Endovascular treatment of the nutcracker syndrome with secondary pelvic congestion syndrome: A case report

Abstract

Introduction: Pelvic congestion syndrome (PCS) is a relatively rare disease caused by various etiologies, including reflux or obstruction of the gonadal, gluteal, or periuterine veins. Consequently, its diagnosis is difficult, and it is often underdiagnosed in clinical practice. The nutcracker syndrome (NCS), which is characterized by symptoms arising from the compression of the left renal vein (LRV) between the superior mesenteric artery and aorta, is one of the etiologies of PCS. Various approaches have been proposed for the treatment of NCS with secondary PCS; nonetheless, no validated methods are currently available. Herein, we report the case of a 60-year-old female patient diagnosed with NCS and secondary PCS. Additionally, we describe the novel manner in which she was successfully treated with endovascular treatment, in the form of LRV stenting. Case report: The patient presented to our department with a chronic unknown etiology of fatigue and dull pain in the lower abdominal, pelvic, and bilateral outer thigh muscles. Contrast-enhanced computed tomography (CT) revealed left ovarian vein reflux and the presence of pelvic varicose veins, leading to the diagnosis of PCS secondary to the NCS. Results: We performed LRV stent placement using a 12 x 40 mm stent (E-Luminex; BARD Inc., Billerica, Massachusetts, USA). Her symptoms resolved after a month post-stenting. The post-stenting contrast-enhanced CT showed resolution of the pelvic varicose veins. Conclusions: LRV stenting is an advantageous treatment option for PCS secondary to the NCS because it is minimally invasive and allows for hemodynamic evaluation during treatment.

Keywords

• Pelvic congestion syndrome
• Nutcracker syndrome
• Left renal vein
• Aorta
• Superior mesenteric artery
• Venous hypertension