What is the treatment for May Thurner syndrome?

Treatment of May-Thurner Syndrome

The standard treatment for May-Thurner syndrome includes endovascular intervention with stent placement followed by anticoagulation therapy to prevent recurrent deep vein thrombosis and post-thrombotic syndrome. 1

Understanding May-Thurner Syndrome

• May-Thurner syndrome (MTS) is an anatomical variant characterized by compression of the left common iliac vein by the overlying right common iliac artery against the lumbar vertebrae, leading to venous stenosis 1, 2
• This compression predisposes patients to deep vein thrombosis (DVT), particularly in the left lower extremity 3
• While more common in women, MTS can also occur in men and should be considered in young patients with left-sided DVT without other risk factors 2

Diagnostic Approach

• Duplex ultrasound is the first-line imaging examination for suspected DVT, though it may not visualize the common iliac vein compression 4
• CT venography or MR venography should be performed when MTS is suspected to visualize the iliac vein compression 1, 4
• Diagnosis should be considered in patients with left-sided iliofemoral DVT, especially when unprovoked or recurrent 1

Treatment Algorithm

1. Acute Management with Limb-Threatening Compromise

• Catheter-directed thrombolysis (CDT) or pharmacomechanical catheter-directed thrombolysis (PCDT) is recommended for patients with iliofemoral DVT associated with limb-threatening circulatory compromise (phlegmasia cerulea dolens) 1
• Transfer to a center with endovascular thrombolysis expertise should be considered if these capabilities are not available locally 1

2. Standard Treatment Approach

• Endovascular intervention with stent placement is the preferred treatment for MTS to address the mechanical compression 1, 5
• Options include:
  • Catheter-directed thrombolysis to dissolve the existing thrombus 1, 6
  • Pharmacomechanical thrombectomy to remove the thrombus 2
  • Angioplasty and stenting of the compressed iliac vein 1, 6
• Anticoagulation therapy should be initiated and continued after intervention 5, 2, 3

3. Anticoagulation Options

• Traditional approach includes warfarin therapy following initial heparinization 5, 3
• Novel oral anticoagulants (NOACs) like rivaroxaban or apixaban can be considered as alternatives to warfarin 5, 2
• Duration of anticoagulation is typically long-term to prevent recurrent thrombosis 5, 3

4. Follow-up Management

• Regular imaging follow-up to assess stent patency 5
• Monitoring for signs of recurrent thrombosis or post-thrombotic syndrome 6
• Continued anticoagulation as prescribed 5, 2

Special Considerations

• Anticoagulation alone is generally insufficient for MTS as it does not address the underlying mechanical compression and may lead to recurrent DVT or post-thrombotic syndrome 6
• Surgical venous thrombectomy by experienced surgeons may be considered in patients with iliofemoral DVT who have contraindications to or failure of catheter-directed therapies 1
• Rare variants such as right-sided MTS can occur in patients with anatomical variations like left-sided inferior vena cava 7

Treatment Efficacy

• Endovascular treatment with stenting has shown good outcomes in maintaining venous patency 1
• Studies have demonstrated that stent placement following thrombus removal significantly reduces the rate of early rethrombosis compared to thrombus removal alone 1
• Proper treatment reduces the risk of post-thrombotic syndrome and improves quality of life 1