Vascular surgeons Robert Hacker and Deena Chihade on venous compressions, stenting, and POTS

Vascular surgeons Drs. Hacker and Chihade describe a large subgroup of POTS/dysautonomia patients in whom venous compression syndromes—especially May-Thurner (left iliac vein compressed by the right iliac artery) and Nutcracker (left renal vein compressed between the aorta and superior mesenteric artery)—appear extremely common and potentially treatable. In their practice, roughly 95–97% of dysautonomia patients they evaluate show these compressions, which can cause pelvic and leg venous pooling, pelvic pain, heavy periods, GI and bladder issues, headaches, and classic POTS symptoms by limiting venous return to the heart. They use detailed history, targeted duplex ultrasound, and then a diagnostic venogram with intravascular ultrasound (IVUS); treatment, when chosen, is minimally invasive stenting of the compressed veins (typically a covered stent in the left renal vein and a nitinol stent in the left iliac vein), done under local anesthetic plus light sedation, usually in under 30 minutes per site. They counsel patients conservatively—emphasizing that stents correct only the anatomical venous problem, not the entire dysautonomia—and report no serious complications to date, with many patients experiencing meaningful reductions in syncope, tachycardia burden, pelvic pain, bowel/bladder symptoms, headaches, and exercise or daily-function limitations (occasionally near-complete remission, more often partial but important improvement). They see similar compressions and benefits in patients with EDS and/or MCAS, argue that chronic venous pooling may help drive mast-cell and autonomic overactivation, and stress that sensitive patients have tolerated modern contrast and stent materials well in their series. They differentiate their approach from some interventional radiology practices that focus on coiling pelvic veins without stenting the upstream compression, which they believe often worsens symptoms. Overall, they propose that venous compression is a major, under-recognized contributor to POTS/dysautonomia in many patients, and that systematic evaluation and carefully performed stenting—within a broader multidisciplinary POTS care plan—can restore significant function for selected individuals. Their information and images are available at stlvascular.com and on Instagram at @STLvascular.