May-Thurnerjev sindrom kot dejavnik tveganja za nastanek globoke venske tromboze in potrombotičnega sindroma pri mladih ženskah

Kovač, Ana (avtor), Kozak, Matija (mentor)

IZHODIŠČE Venska tromboza je pogosta bolezen, ki lahko v akutnem obdobju povzroči pljučno embolijo, kasneje pa številne težave v sklopu potrombotičnega sindroma. Vzroke za nastanek venske tromboze je opredelil že Virchow s triado venske staze, hiperkoagulabilnosti in poškodb žilne stene. Izmed anatomskih razlogov za vensko stazo se kot možen dejavnik tveganja omenja May-Thurnerjev sindrom. Pri tem sindromu gre za nastanek vezivne zadebelitve intime leve skupne iliakalne vene zaradi pritiska in kroničnih pulzacij desne iliakalne arterije, ki poteka nad veno, ter lumbalnega vretenca, ki leži pod veno. Vezivna zadebelitev povzroča kronično motnjo odtoka, kar lahko vodi v nastanek venske hipertenzije. Sindrom najpogosteje odkrijejo pri mladih ženskah v rodni dobi, vendar je natančna pojavnost neznana, sindrom kot sprožilni dejavnik venske tromboze je slabo opredeljen. Potrombotični sindrom je pozni zaplet venske tromboze. Patofiziološko gre za okvaro mikrocirkulacije v sklopu venske hipertenzije, ki je posledica okvare zaklopk, ki nastanejo v nekaj dneh do tednih po venski trombozi, in ostanka strdkov v veni. Dejavniki tveganja za nastanek so številni in nekateri slabo raziskani. Potrombotični sindrom močno zmanjša kvaliteto življenja po preboleli venski trombozi. Namen raziskave je ugotoviti pomen May-Thurnerjevega sindroma na nastanek venske tromboze in potrombotičnega sindroma pri mladih ženskah. HIPOTEZE May-Thurnerjev sindrom pogosto odkrijejo pri mladih ženskah. Ker povzroča motnjo v venskem odtoku, je pomemben dejavnik tveganja za nastanek levostranske venske tromboze pri mladih ženskah. Zaradi povzročanja motnje v venskem odtoku in s tem povzročanja venske hipertenzije je May-Thurnerjev sindrom dejavnik tveganja za razvoj potrombotičnega sindroma pri mladih ženskah s prebolelo proksimalno globoko levostransko vensko trombozo. METODE Vpliv May-Thurnerjevega sindroma na vensko trombozo Vključili smo 68 bolnic, starih od 18 do 45 let, ki so se med leti 2010 in 2016 zdravile v ambulanti Kliničnega oddelka za žilne bolezni zaradi levostranske proksimalne globoke venske tromboze v preteklosti, in jih primerjali s skupino bolnic, starih od 18 do 45 let (N=60), ki tromboze niso prebolele. Za opredelitev May-Thurnerjevega sindroma smo opravili magnetnoresonančno venografijo. Vpliv May-Thurnerjevega sindroma na potrombotični sindrom Bolnicam (N=68) s prebolelo proksimalno levostransko vensko trombozo smo s pomočjo Villalta točkovnika ocenili prisotnost potrombotičnega sindroma. Bolnice, ki so razvile potrombotični sindrom, smo primerjali glede na povrhnje in globoko vensko popuščanje in ostanek strdka ter glede prisotnosti May-Thurnerjevega sindroma s skupino bolnic, ki potrombotičnega sindroma niso razvile. REZULTATI May-Thurnerjev sindrom kot dejavnik tveganja za vensko trombozo May-Thurnerjev sindrom je bil prisoten pri 53 % bolnic, ki so prebolele vensko trombozo, in pri 25 % bolnic, ki niso prebolele venske tromboze. Izkazalo se je, da je May-Thurnerjev sindrom dejavnik tveganja za nastanek venske tromboze (razmerje obetov (OR) 3,32, 95 % interval zaupanja (IZ) 1,59 – 6,94, P = 0,001). Na nastanek venske tromboze poleg May-Thurnerjevega sindroma v tej starosti vplivajo tudi nosečnost (OR 12,59), jemanje oralne hormonske kontracepcije (OR 3,12), trombofilija (OR 11,31), debelost (indeks telesne mase nad 30 kg/m2, OR 12,07), pozitivna družinska anamneza in drugi zabeleženi dejavniki tveganja. May-Thurnerjev sindrom kot dejavnik tveganja za nastanek potrombotičnega sindroma Od 68 bolnic, ki so prebolele vensko trombozo, jih je 25 razvilo potrombotični sindrom (36,8 %). May-Thurnerjev sindrom pri njih ni bil povezan z nastankom potrombotičnega sindroma (razmerje tveganj (RR) 1,13; P = 0,80). Od drugih dejavnikov tveganja, ki smo jih ocenjevali, je bilo globoko in povrhnje vensko popuščanje značilno povezano z nastankom potrombotičnega sindroma (RR 1,95; P = 0,01 in RR 4,27; P=0,0001), medtem ko je ostanek strdka po venski trombozi pokazal le trend (RR 1,65; P = 0,07). ZAKLJUČEK Potrdili smo, da je May-Thurnerjev sindrom dejavnik tveganja za nastanek venske tromboze pri mladih ženskah s prebolelo levostransko vensko trombozo. V naši raziskavi smo prvi ocenjevali pomen May-Thurnerjevega sindroma kot dejavnika tveganja za nastanek potrombotičnega sindroma pri mladih ženskah s prebolelo levostransko vensko trombozo in ugotovili, da ne vpliva na njegov nastanek.

• Jezik: Slovenski jezik
• Ključne besede: May-Thurnerjev sindrom, globoka venska tromboza, potrombotični sindrom, ultrazvočni pregled, magnetnoresonančna venografija.
• Vrsta gradiva: Doktorsko delo/naloga
• Organizacija: MF - Medicinska fakulteta
• Leto izida: 2020
• PID: 20.500.12556/RUL-116864
• Datum objave v RUL: 14.06.2020

Sekundarni jezik

• Jezik: Angleški jezik
• Naslov: May-Thurner syndrome as a risk factor for deep venous thrombosis and post-thrombotic syndrome in young women

Izvleček

ABSTRACT BACKGROUND Venous thrombosis is a common disease with frequent complications, such as pulmonary embolism in the acute period, and post-thrombotic syndrome in the later period. Risk factors for venous thrombosis have been explained by Virchow’s triad of endothelial injury, hypercoagulability and venous stasis. May-Thurner's syndrome is an anatomic cause of venous stasis. It involves the formation of hyperplasia of the venous intima in the left common iliacal vein due to chronic pulsations of the right iliac artery that runs over the vein, and the lumbar vertebra that lies under the vein. The intraluminal thickening causes a chronic venous disorder, which can lead to venous hypertension. The exact incidence of the syndrome is unknown and is likely to be underestimated, and the syndrome as a risk factor in venous thrombosis is poorly defined. Post-thrombotic syndrome is a common late complication of venous thrombosis. Its pathophysiology is not fully understood, but probably involves the interplay between damaged venous valves, residual venous thrombosis or obstruction, and impaired microcirculation due to consecutive persistent venous hypertension. The risk factors for the development of post-thrombotic syndrome are numerous and some are poorly researched. Post-thrombotic syndrome may severely diminish quality of life. The purpose of the study was to assess the importance of MTS in developing acute left leg deep venous thrombosis and consecutive development of post-thrombotic syndrome. HYPOTHESIS May-Thurner syndrome is an important risk factor for the occurrence of deep left-sided venous thrombosis in young women. May-Thurner syndrome is a risk factor for the development of post-thrombotic syndrome in young women with a history of proximal left-sided deep venous thrombosis. METHODS Influence of May-Thurner syndrome on developing deep venous thrombosis The first part was a case-control study where 68 female patients, aged between 18 and 45 years, treated due to left-sided proximal venous thrombosis in the past, were compared with the same age group patients without thrombosis (n=60). Magnetic resonance venography was performed to confirm May-Thurner syndrome. Influence of May-Thurner syndrome on developing post-thrombotic syndrome Patients with a history of left leg proximal deep venous thrombosis (n=68) were segregated according to the presence or absence of post-thrombotic syndrome according to Villalta score. Patients who developed post-thrombotic syndrome (n=25) were compared with known risk factors for the development of the post-thrombotic syndrome (deep or superficial venous insufficiency, residual thrombus) and the presence of May-Thurner syndrome with a group of patients, who did not develop a post-thrombotic syndrome (n=43). RESULTS May-Thurner syndrome as a risk factor for deep venous thrombosis May-Thurner syndrome was present in 53 % patients with venous thrombosis and in 25 % patients without thrombosis. May-Thurner syndrome was significantly related to venous thrombosis risk (odds ratio (OR) 3,32, 95 % confidence interval (CI) 1,56 – 6,94, P = 0,001). Other risk factors - pregnancy (OR 12,59), use of oral contraceptives and hormonal replacement therapy (OR 3,12), thrombophilia (OR 11,31), obesity (body mass index above 30 kg/m2, OR 12,07), positive family history of venous thromboembolism and other factors were also statistically related to venous thrombosis risk. May-Thurner syndrome as a risk factor for post-thrombotic syndrome Out of 68 patients, 25 developed post-thrombotic syndrome (36,8 %). May-Thurner syndrome was not linked to development of post-thrombotic syndrome (risk ratio (RR) 1,13, P = 0,80). Deep and superficial venous insufficiency were statistically significant related to post-thrombotic syndrome (RR 1,95; P = 0,01 and RR 4,27; P=0,0001, respectively), while residual thrombosis showed only trend (RR 1,65; P = 0,07). CONCLUSION We confirmed that May-Thurner syndrome is an important risk factor for the occurrence of deep venous thrombosis in young women. We did not confirm that May-Thurner is an important risk factor for post-thrombotic syndrome development in young women with a history of proximal left leg venous thrombosis.

• Ključne besede: May-Thurner syndrome, deep venous thrombosis, post-thrombotic syndrome, vein ultrasound of the lower extremities, magnetic resonance venography.