Extremity compartment syndrome in post body contouring...
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Authors have no financial interest related to this study. Acute onset of unilateral lower extremity swelling, pain and numbness with any evidence of DVT during the early postoperative period following an abdominoplasty procedure might be due to extrinsic compression of the left iliac vein due to increased intraabdominal pressure. BACKGROUND SPECIFIC AIMS METHODS RESULTS DISCLOSURES CONCLUSIONS AND IMPLICATIONS REFERENCES Extremity compartment syndrome in post body contouring patients resulting from May-Thurner Syndrome and NIVL Kerem H. Bortecen, MD, Arno Rotgans, MD, Christopher Hollingsworth, MD, Ryan Neinstein, MD, Jason Hanks, MD, Raghu Idupuganti, MD and David A. Greuner, MD 14 East 60th Street, Suite 501, New York, NY 10022 The compression of the left common iliac vein between the right iliac artery and the spine typically, known as May-Thurner Syndrome (MTS) or NIVL (Non-thrombotic Iliac Lesion), is often found incidentally in asymptomatic patients, or patients with symptoms attributed to other neurologic or muscular causes. It can also present with chronic lower extremity symptoms such as swelling, heaviness, cramps or with chronic pelvic and lower back pain. Increased risk of deep venous thrombosis (DVT) is a well-known potential complication of abdominoplasty or ventral hernia repair usually attributed to increased intraabdominal pressure (IAP) leading decreased venous return, venous stasis, and thus thrombosis. Secondary extremity compartment syndrome due to IAP with aggressive fluid resuscitation has been described in the trauma literature. Here, we present a case report of postoperative extremity compartment syndrome in patients with MTS as an unusual postoperative complication of abdominoplasty with ventral hernia repair operation. Two patients who presented with an early postoperative left lower extremity pain and numbness following abdominoplasty and ventral hernia repair in the absence of DVT. Venography and IVUS confirmed severe left common iliac vein stenosis. It should be noted, that in both instances, lower extremity duplex was negative for typical flow reversal seen in DVT. In addition, both patients did not have a significant amount of lower extremity swelling, making this symptom not a significant predictive factor for this condition. In both patients, pain was increased by standing upright and activity, indicative of exacerbation with venous pooling. A good technical result was achieved following an endovascular stent placement, with restoration of blood flow and complete resolution of symptoms, immediately post treatment. Secondary extremity compartment syndrome in the absence of DVT is an unusual postoperative complication of abdominoplasty, panniculectomy, ventral hernia repair, and any other procedure increasing abdominal compartment pressure. MTS should be ruled out in patients with severe diffuse unilateral extremity numbness and pain, particularly the left lower extremity, with or without the presence of swelling. Endovascular intervention is warranted to relieve the anatomical compression and alleviate symptoms. It should be noted that in almost all cases, the pain is significantly exacerbated by standing or activity, whereas it is placated somewhat by laying supine, due to venous pooling. We believe that this significant aberration in flow, if left untreated, and especially if combined with limitation of patient activity due to pain, is a significant contributing factor to DVT and PE in post contouring patients, especially in the post obese population, where compartment pressures are typically altered to a much higher degree due to much higher levels of fascial laxity in these patients. This hypothesis is corroborated by the much higher levels of DVT and PE seen in massive weight loss patients, although it is likely not the only factor contributing to this higher incidence of thrombotic complications. A 56-year-old female patient with bilateral chronic groin folliculitis and symptomatic bilateral femoral hernia underwent a bilateral modified McVay repair with advancement flap closure and liposuction of groin and distal medial thigh areas. On POD 11, the patient presented with left lower extremity pain and worsening sharp, shooting pain radiating down her left calf, interfering with her mobility. She was taken for diagnostic venogram and intravascular ultrasound of left popliteal vein, left common femoral vein, left external iliac vein, left common iliac vein and inferior vena cava revealed over approximately 56.2% stenosis at the proximal left common iliac vein, a finding consistent with May- Thurner Syndrome with additional stenotic lesions at distal common iliac, proximal and distal external iliac veins. Flow limitation was noted on venography, with no acute clot present. An 18 x 90 mm wall stent (WALLSTENT™ Endoprosthesis, Boston Scientific) was deployed in the left common iliac and external iliac veins followed by a 20 x 40 balloon angioplasty. Fluoroscopy imaging demonstrated excellent flow post-treatment. Patient symptoms resolved immediately. Postoperative anticoagulation protocol was initiated with Aspirin and Plavix for 30 days. (Figs. 1, 2 and 3). Post-procedure Duplex imaging in 48 hours demonstrated compressibility without evidence of intraluminal thrombus or increased echogenity from the level of common femoral to the popliteal vein. Doppler signals demonstrated normal response to augmentation maneuvers indicating patency without obstruction. On her follow up visit a week later, she reported persistence of the complete resolution of her left lower extremity symptoms. She developed no new complications and was subsequently taken off her Plavix and Aspirin. A 41-year-old female patient with symptomatic complex incisional ventral hernia underwent complex abdominal reconstruction with bilateral rectus flap component separation, panniculectomy, bilateral advancement abdominal wall flap closure, debulking liposuction and autologous fat graft to bilateral hips. Postoperative course was complicated with worsening of her chronic pelvic pain and increasing left lower extremity pain and numbness. She underwent a diagnostic pelvic venogram and intravascular ultrasound. IVUS demonstrated over 65% stenosis at the proximal left common iliac vein. Venogram was significant for severe reflux and pancaking of the left common iliac vein and significant pre-stenotic dilatation as well as collateral flow through a middle sacral collateral with significant reflux distally into the left external iliac vein and left hypogastric vein with pelvic varicosities. ). The left gonadal vein was found to be moderately dilated with significant reflux, pelvic collaterals and significant arborization on the uterus. No clear stenosis was detected on the right common iliac vein. The left gonadal vein was embolized using Gelfoam and Penumbra coil. Venogram demonstrating stenosis at the proximal common iliac vein. Postdeployment of wall stent in the left common iliac vein and left external iliac vein Intravascular ultrasound demonstrating 56.2% stenosis at the proximal left common iliac vein Venogram demonstrating stenosis at the proximal common iliac vein with additional stenotic lesions at distal common iliac, proximal and distal external iliac veins. Postdeployment of wall stent in the left common iliac vein and left external iliac vein 1. May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8: 419-27 2. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989; 240: 97–104. 3. Graça Neto L, Araújo LR, Rudy MR, Auersvald LA, Graf R. Intraabdominal pressure in abdominoplasty patients. Aesthetic Plast Surg. 2006; 30: 655–8. Intravascular ultrasound demonstrating 68.8% stenosis at the proximal left common iliac vein Dilated left gonadal vein with significant reflux, pelvic collaterals and significant arborization on the uterus A 16 x 90 mm wall stent (WALLSTENT™ Endoprosthesis, Boston Scientific) was deployed in the left common and left external iliac veins. Post-procedure anticoagulation protocol was initiated with Plavix for 30 days. Resolution of her left sided lower extremity pain was noted in the PACU.
Transcript of Extremity compartment syndrome in post body contouring...
Authors have no financial interest related to this study.
Acute onset of unilateral lower extremity swelling, pain and numbness withany evidence of DVT during the early postoperative period following anabdominoplasty procedure might be due to extrinsic compression of the leftiliac vein due to increased intraabdominal pressure.
BACKGROUND
SPECIFIC AIMS
METHODS
RESULTS
DISCLOSURES
CONCLUSIONS AND IMPLICATIONS
REFERENCES
Extremity compartment syndrome in post body contouring patients resulting from May-Thurner Syndrome and NIVLKerem H. Bortecen, MD, Arno Rotgans, MD, Christopher Hollingsworth, MD, Ryan Neinstein, MD, Jason Hanks, MD, Raghu Idupuganti, MD and David A. Greuner, MD14 East 60th Street, Suite 501, New York, NY 10022
The compression of the left common iliac vein between the right iliac arteryand the spine typically, known as May-Thurner Syndrome (MTS) or NIVL(Non-thrombotic Iliac Lesion), is often found incidentally in asymptomaticpatients, or patients with symptoms attributed to other neurologic or muscularcauses. It can also present with chronic lower extremity symptoms such asswelling, heaviness, cramps or with chronic pelvic and lower back pain.Increased risk of deep venous thrombosis (DVT) is a well-known potentialcomplication of abdominoplasty or ventral hernia repair usually attributed toincreased intraabdominal pressure (IAP) leading decreased venous return,venous stasis, and thus thrombosis.Secondary extremity compartment syndrome due to IAP with aggressive fluidresuscitation has been described in the trauma literature.
Here, we present a case report of postoperative extremity compartmentsyndrome in patients with MTS as an unusual postoperative complication ofabdominoplasty with ventral hernia repair operation.
Two patients who presented with an early postoperative left lower extremitypain and numbness following abdominoplasty and ventral hernia repair inthe absence of DVT. Venography and IVUS confirmed severe left commoniliac vein stenosis.
It should be noted, that in both instances, lower extremity duplex wasnegative for typical flow reversal seen in DVT. In addition, both patientsdid not have a significant amount of lower extremity swelling, making thissymptom not a significant predictive factor for this condition. In bothpatients, pain was increased by standing upright and activity, indicative ofexacerbation with venous pooling.
A good technical result was achieved following an endovascular stent placement, withrestoration of blood flow and complete resolution of symptoms, immediately posttreatment.
Secondary extremity compartment syndrome in the absence of DVT is an unusualpostoperative complication of abdominoplasty, panniculectomy, ventral hernia repair, andany other procedure increasing abdominal compartment pressure. MTS should be ruledout in patients with severe diffuse unilateral extremity numbness and pain, particularly theleft lower extremity, with or without the presence of swelling. Endovascular interventionis warranted to relieve the anatomical compression and alleviate symptoms. It should benoted that in almost all cases, the pain is significantly exacerbated by standing or activity,whereas it is placated somewhat by laying supine, due to venous pooling.
We believe that this significant aberration in flow, if left untreated, and especially ifcombined with limitation of patient activity due to pain, is a significant contributing factorto DVT and PE in post contouring patients, especially in the post obese population, wherecompartment pressures are typically altered to a much higher degree due to much higherlevels of fascial laxity in these patients. This hypothesis is corroborated by the muchhigher levels of DVT and PE seen in massive weight loss patients, although it is likely notthe only factor contributing to this higher incidence of thrombotic complications.
A 56-year-old female patient with bilateral chronic groin folliculitis and symptomatic bilateral femoralhernia underwent a bilateral modified McVay repair with advancement flap closure and liposuction ofgroin and distal medial thigh areas. On POD 11, the patient presented with left lower extremity pain andworsening sharp, shooting pain radiating down her left calf, interfering with her mobility.She was taken for diagnostic venogram and intravascular ultrasound of left popliteal vein, left commonfemoral vein, left external iliac vein, left common iliac vein and inferior vena cava revealed overapproximately 56.2% stenosis at the proximal left common iliac vein, a finding consistent with May-Thurner Syndrome with additional stenotic lesions at distal common iliac, proximal and distal external iliacveins. Flow limitation was noted on venography, with no acute clot present. An 18 x 90 mm wall stent(WALLSTENT™ Endoprosthesis, Boston Scientific) was deployed in the left common iliac and externaliliac veins followed by a 20 x 40 balloon angioplasty. Fluoroscopy imaging demonstrated excellent flowpost-treatment. Patient symptoms resolved immediately. Postoperative anticoagulation protocol wasinitiated with Aspirin and Plavix for 30 days. (Figs. 1, 2 and 3). Post-procedure Duplex imaging in 48hours demonstrated compressibility without evidence of intraluminal thrombus or increased echogenityfrom the level of common femoral to the popliteal vein. Doppler signals demonstrated normal response toaugmentation maneuvers indicating patency without obstruction. On her follow up visit a week later, shereported persistence of the complete resolution of her left lower extremity symptoms. She developed nonew complications and was subsequently taken off her Plavix and Aspirin.
A 41-year-old female patient with symptomatic complex incisional ventral hernia underwent complexabdominal reconstruction with bilateral rectus flap component separation, panniculectomy, bilateraladvancement abdominal wall flap closure, debulking liposuction and autologous fat graft to bilateral hips.Postoperative course was complicated with worsening of her chronic pelvic pain and increasing left lowerextremity pain and numbness.She underwent a diagnostic pelvic venogram and intravascular ultrasound. IVUS demonstrated over 65%stenosis at the proximal left common iliac vein. Venogram was significant for severe reflux and pancakingof the left common iliac vein and significant pre-stenotic dilatation as well as collateral flow through amiddle sacral collateral with significant reflux distally into the left external iliac vein and left hypogastricvein with pelvic varicosities. ). The left gonadal vein was found to be moderately dilated with significantreflux, pelvic collaterals and significant arborization on the uterus. No clear stenosis was detected on theright common iliac vein. The left gonadal vein was embolized using Gelfoam and Penumbra coil.
Venogram demonstrating stenosis at the proximal common iliac vein. Post-‐deployment of wall stent in the left common iliac vein and left external iliac vein
Intravascular ultrasound demonstrating 56.2% stenosis at the proximal left common iliac vein
Venogram demonstrating stenosis at the proximal common iliac vein with additional stenotic lesions at distal common iliac,
proximal and distal external iliac veins.
Post-‐deployment of wall stent in the left common iliac vein and left external iliac vein
1. May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8: 419-272. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989; 240: 97–104. 3. Graça Neto L, Araújo LR, Rudy MR, Auersvald LA, Graf R. Intraabdominal pressure in abdominoplasty patients. Aesthetic Plast Surg. 2006; 30: 655–8. Intravascular ultrasound
demonstrating 68.8% stenosis at the proximal left common iliac vein
Dilated left gonadal vein with significant reflux, pelvic collaterals and significant
arborization on the uterus
A 16 x 90 mm wall stent (WALLSTENT™ Endoprosthesis, Boston Scientific) wasdeployed in the left common and left external iliac veins. Post-procedureanticoagulation protocol was initiated with Plavix for 30 days. Resolution of her leftsided lower extremity pain was noted in the PACU.
