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We present a case of a 21-year-old African-American man with no significant past medical history who came to the emergency department with left lower limb swelling associated with shortness of breath, and was eventually diagnosed to have extensive left lower extremity deep vein thrombosis (DVT) along with acute bilateral extensive pulmonary embolism (PE) as a consequence to MTS. MTS should be considered in the differential when young patients present with unprovoked or recurrent left-sided DVT. Diagnosis of this anatomical variant is critical as it may need long-term anticoagulation and consideration of pharmaco-mechanical intervention such as mechanical thrombectomy and venoplasty with or without stenting.<\/jats:p>","DOI":"10.1136\/bcr-2018-227046","type":"journal-article","created":{"date-parts":[[2019,4,2]],"date-time":"2019-04-02T07:25:14Z","timestamp":1554189914000},"page":"e227046","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Acute bilateral pulmonary embolism in a 21-year-old: is May-Thurner syndrome in our differential?"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5211-1285","authenticated-orcid":false,"given":"Rajarshi","family":"Bhadra","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, Ohio, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Meyappan","family":"Somasundaram","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, Ohio, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel V","family":"Iltchev","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, St. Vincent Charity Medical Center, Cleveland, Ohio, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Keyvan","family":"Ravakhah","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, Ohio, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2019,4,1]]},"reference":[{"key":"2025082703240473000_12.4.e227046.1","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1007\/s11239-015-1316-1","article-title":"Guidance for the evaluation and treatment of hereditary and acquired thrombophilia","volume":"41","author":"Stevens","year":"2016","journal-title":"J Thromb Thrombolysis"},{"doi-asserted-by":"publisher","key":"2025082703240473000_12.4.e227046.2","DOI":"10.1111\/j.1365-2141.2009.08022.x"},{"key":"2025082703240473000_12.4.e227046.3","first-page":"101","article-title":"Prevention and treatment of venous thromboembolism. 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