Treatment rationale in nutcracker syndrome with concurrent pelvic congestion syndrome

Abstract

The optimal management strategy of nutcracker syndrome is debated, especially in the setting of concurrent pelvic congestion syndrome. In this article, we describe our treatment algorithm as illustrated by four different case scenarios. In our experience, renocaval pressure gradients are often inconclusive, but evaluation of the left renal vein waveform as well as a "test PTA" with evidence of a waist in the balloon can be helpful in unmasking a relevant stenosis. We consider nutcracker syndrome not to be a contraindication for ovarian vein embolization. Decision for simultaneous or sequential stenting should be based on angiographic findings and clinical course.

Keywords: Gonadal vein embolization; Nutcracker syndrome; Pelvic congestion syndrome; Stenting.

Fig. 1

a Digital subtraction venography depicting a severely refluxing left ovarian vein (1) and paravertebral venous collaterals (2) in patient 1. The aortomesenteric portion of the LRV is not opacified. b After embolization of the left ovarian vein, paravertebral and renosplenic (3) collateral flow is noticeably increased with opacification of the portal vein (4). c On inflation of a 10 mm PTA balloon, a significant waist can be seen (5). d After implantation of a 12 mm self-expandable stent, collateral flow is significantly reduced

Fig. 2

Pressure curves in the LRV (red) and the IVC (yellow) show no renocaval pressure gradient at baseline (top), after embolization of the left ovarian vein (middle) and after stenting of the LRV (bottom). Note the restored cardiac modulation of the LRV waveform after stenting

Fig. 3

Typical nutcracker anatomy in patient 2. a Sagittal reformatted CT shows a near-parallel course of the proximal SMA (black arrowhead) and the aorta. Note the slit-like compression of the LRV (white arrowhead) b Axial slices depict a focal narrowing of the aortomesenteric portion of the LRV with „beak sign “ and a hilar-to-aortomesenteric diameter ratio of > 5

Fig. 4

a Digital subtraction venography in patient 3 shows renosplenic (1) and paravertebral (2) collaterals, but only a diminutive left ovarian vein (3). b A significant waist (4) is observed on dilatation of a 10 mm PTA balloon

Fig. 5

Circumaortic course of the LRV with separate pre- and retroaortic branches (a and b, respectively) in patient 4. c After embolization of the left ovarian vein, no collaterals are seen on venography. The more cranial preaortic and the more inferior retroaortic branches are clearly depicted. d Only a minimal waist is observed in the 12 mm PTA balloon (arrowhead)

Fig. 6

Proposed treatment algorithm used in our institution for patients with PCS and suspected NCS