Nurse practitioner Missouri City, Texas, United States
Disclosure(s):
Preethi Antony, AGACNP-BC: No financial relationships to disclose
Background: May–Thurner syndrome, caused by compression of the left iliac vein by the right iliac artery, is an uncommon but important contributor to iliac–femoral thrombosis. Although exceedingly rare, spontaneous iliac vein rupture can precipitate catastrophic retroperitoneal hemorrhage, creating a complex management dilemma between controlling bleeding and treating extensive thrombosis.
Methods: We report a case of hemorrhagic shock due to retroperitoneal bleeding from an iliac vein rupture. A 50‑year‑old man with prior left lower lobectomy for lung adenocarcinoma arrived in shock immediately after a 17‑hour international flight. Imaging demonstrated acute segmental right lower lobe pulmonary embolism without right‑ventricular strain, extensive DVT in the inferior vena cava and left Iliac Vein, and a large retroperitoneal hematoma with active extravasation and associated May–Thurner anatomy (see image1). The extensive thrombotic load likely generated sufficient mechanical distortion of the iliac vein wall to precipitate its spontaneous rupture. Interventional radiologist performed a catheter directed ileocaval thrombectomy and left iliac vein stenting. He received 1 unit packed red blood cell transfusion, and the vasopressor need rapidly declined, and he was weaned off within 6 hours. Heparin infusion was initiated with close monitoring in the ICU; repeat CT at 48 hours showed no further bleeding. He was transitioned to apixaban and aspirin and discharged home in stable condition.
Outcome: This case highlights the complex May–Thurner syndrome and extensive DVT in patients presenting with spontaneous iliac vein rupture. Successful management required rapid recognition, endovascular thrombectomy, venous stenting, and carefully titrated anticoagulation within a multidisciplinary framework.
Conclusion: Spontaneous iliac vein rupture is rare but potentially fatal. Early diagnosis and coordinated endovascular intervention are critical to stabilizing hemorrhagic shock and preventing further thrombotic complications.
