Anesthetic Management of a Patient With Symptomatic May-Thurner Syndrome: A Case Report

Abstract

May-Thurner syndrome (MTS) is characterized by the compression of the left common iliac vein by the overlying right common iliac artery, which can lead to venous insufficiency, obstruction, and an increased risk of iliofemoral deep vein thrombosis (DVT) and pulmonary embolism (PE). We report the perioperative anesthetic management of a 38-year-old female with symptomatic MTS who underwent a total laparoscopic hysterectomy, bilateral salpingectomy, and lysis of adhesions for abnormal uterine bleeding. The patient had a history of persistent left lower extremity symptoms despite prior left common iliac vein stenting and was on chronic anticoagulation therapy with rivaroxaban. Given her history of severe postoperative nausea and vomiting (PONV), total intravenous anesthesia (TIVA) with propofol and dexmedetomidine was utilized, along with standard induction agents and antiemetic prophylaxis. Invasive arterial monitoring was employed due to her elevated thromboembolic risk, and intermittent pneumatic compression devices were applied. The patient tolerated the procedure without complications and was restarted on rivaroxaban at discharge on postoperative day two. This case highlights key perioperative considerations in patients with MTS, including thromboembolic and bleeding risks, the timing of anticoagulation cessation and resumption, and the implications for anesthetic technique. Although no definitive evidence exists favoring one anesthetic technique over another in MTS, the use of TIVA may offer theoretical benefits that need to be researched further. In addition, the use of intraoperative measures to maintain normothermia and euvolemia was prioritized to mitigate bleeding risk. This case underscores the importance of individualized anesthetic planning and multidisciplinary collaboration when managing patients with symptomatic MTS undergoing surgery.

Keywords: anticoagulation; deep vein thrombosis (dvt); may-thurner syndrome (mts); pulmonary embolism (pe); total intravenous anesthesia (tiva); vascular compression; venous stent; volatile anesthetics.

Figure 1. Axial CT view of the RCIA, LCIA, RCIV, and stented LCIV.

CT: computed tomography; RCIA: right common iliac artery; LCIA: left common iliac artery; RCIV: right common iliac vein; LCIV: left common iliac vein The pink arrow shows the RCIV. The red arrow shows the RCIA. The blue arrow shows the stented LCIV. The yellow arrow shows the LCIA.

Figure 2. Coronal CT view of the stented LCIV.

CT: computed tomography; LCIV: left common iliac vein

Figure 3. Preoperative electrocardiogram showing sinus tachycardia with otherwise normal findings.

aVR: augmented vector right; aVL: augmented vector left; aVF: augmented vector foot