Anticoagulation Management in May-Thurner Syndrome

Initial Anticoagulation Period

All patients with May-Thurner syndrome require a minimum of 3 months of therapeutic anticoagulation after stent placement to prevent thrombus extension and early recurrence, as recommended by the European Society of Cardiology and the International Society on Thrombosis and Haemostasis 1, 2
The initial 3-6 month period should use therapeutic-dose anticoagulation with either direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban, or warfarin with INR target 2.0-3.0, according to the European Heart Journal and the Journal of Thrombosis and Haemostasis 1, 4

The decision to continue anticoagulation beyond 3-6 months should favor indefinite therapy in most cases, as the persistent anatomical compression represents an ongoing risk factor, as suggested by the European Heart Journal 1
Patients with low to moderate bleeding risk (age <70 years, no previous major bleeding, no concomitant antiplatelet therapy, no severe renal/hepatic impairment, good medication adherence) may benefit from indefinite anticoagulation, according to the American College of Cardiology 3, 5

After completing 6 months of therapeutic anticoagulation, reduced-dose DOACs such as apixaban 2.5 mg twice daily or rivaroxaban 10 mg once daily may be considered to balance efficacy against recurrence with lower bleeding risk, as recommended by the European Society of Cardiology and supported by the European Heart Journal 1, 3

Patients with May-Thurner syndrome should be reassessed at minimum annually (or every 3-6 months if high bleeding risk) for bleeding risk factors, medication adherence, hepatic and renal function, and drug tolerance, as suggested by the European Heart Journal and the American College of Cardiology 1, 3