13 - Long-term Outcomes of Ascending Lumbar Vein Embolization in The Management of New-daily Persistent Headache Associated with May-Thurner Physiology – A Follow-up Study

Monday, March 31, 2025

12:10 PM – 1:10 PM CT

Location: Music City Center, Expo Poster Area

Poster Presenter(s)

Samuel B. Ogunlade, MD

Research Trainee
Mayo Clinic, Florida, United States

Author/Co-author(s)

mohamed A K Elboraey, MD

Resident
Mayo Clinic, Florida, United States
TR

Todd Rozen, MD

Professor
Mayo Clinic, Florida, United States
AL

Andrew R. Lewis, MD

Assistant Professor
Mayo Clinic Florida, United States
Beau B. Toskich, MD, FSIR

Professor
Department of Radiology, Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL 32224, United States, United States
ZD

Zlatko Devcic, MD

Assistant Professor of Radiology
Mayo Clinic Florida, United States

Purpose: New daily persistent headache (NDPH) is a debilitating condition recently linked to deep venous congestion disorders like May-Thurner physiology (MTP), caused by compression of the left common iliac vein (LCIV) by the right common iliac artery. This compression can lead to retrograde flow into the ascending lumbar vein (ALV) and epidural venous plexus (EVP) congestion, potentially altering spinal and intracranial pressures, and causing NDPH. This study aims to evaluate the long-term efficacy and safety of ALV embolization in treating NDPH associated with MTP, focusing on patient outcomes and symptom resolution over extended follow-up.

Materials and Methods: Three patients (100% female; mean age 47 years; range 32–57) were referred by a headache neurologist after failing cerebrospinal fluid (CSF) pressure-lowering medications, headache abortive treatments, and other minimally-invasive therapies. All underwent ALV embolization and were followed up for a mean duration of 17 months (range: 13–22 months). The mean preprocedural NDPH duration was 10 years (range: 2–24 years). Venography showed severe LCIV compression, causing retrograde ALV flow and EVP congestion. ALV embolization was performed using vascular plugs and microcoils, with no complications. Medical records were retrospectively reviewed to evaluate the outcomes during this extended follow-up period.

Results: All three patients showed significant improvement in headache severity and frequency. Two patients, followed for 15 and 22 months, reported complete resolution of daily headaches [Visual Analogue Scale (VAS) 0/10] from a preprocedural VAS 8/10 and VAS 7/10, respectively. The third, at 13 months, experienced reduced migraine frequency and severity from daily headaches (VAS 9/10) to 1-2 times weekly (VAS 2/10). Two patients had resolution of CSF-venous fistula. All patients reported enhanced quality of life and reduced reliance on headache medications.

Conclusion: This study shows that ALV embolization significantly reduced headache severity and frequency in patients with NDPH associated with MTP. While the results are promising, the possibility of a placebo effect exists and should be further evaluated through prospective clinical trials with larger cohorts. Routine lumbar vein embolization in patients with deep venous compression is not recommended; these cases involve highly selected patients managed by a multidisciplinary team, with neurologist follow-up.