May Thurner Syndrome: Can we stent it and forget it ?

Background: May-Thurner Syndrome (MTS) is a cause of venous obstruction and acute Deep Vein Thrombosis (DVT) in young females, due to extrinsic venous compression of left ilio-caval venous territory. It generally presents with unilateral lower limb swelling and DVT and long-term management requires endovascular stenting with anticoagulation. Little data is available on long term post-interventional outcomes. Case: A 73-year-old female with MTS, who underwent endovascular stenting of left external and common iliac vein 11 months ago, presented with recurrent symptoms. She had completed almost a year of oral anticoagulation with Eliquis approximately 45 days before presentation. She was found to have extensive left lower limb DVT with stent occlusion and bilateral multiple pulmonary emboli (PE). The patient was immediately initiated on heparin anticoagulation and underwent catheter mediated thrombolysis with complete dissolution of DVT and clinical improvement. She recovered and was discharged on indefinite oral anticoagulation. Discussion: In our case, the patient was diagnosed at an unusual age and had a complication of PE that is also less commonly seen with DVTs arising out of MTS lesions. The effect of stenting on this PE risk if DVT recurs, is not known and her recurrence was after she completed current guideline recommended management. These atypical features and knowledge gaps highlight the need for more data on MTS, especially for anticoagulation policies after stenting. Conclusion: May Thurner Syndrome is an important cause of acute DVT and lower limb swelling. Our case highlights the possibility of recurrence and its risk for PE, despite recommended definitive management.