| Summary: | We report the management of symptomatic May-Thurner syndrome refractory to endovascular techniques with left gonadal vein to inferior vena cava bypass. The patient's presentation was exceptional—a young individual with end-stage renal disease status post four failed kidney transplants, dwindling options for dialysis access, and an unusable left thigh arteriovenous graft owing to severe lower extremity edema secondary to common iliac vein compression. Postoperatively, swelling was markedly alleviated and the thigh graft was functional. Discussed are endovascular and venous bypass techniques for management of May-Thurner-associated lesions, as well as approaches to end-stage hemodialysis access salvage. Keywords: May-Thurner syndrome, Hemodialysis access salvage, Venous bypass, Iliac venous system
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