What is the recommended treatment for May-Thurner syndrome?

Management of May-Thurner Syndrome

For patients with May-Thurner syndrome, endovascular stent placement following catheter-directed thrombolysis is the recommended treatment approach, as standard anticoagulation alone is insufficient for treating MTS-related DVT. 1

Diagnosis and Presentation

May-Thurner syndrome (MTS) is characterized by compression of the left common iliac vein by the right common iliac artery against the lumbar spine, resulting in venous outflow obstruction. Common presentations include:

• Left-sided lower extremity deep vein thrombosis (most common)
• Recurrent unprovoked DVTs of the left lower extremity despite anticoagulation
• Venous claudication
• Chronic leg swelling
• Skin changes consistent with venous insufficiency
• Venous ulceration in advanced cases 1

Treatment Algorithm

1. Acute DVT with May-Thurner Syndrome

• First-line therapy: Catheter-directed thrombolysis (CDT) or pharmacomechanical catheter-directed thrombolysis (PCDT) followed by endovascular stent placement 2, 1

  • Indications: Limb-threatening circulatory compromise, rapid thrombus extension despite anticoagulation, or symptomatic deterioration despite anticoagulation 1
  • CDT has shown technical success rates of 91.3% with complete thrombolysis achieved in 77.7% of DVT patients 3

• Stent placement: Self-expanding venous stents in the compressed iliac vein segment after thrombolysis 1

  • Improves patency rates compared to anticoagulation alone
  • Studies show 90-96% patency rates at 1-year follow-up 3, 4

2. Chronic May-Thurner Syndrome without DVT

• Treatment: Angioplasty and stent placement in the compressed venous segment 3
• Follow-up: Regular monitoring with duplex ultrasound to assess stent patency 1

3. Post-Procedural Management

• Anticoagulation: Required after stent placement for at least 6 months 1
  • May need to be extended or indefinite in cases of recurrent thrombosis
  • Traditional anticoagulation with warfarin has been the standard, though limited evidence suggests novel oral anticoagulants like rivaroxaban may be effective 5

Outcomes and Follow-up

• Complete symptomatic regression occurs in approximately 82.6% of patients following endovascular treatment 3
• Regular follow-up with Doppler ultrasonography is essential to monitor stent patency 3
• Long-term anticoagulation decisions should be based on:
  • Stent patency
  • History of recurrent thrombosis
  • Presence of other thrombotic risk factors

Important Considerations

• MTS should be considered in all patients with left-sided DVT, especially young females, though it can occur in males as well 6
• Early intervention is critical to prevent post-thrombotic syndrome and chronic venous hypertension 6
• Endovascular treatment has largely replaced open surgical approaches due to lower morbidity and good technical success rates 7, 4
• Without appropriate treatment (stenting), patients with MTS have high rates of recurrent DVT and post-thrombotic syndrome 2

Potential Complications

• Stent restenosis or thrombosis (occurs in approximately 10% of cases) 3
• Incomplete thrombolysis
• Bleeding complications from thrombolytic therapy
• Post-thrombotic syndrome if treatment is delayed or inadequate

The evidence strongly supports that endovascular intervention with stenting is superior to anticoagulation alone for May-Thurner syndrome, with high technical success rates and significant symptom improvement in the majority of patients.