Multimodality imaging of right-sided May-Thurner syndrome for accurate diagnosis and effective endovascular therapy: three case reports

Paola P. Alva-Espinoza, Department of Radiology and Imaging, Zambrano Hellion Hospital, TecSalud, San Pedro Garza Garcia, Monterrey. Nuevo Leon, Mexico;
Miguel A. Hinostroza-Sanchez, Department of Interventional Radiology. Zambrano Hellion Hospital, TecSalud, San Pedro Garza Garcia; Department of Radiology and Imaging, Hospital Christus Muguerza Alta Especialidad; Nuevo Leon, Mexico;
Marcelo Valdes-Hernandez, Hospital Regional Monterrey, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Monterrey, Nuevo Leon, Mexico;
Karla I. Soto-Valdez, Department of Radiology and Imaging, Zambrano Hellion Hospital, TecSalud, San Pedro Garza Garcia, Monterrey. Nuevo Leon, Mexico;
Francisco E. Puente-Gallegos, Department of Interventional Radiology. Zambrano Hellion Hospital, TecSalud, San Pedro Garza Garcia, Monterrey. Nuevo Leon, Mexico;

Right-sided May-Thurner syndrome (MTS) is a rare variant involving iliac vein compression and can lead to delayed diagnosis. We present three male patients with chronic venous insufficiency of the right lower extremity who underwent Doppler ultrasound (US), digital subtraction venography (DSV), and intravascular ultrasound (IVUS). Doppler US identified hemodynamic abnormalities suggestive of venous obstruction. DSV demonstrated focal stenosis, intraluminal defects, and collateral circulation. IVUS confirmed significant luminal narrowing and precisely characterized the stenosis. All patients underwent thrombectomy, balloon angioplasty, and placement of an uncovered self-expanding stent, achieving adequate stent expansion and restoration of venous flow. These cases highlight the value of multimodal imaging for accurate diagnosis and effective endovascular management of right-sided MTS, particularly when iliac vein compression is atypical. Right-sided MTS is an unusual entity that is often overlooked in clinical practice. It is important to document the success of multimodal imaging, as diagnoses are often delayed due to its rarity. Therefore, combining Doppler US, DSV, and IVUS compensates for the limitations of each imaging modality. Endovascular therapy is the standard of care for restoring venous flow in right-sided MTS. It is safe, minimally invasive, and provides immediate restoration of vessel patency. This is the first report of three men with right-sided MTS, published for educational purposes.

Keywords: May-Thurner syndrome. Iliac vein compression. Doppler. Intravascular ultrasound. Digital subtraction venography. Endovascular procedures.