P077: ANESTHETIC MANAGEMENT OF A PATIENT WITH SYMPTOMATIC MAY-THURNER SYNDROME: A CASE REPORT
Matthew J McIntyre, BS1; Gisele J Wakim, MD2
1University of Miami Miller School of Medicine; 2University of Miami / Jackson Memorial Hospital
Introduction: May-Thurner syndrome (MTS) is characterized by the compression of the left common iliac vein (LCIV) by the overlying right common iliac artery (RCIA) against the fifth lumbar vertebrae. Many patients with MTS are asymptomatic; however, compression of the LCIV can lead to venous insufficiency, obstruction, and stenosis. MTS can also lead to iliofemoral deep vein thrombosis (DVT) and pulmonary embolism (PE). The prevalence of MTS in literature is variable and dependent on the population being studied. One study found that 14.8% of patients with left-sided chronic venous disease had MTS. Anesthetic risks include perioperative DVT or PE. There is currently no recommended anesthetic management for patients with MTS in the literature.
Methods: We present the case of a 38 y/o female, ASA II, 170cm, 74kg, with a history of MTS who presented for a total laparoscopic hysterectomy, bilateral salpingectomy, and lysis of adhesions for abnormal uterine bleeding secondary to fibroids. Medical history was significant for symptomatic MTS with persistent LLE pain, swelling, and hyperpigmentation without a history of DVT or PE. Other medical history included asthma, anemia, and severe PONV. She received an LCIV stent in 2015 and a stent revision in 2018 for persistent symptoms. Medications included rivaroxaban 20mg nightly for anticoagulation, stopped 7 days before surgery, and albuterol PRN. The patient endorsed good exercise tolerance. Preoperative labs showed HgB 11.5, Hct 36.5, Plt 275, PT 12.9, APTT 27, INR 0.98, D-Dimer 0.34. EKG showed normal sinus rhythm.
Results: Given the patient’s history of severe PONV, we proceeded with total intravenous anesthesia using propofol and dexmedetomidine and standard induction with fentanyl, propofol, and rocuronium. Due to the patient’s increased risk of a thromboembolic event, a radial A-line was placed to monitor hemodynamic instability. TIVA has also been shown to decrease coagulability, increase fibrinolysis, and decrease venous stasis compared to volatile anesthetics. Furthermore, a study showed patients undergoing TIVA in knee arthroplasty had a lower incidence of DVT compared to patients receiving volatile anesthesia. Patients with MTS in the lithotomy position are at even greater risk of DVT due to increased compression of the LCIV during hip flexion. Lower extremity intermittent pneumatic compression devices were utilized. A Bair Hugger was placed for body temperature management. Activated clotting time at the beginning and end of the procedure was 148 and 150 respectively. The use of NSAIDs was avoided. The patient tolerated the anesthesia and surgery well, with no perioperative complications. She was discharged on POD-2 and was restarted on rivaroxaban 20mg upon discharge.
Discussion: This case discusses the anesthetic management of a mechanically hypercoagulable patient secondary to MTS. A careful balance of anticoagulation is required to prevent hypercoagulability and excessive bleeding risk. Invasive monitoring with an A-line is also necessary due to the risk of DVT and PE. Although TIVA was definitively indicated for her PONV, it is worth considering TIVA over volatile anesthetics in patients with MTS due to decreased coagulability, increased fibrinolysis, and decreased venous stasis.