Iliofemoral Deep Vein Thrombosis After Onset of Oral Contraceptive Pills in a Young Female Patient with Previously Undiagnosed May-Thurner Syndrome

Purpose: May-Thurner syndrome (MTS) is characterized by compressive obstruction of the left iliac vein by the right common iliac artery. This results in an increased incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), and symptoms of postthrombotic syndrome. The estimated incidence of MTS anatomy is 22% to 24%. However, the progression to thrombosis is believed to be influenced by factors related to the patient’s coagulation profile. The increased risk of DVT in patients taking oral contraceptive pills (OCPs) is well reported. In the presence of underlying iliofemoral venous obstruction, anticoagulation alone has proven to be ineffective, and venoplasty and stenting of the obstruction has proven to be most efficacious. We aim to present a young female patient with previously undiagnosed MTS who presented with DVT after initiation of OCPs.

Materials and Methods: A 19-year-old woman with previously undiagnosed MTS presented with acute left iliofemoral DVT after the initiation of OCPs. Diagnosis of DVT was made by history, PE, duplex ultrasonography, and computed tomography. The patient underwent screening for hypercoagulable disorders. Treatment included anticoagulation with intravenous heparin followed by endovascular intervention. An inferior vena cava (IVC) protective embolic device was placed during intervention, and single-session thrombectomy with left common iliac venous stent placement was performed. Postoperatively, the patient was started on aspirin and transitioned to Eliquis. Duplex ultrasonography and clinical examination were performed at 1 month. Hypercoagulable workup was negative.

Results: The patient had left iliofemoral thrombosis with clot extension into the infrarenal IVC. Thus, an IVC protective embolic device from the contralateral limb was placed during intervention. Successful thrombectomy with complete thrombus removal was noted on venography and intravascular ultrasonography (IVUS). However, IVUS demonstrated 100% occlusion of the left common iliac vein. The patient was treated with a self-expanding nitinol VICI venous stent of the left iliac vein. The overall technical success rate was 100% with complete thrombus removal and stent patency documented at the end of the procedure and at 1 month. There were no complications. The patient experienced resolution of her clinical symptoms.

Conclusions: Women taking OCPs presenting with left-sided iliofemoral DVT should be screened for underlying May-Thurner anatomy. When MTS is diagnosed, aggressive endovascular management should be pursued with venoplasty and stenting of the underlying obstruction in addition to anticoagulation.