Varicocele in May Thurner Syndrome
By: Windsor Ting, MD
Icahn School of Medicine at Mount Sinai, NY
This case describes a male with bilateral lower extremity edema, an uncomfortable lump in his left groin and varicose veins.
A healthy 62 y/o male presenting with a long history of superficial venous insufficiency, CEAP Class V, in both lower extremities complicated by ulceration, bleeding, edema, and multiple venous-like symptoms. His varicose veins were treated with bilateral endovenous laser ablations of the great saphenous veins. After the endovenous thermal ablations, the patient reported symptomatic improvement in his lower extremities except for persistent edema bilaterally. During an office visit, the patient also reported a left groin lump that was most uncomfortable when standing for many years. Physical exam showed 3+ edema in his lower extremities, moderate severity venous stasis dermatitis, and absence of any varicose veins. There was no inguinal hernia and no obvious varicocele. A MRV of the abdomen and pelvis demonstrated significant stenosis of the left common iliac vein and the right external iliac vein, a prominent left gonadal vein, bilateral varicoceles and prominent subcutaneous engorged veins in both groins. Venogram and intravascular ultrasound confirmed these findings during endovascular interventions. Both iliac veins were stented with 18 mm x 90 mm Wallstents (Boston Scientific, MA). In a staged procedure, the left gonadal vein was selectively catheterized and embolized with 3% sodium tetradecyl foam. Two months after these procedures, the patient reported improvement in the lower extremity edema. The groin lump which was previously soft has become hard and mildly tender to palpation.
Reports on varicose veins, proximal venous outflow obstruction as in May Thurner Syndrome, and gonadal vein reflux resulting in varicocele or pelvic congestion syndrome have described these venous conditions primarily as separate and unrelated. This case suggests that in at least some selected patients, there may be a possible interrelationship between these three venous conditions.
The varicocele, a male equivalent of the female pelvic congestion syndrome, is due to reflux in the left testicular vein or gonadal vein. Several causes of gonadal vein reflux have been reported including a venous outflow obstruction in the left renal vein as seen in the Nutcracker syndrome and a quantitative and/or functional abnormality in the venous valves within the gonadal vein. Many of these patients are asymptomatic, but varicocele has been reported as a contributory cause of infertility in male. The “bag of worms” is the classic physical finding associated with varicocele, but the condition may not be easily apparent on exam especially for the vascular specialist. Venography confirms the diagnosis but requires a high index of suspicion for the presence of varicocele. In addition to physical exam, ultrasound and magnetic resonance are utilized in diagnosis but ultrasonography is operator dependent. While there are increasing reports on embolization as a treatment in varicocele, most are being treated with open surgery including a microsurgical approach.
When first seen, this patient appeared to have severe varicose veins due to truncal saphenous vein reflux. The persistence of his edema after endovenous thermal ablation of both saphenous veins led one to suspect the presence of additional venous pathology. The complaint of a chronic painful lump in the left groin associated with standing but without the finding of an inguinal hernia on exam raised the suspicion of a varicocele. The MRV of this patient demonstrated compression of both iliac veins (Figures 1 and 2) and a prominent left gonadal vein with varicocele. This patient’s triad of varicose veins, lower extremity edema, and varicocele raised the question whether venous outflow obstruction in the iliac vein plays a pivotal role in the development of all three venous conditions in this patient. Venous hypertension in the deep veins due to a proximal venous outflow obstruction in the setting of an incompetent saphenofemoral valve is known to cause superficial varicose veins in the lower extremity. The same proximal venous hypertension can result in lower extremity edema with or without varicose veins. While proximal renal vein obstruction is associated with gonadal vein reflux, the presence of a concurrent iliac vein obstruction may accentuate the sequelae of gonadal vein reflux by obstructing the collateral venous return from the iliac venous circuit. This case of three common venous disease states in one patient illustrates the potential role of a proximal venous outflow obstruction in the iliac vein as an important cause of lower extremity venous disease.
Figure 2: MRV showing stenosis of the right external iliac vein.
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