Not Uncommon, Rather Underdiagnosed: A Case Series of Nonhealing Leg Ulcers Attributable to Right-sided Nonthrombotic Iliac Vein Lesion

Purpose: Right-sided nonthrombotic iliac vein lesions (NIVLs) are a clinically significant but frequently underrecognized cause of chronic, nonhealing venous leg ulcers. While classical May–Thurner syndrome typically involves left iliac vein compression, right-sided nonthrombotic compressions, often due to anatomical variants or external factors, can result in significant venous hypertension and persistent ulceration, despite the absence of thrombosis or prior deep vein thrombosis (DVT). Methods: In this retrospective analysis at a single tertiary vascular center (September 2023–June 2025), 44 patients with chronic lower limb ulcers were evaluated. Right common iliac vein compression (≥50% stenosis by intravascular ultrasound IVUS) but no DVT was documented in 13 (29.5%) patients. All patients had ulcers refractory to standard compression therapy. IVUS confirmed right iliac vein stenosis, and patients with ≥60% compression underwent endovascular stenting with venous stent. Results: This cohort represented the largest single-center series focusing on right-sided NIVL (13 cases) and associated ulceration, demonstrating that endovascular intervention is safe and effective. Postintervention, 12 out of 13 cases of ulcer healing were observed at the end of 6 months, underscoring the contribution of proximal venous outflow obstruction to ulcer chronicity. Conclusion: Early recognition and management of right-sided NIVLs could significantly reduce morbidity, ulcer chronicity, and associated healthcare burden. Routine noninvasive imaging like duplex was often inconclusive, highlighting the importance of central venous assessment with advanced modalities like IVUS in refractory, unilateral leg ulcers.