS), coupled with chest radiographs (CXR) would optimize PE diagnosis in the ED.

METHODS:

We performed a retrospective cohort study of consecutive ED patients who underwent CTPE (January - June 2010). We retrospectively scored PERC and RGS. RGS was considered low probability (LP) if <4. CXRs were evaluated and findings were dichotomized into those representing potential alternate diagnoses (pulmonary edema, consolidation, pleural effusion) and all others. We compared the ability of scoring tools alone (PERC and RGS) and then in combination with CXR findings (PERC+CXR, RGS+CXR) to exclude PE. Area under the receiver operating characteristic curves (AUROCs) and negative predictive values (NPVs) served as endpoints.

RESULTS:

The cohort included 776 subjects (mean age: 50.6 + 16.5 years; female: 71.6%; 6.6% diagnosed with PE) and 58.8% (n=456) had a concurrent CXR. In the entire cohort, PERC was LP in 22.9% and RGS was LP in 41.0%. Among non-LP PERC patients, 7.9% had a PE compared to 8.7% of non-LP patients by RGS (p=0.61). NPVs were similar (97.8% for PERC, 96.5% for RGS). The rate of PE in LP RGS patients was 3.5% vs 2.2% for PERC (p=0.45). When CXR demonstrated an alternative diagnosis, 5.5% were still diagnosed with PE compared to 5.7% without alternative diagnoses (p=0.93). When either RGS or PERC was LP and CXR showed an alternate diagnosis, no subject had a PE. The AUROCs for PERC and RGS were 0.71 vs 0.63, respectively. When CXR was added to PERC and RGS, AUROCs were similar.

CONCLUSIONS:

RGS and PERC have similar diagnostic yield for PE. When combined with radiographic findings for alternative diagnoses, both PERC and RGS can safely rule out PE.

CLINICAL IMPLICATIONS:

When PERC or RGS are low probability with a concomitant CXR demonstrating an alternative diagnosis, the likelihood for PE is low. Such screening tools can be used to exclude PE and minimize use of CTPE in the ED.DISCLOSURE: The following authors have nothing to disclose: Genese Lamare, A. Shorr, Chee ChanNo Product/Research Disclosure InformationWashington Hospital Center, Washington, DC.

SESSION TYPE: Surgery Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

We report a case of May-Thurner syndrome leading to extensive left lower extremity deep venous thrombosis (DVT).

CASE PRESENTATION:

A 39 year-old-male developed acute left leg pain and swelling after several long plane flights. He was diagnosed with an acute lower extremity DVT extending from the left external iliac vein through the left posterior tibialis vein and was started on IV unfractionated heparin. Due to extensive left leg pain and swelling, the patient was referred to vascular surgery for further management. The patient underwent catheter-directed thrombolysis and mechanical thrombectomy. After clearance of clot, venography demonstrated significant left common iliac vein stenosis, consistent with a diagnosis of May-Thurner Syndrome. Balloon angioplasty and stenting of the site were performed with 0% residual stenosis. Post-procedure, the patient's lower extremity edema and pain markedly improved. Hypercoagulable work-up revealed protein C deficiency. The patient was discharged on warfarin with a recommendation for life-long anticoagulation.

DISCUSSION:

May-Thurner syndrome, or IVCS, has been described as compression of the left common iliac vein between the overlying right common iliac artery and the underlying vertebral body. The predilection for left lower extremity DVT was first reported by Virchow. A century later, May and Thurner described intraluminal spurs within the compressed left iliac vein that were hypothesized to predispose to left iliofemoral DVT formation. In fact, this anatomic pattern is seen in approximately 2-3% of normal adults, and, when associated with DVT, is often complicated by clot recurrence and/or post-phlebitic syndrome. Despite its prevalence, IVCS has often been overlooked as a cause of extensive DVT, and only recently with the use of endovascular therapies is it being diagnosed with increasing frequency. Unfortunately ultrasound of the lower extremities, and even CT venography, may not demonstrate the vascular compression. Magnetic resonance venography or endovascular venography are preferred methods of diagnosis, but these tests are not routinely ordered as part of a workup for lower extremity DVT. A randomized controlled trial by Plate et al demonstrated that in these patients, leg swelling and ulcers were nearly twice as common when patients were treated with anticoagulation alone versus anticoagulation plus surgical intervention.

CONCLUSIONS:

In patients with extensive left iliofemoral DVT, one should consider an anatomic cause such as IVCS, as medical management alone may not suffice.1) O'Sullivan GJ, Semba CP, Bittner CA, et al. Endovascular management of iliac vein compression (May-Thurner) syndrome. JVIR 2000; 11:823-836.2) Ludwig B, Han T, Amundson D. Postthrombotic syndrome complicating a case of May-Thurner syndrome despite endovascular therapy. Chest 2006; 129:1382-1386.DISCLOSURE: The following authors have nothing to disclose: Deirdre Kathman, John Madison, Scott KopecNo Product/Research Disclosure InformationUMass Memorial Medical Center, Worcester, MA.