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Clinical Images

A Young Woman Presenting With Extensive Deep Vein Thrombosis

Jean Liew, MD

June 9, 2017

A 27-year-old African American woman presented with an acutely swollen and painful left lower extremity in conjunction with low back pain. She reported the recent initiation of a vaginal ring contraceptive, but her personal and family history were otherwise negative for other thrombotic risk factors. 

Her vital signs were within the normal limits. Her exam was remarkable for an anxious-appearing young woman with a swollen and exquisitely tender left lower extremity. Distal pulses were intact, but the left lower extremity was asymmetrically larger than the right lower extremity. Venous duplex ultrasound of the left leg, with confirmatory CT scan with contrast (See Image 1), revealed extensive iliofemoral deep vein thrombosis (DVT) with extension into the inferior vena cava. 

She was diagnosed with May-Thurner syndrome, an anatomical variant where the right common iliac artery causes compression of the left common iliac vein, predisposing to left-sided DVT. She underwent thrombolysis followed by thrombectomy and angioplasty, which failed to completely resolve the clot. Stenting could not be performed given the extensive remaining clot burden. She noted improvement, but not resolution, of her leg pain and swelling. She was discharged on rivaroxaban anticoagulation and recommended to stop the estrogen-containing contraceptive.

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1. DeLoughery, Thomas G. Estrogen and thrombosis: controversies and common sense. Reviews in Endocrine and Metabolic Disorders 12.2 (2011): 77-84.
2. Vandenbroucke, Jan P., et al. Oral contraceptives and the risk of venous thrombosis. New England Journal of Medicine 344.20 (2001): 1527-1535.
3. Carrier, Marc, et al. Screening for occult cancer in unprovoked venous thromboembolism. New England Journal of Medicine 373.8 (2015): 697-704.
4. Kalu, Shivani, et al. May-thurner syndrome: a case report and review of the literature. Case reports in vascular medicine 2013 (2013).


Author information:

Jean Liew, MD is an Internal Medicine resident at Oregon Health and Science University in Portland, Oregon.