Spontaneous iliac vein rupture associated with acute deep vein and ovarian vein thrombosis in the absence of typical May-Thurner anatomy: a case report

Spontaneous iliac vein rupture (SIVR) is a rare but highly lethal vascular emergency. May-Thurner syndrome (MTS) has long been regarded as its most important anatomical prerequisite. However, venous outflow obstruction and venous hypertension caused by acute deep vein thrombosis (DVT) and ovarian vein thrombosis (OVT) may also contribute to its occurrence. A 62-year-old postmenopausal woman presented with left lower extremity swelling and pain. She was diagnosed with left lower extremity DVT and left OVT at a local hospital. Four hours after implantation of an inferior vena cava (IVC) filter via the right femoral vein approach, she developed sudden abdominal pain and a progressive decrease in hemoglobin. She was emergently transferred to our hospital. Digital subtraction angiography (DSA) venography confirmed rupture of the distal left external iliac vein, accompanied by a retroperitoneal hematoma and hemorrhagic shock. An emergency one-stop interventional strategy was performed, comprising covered stent closure of the rupture, thrombus aspiration, and catheter-directed thrombolysis (CDT), followed by postoperative anticoagulation, thrombolysis, and supportive care. The patient recovered, and at 12-month follow-up, the stent remained patent without recurrent thrombosis. In the absence of typical MTS anatomy, venous outflow obstruction and venous hypertension caused by acute DVT complicated by OVT may be associated with iliac vein rupture. In postmenopausal women without typical predisposing factors, the triad of DVT, OVT, and SIVR should be suspected when lower extremity swelling is accompanied by abdominal pain. Interventional closure combined with thrombus removal may be a feasible rescue strategy. However, a single case report cannot establish causality, and further research is warranted.