From the Guidelines
May-Thurner syndrome, a vascular condition where the left iliac vein is compressed, is typically managed with anticoagulation therapy, and in some cases, additional intervention such as stenting may be considered to address the underlying obstructive cause. When considering the management of May-Thurner syndrome, it's essential to prioritize anticoagulation as the primary treatment approach, as indicated by recent studies 1, 2. The standard of care for iliofemoral venous thrombosis, which includes May-Thurner syndrome, involves anticoagulation in patients without contraindications, with cross-sectional imaging used to assess for underlying obstructive causes 1. Some key points to consider in the management of May-Thurner syndrome include:
- Anticoagulation is generally the first-line therapy for acute iliofemoral deep vein thrombosis (DVT) 2
- Presentation of acute left-sided DVT, particularly in young and healthy patients, should raise suspicion for a compression syndrome such as May-Thurner syndrome 2
- Recurrent VTE in the affected limb has been observed more frequently with anticoagulation alone compared to those who underwent additional treatment with thrombectomy and iliac vein stenting 2
- Despite the general consensus to treat iliac vein obstructive lesions with stents in addition to anticoagulation, there is limited literature rigorously testing this practice against anticoagulation alone in prospective randomized controlled trials 2. Given the current evidence, the most appropriate management approach for May-Thurner syndrome is anticoagulation therapy, with consideration of additional interventions such as stenting on a case-by-case basis.
From the Research
May-Thurner Syndrome
- May-Thurner syndrome is an anatomical condition characterized by compression of the left common iliac vein by the right common iliac artery, causing venous outflow obstruction 3.
- It is an uncommon cause of deep vein thrombosis and is more prevalent among women, but can also occur in young males without risk factors 3.
- The condition can cause symptoms such as left lower limb pain, edema, and pallor, and can lead to deep vein thrombosis and pulmonary embolism 3.
Diagnosis and Treatment
- Diagnosis of May-Thurner syndrome can be made using duplex ultrasound, and computer tomography venography can be used to visualize the common iliac vein if it is not visible on ultrasound 3.
- Endovascular treatment, including thrombolysis and stent placement, is preferred over anticoagulation alone, especially in otherwise fit patients presenting early 3, 4.
- Anticoagulation therapy, such as warfarin or low-molecular-weight heparin, is recommended for preventing and treating venous thromboembolism, and for preventing stroke in persons with atrial fibrillation 5, 6.
- Direct oral anticoagulants, such as rivaroxaban, are alternatives to low molecular weight heparin in most cancer-associated thrombosis patients, and have been shown to be effective and safe in reducing the risk of recurrent venous thromboembolism 7.
Management of May-Thurner Syndrome
- Clinicians should have a low threshold to investigate for May-Thurner syndrome in patients with left lower limb venous thrombotic events, regardless of risk factors 3.
- Endovascular treatment, including stent placement, can be effective in reducing the risk of recurrent thrombosis and minimizing the long-term sequelae of deep vein thrombosis 3, 4.
- Anticoagulation therapy should be individualized based on patient preferences, monitoring constraints, and the risk of bleeding and interactions 5, 6.