What is the surgical treatment for May Thurner syndrome?

Surgical Treatment of May Thurner Syndrome

Endovascular stent placement is the recommended surgical treatment for symptomatic May Thurner syndrome, with stent sizing 1-4mm larger than the reference vessel diameter and length >60mm to prevent migration. 1

Diagnosis and Evaluation

Before surgical intervention, proper diagnosis is essential:

• Initial imaging with ultrasound duplex Doppler of lower extremities
• Confirmation with advanced imaging:
  • CT Venography (CTV)
  • MR Venography
• Assessment of compression severity by measuring vessel diameter

Surgical Treatment Algorithm

1. Endovascular Approach (First-Line)

• Catheter-Directed Thrombolysis (CDT) or Pharmacomechanical Catheter-Directed Thrombolysis (PCDT)

  • Indicated when thrombosis is present
  • Dissolves existing thrombus before stent placement 1

• Endovascular Stent Placement

  • Technical specifications:
    • Stent size: 1-4mm larger than normal reference vessel diameter
    • Stent length: >60mm to prevent migration
    • Self-expandable stents preferred (83-98% anatomic success rate)
    • Pre- and post-stent dilation to match reference vessel 1

2. Post-Procedure Management

• Anticoagulation Therapy

  • For patients with previous thrombosis: 3-6 months of anticoagulation
  • Options include:
    • Low-molecular-weight heparin (LMWH)
    • Direct oral anticoagulants (preferred over unfractionated heparin) 1, 2
  • For patients without thrombosis history: anticoagulation may not be necessary 1

• Follow-up Protocol

  • Regular clinical surveillance with imaging
  • Doppler ultrasonography to monitor:
    • Resolution of compression
    • Stent patency
    • Recurrent thrombosis 1

Special Considerations

• Right-sided May Thurner Syndrome

  • Rare variant that may occur with left-sided inferior vena cava
  • Management principles remain the same: angioplasty, thrombolysis, and endoluminal stent placement 3

• Anatomical Variations

  • The syndrome involves compression of the left common iliac vein between the right common iliac artery and the spine
  • Can lead to intraluminal web formation inside the vein 4, 5

Outcomes and Complications

• Success Rates

  • Long-term patency rates for properly placed stents: 96-99% 1
  • Endovascular management has shown excellent outcomes compared to conservative management 5, 6

• Potential Complications

  • Stent migration
  • Stent stenosis
  • Thrombosis (may require repeat stenting) 2
  • Insertion site thrombosis (10% of cases) 1

Conclusion

Endovascular stent placement represents the current standard of care for May Thurner syndrome, replacing historical approaches of anticoagulation alone. This approach addresses both the mechanical compression with stent placement and the thrombus burden with chemical dissolution when necessary 6. Conservative management with anticoagulation alone has shown poor outcomes due to the mechanical nature of the obstruction 5.