Treatment of May-Thurner Syndrome
Endovascular intervention with stent placement is the preferred treatment for May-Thurner syndrome, typically preceded by catheter-directed thrombolysis when acute deep vein thrombosis is present. 1
Initial Management for Acute Presentation
When patients present with acute iliofemoral DVT secondary to May-Thurner syndrome:
Begin immediate anticoagulation with intravenous unfractionated heparin (UFH) or low molecular weight heparin (LMWH) as first-line therapy. 2
Catheter-directed thrombolysis (CDT) or pharmacomechanical catheter-directed thrombolysis (PCDT) is recommended for extensive iliofemoral DVT to prevent post-thrombotic syndrome in patients at low bleeding risk. 1, 2
Urgent CDT or PCDT is mandatory for patients with limb-threatening circulatory compromise (phlegmasia cerulea dolens). 1, 2
Complete thrombolysis can be achieved in approximately 77% of patients with this approach. 3
Definitive Endovascular Treatment
The cornerstone of MTS treatment addresses the underlying mechanical compression:
Angioplasty and stenting of the compressed iliac vein should be performed after thrombus removal to address the anatomical compression of the left common iliac vein. 1, 4
Stent placement following thrombus removal significantly reduces early rethrombosis compared to thrombus removal alone. 1
Technical success rates exceed 90%, with mean 1-year patency rates of 96%. 4
Intravascular ultrasound (IVUS) or venography should guide stenting for lesions with >50% diameter stenosis. 5
Long-Term Anticoagulation
Following endovascular intervention:
Transition to oral anticoagulation with warfarin (target INR 2.0-3.0) overlapped with initial anticoagulant for minimum 5 days and until INR >2.0 for at least 24 hours. 2
Direct oral anticoagulants (DOACs) such as rivaroxaban can be considered as an alternative to warfarin, though evidence is more limited in this specific population. 2, 6
Alternative Surgical Approach
- Surgical venous thrombectomy by experienced surgeons may be considered only in patients with contraindications to or failure of catheter-directed therapies. 1
Clinical Outcomes
The endovascular approach demonstrates excellent results:
Complete or partial symptom relief occurs in 92-95% of patients at mean follow-up of 22-30 months. 5
Primary patency at 36 months is 91% with secondary patency of 95% in post-thrombotic patients. 5
Stent patency remains complete in 90% of patients during medium-term follow-up. 3
Treatment significantly reduces the risk of post-thrombotic syndrome and improves quality of life. 1
Important Caveats
Female patients are more likely to have left-sided symptoms (odds ratio 4.88) compared to male patients. 5
The majority of MTS patients are female (72%) presenting with acute DVT (77%). 4
Regular duplex ultrasound follow-up is recommended to evaluate venous patency and stent function. 2
IVC filter placement should be considered only if contraindications to anticoagulation exist or anticoagulation fails with recurrent PE. 2