Nutcracker syndrome is a vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric artery sma and aorta, although other variations can exist 1 this can lead to renal venous hypertension, resulting in rupture of thinwalled veins into the collecting system with resultant hematuria. Mesoaortic compression of the left renal vein nutcracker syndrome produces both. A diagnosis of left renal vein entrapment nutcracker syndrome, ncs was supported by. Nutcracker syndrome ncs is a rare pathology, caused by compression of the left renal vein lrv between the abdominal aorta aa and the superior mesenteric artery sma, due to reduction of the angle between aa and sma. The nutcracker syndrome ns may lead to insufficient perirenal collaterals as well as incompetence of the left ovarian vein with consecutive ovarian vein insufficiency. Pcs was first described by taylor in 1948, 1 who described a number of specific patients suffering with pelvic pain. The nutcracker syndrome ncs is the clinical equivalent of. This allows blood to build up or pool, causing pressure and bulging veins resulting in varicose veins in the pelvis. Nutcracker phenomenon of the renal vein and venous pathology of the left kidney. A diagnosis of nutcracker syndrome was made and a left renal.
Pelvic congestion syndrome may present as chronic pelvic pain, dyspareunia, andor pelvic varicosities. The underlying anatomic anomaly, first described by gant in 1937, can lead to left renal venous. In type 1 reflux pathology without a pelvic or suprapelvic obstacle, the reflux can be spontaneous, major, even almost continuous in case of steal syndrome by the ovarian vein, but it is modulated by breathing. Embolization of the ovarian and iliac veins for pelvic congestion syndrome page 1 of 5. Some subtypes of pelvic congestion syndrome include ovarian vein reflux, nutcracker syndrome, and maythurner syndrome. Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. Pelvic congestion syndrome an overview sciencedirect. Pelvic congestion syndrome and ovarian vein reflux. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence pelvic congestion syndrome. Characteristic findings of gross dilation, incompetence, and reflux of the ovarian veins are seen on venography. It also identified an abnormal mass of dilated parauterine varices. Nutcracker syndrome and radiographic evaluation of loin. Symptoms of pelvic venous congestion chronic pelvic pain, dyspareunia, dysuria, and dysmenorrhea have been attributed to massive gonadal reflux.
Whereas a fairly large body of data regarding transcatheter. Once the ovarian vein was catheterized, a nonionic lowosmolality contrast dye. The pelvic venous syndromes, which include pelvic congestion syndrome and vulvar varicosities, are poorly understood disorders of the pelvic venous circulations. The nutcracker syndrome usually affects women aged between 2040 years, especially multiparous women, and venous reflux causes varicose veins of the deep and superficial pelvic venous plexus, responsible for a clinical status typical of left flank and chronic abdominal pain, besides microhematuria. Nutcracker phenomenon and nutcracker syndrome mayo clinic. It is sometimes described as part of the gonadal vein pain syndrome, which is. Before envisaging ovarian embolization, type ii insufficiency, according to the classification described by greiner et al.
Mesoaortic compression of the left renal vein nutcracker syndrome produces. Patients presenting with signs of pelvic venous insufficiency such as vaginal pruritis, irritation, pain, recurrent vaginitis, or chronic. Vulvovaginal varicosities and pelvic congestion syndrome. Nutcracker syndrome symptoms, treatment, causes, surgery. The condition may cause chronic pain, such as a constant dull ache, which can be worsened by standing. Nutcracker syndrome accompanying pelvic congestion. Mesoaortic compression of the left renal vein nutcracker syndrome. Nutcracker syndrome ncs refers to the clinical manifestations of ncp. This syndrome results most commonly from the compression of the left renal vein between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. Nutcracker syndrome european journal of vascular and.
Endovascular treatment of pelvic congestion syndrome. However, they are also well described in asymptomatic parous women. It is a commonly missed and potentiallytreatable cause of chronic abdominopelvic pain. The presence of hematuria, proteinuria, and pain albeit atypically right sided made it nutcracker syndrome. Nutcracker phenomenon refers to compression of the left renal vein, most. Gonadal vein transposition for the treatment of nutcracker syndrome. In most cases, compression of the left renal vein is between the abdominal aorta the main artery in the abdomen and the superior mesenteric artery, which brings blood. I had a ct scan with contrast dye and my kidneys looked great.
Nutcracker syndrome accompanying pelvic congestion syndrome. Although most cases are asymptomatic, this syndrome may result to varicocele, ovarian vein syndrome, hematuria, flank or abdominal pain, lrv hypertension, and pelviuteral varices 3. Primary pelvic insufficiency includes congenital or acquired ovarian vein incompetence from nonobstructive causes. Embolization is performed if abnormal varicose veins or communication with the ovarian veins. Since the left gonadal vein drains via the left renal vein, it can also result in left testicular pain in men or left lower quadrant pain in women, especially during. Venography of the left ovarian vein showed reflux into the pelvis and dilation of 9. Mri and venographic aspects of pelvic venous insufficiency. Tayyaba ahmed do, isabel chan md, in essentials of physical medicine and rehabilitation fourth edition, 2020. Pelvic pain, varicose veins, renal veins, embolization, angioplasty. Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelviccongestion. A therapeutic option in nutcracker syndrome and ovarian. The syndrome can cause ovarian vein reflux, pelvic varices, and symptoms of pelvic congestion 16, 17.
Ovarian vein thrombophlebitis, a condition which typically presents in the first few days postpartum with iliac fossa pain, fevers, and often a pelvic or abdominal mass should be excluded if such features are present. Bilateral laparoscopic transperitonealligation of ovarian veins for treatment of pelvic congestion syndrome. Pelvic congestion syndrome radiology reference article. However, obstruction of the gonadal outflow may produce similar symptoms. Mesoaortic compression of the left renal vein nutcracker syndrome produces both obstruction and reflux, resulting in symptoms of pelvic congestion. Meissner the nutcracker syndrome is characterized by entrapment and compression of the left renal vein between the abdominal aorta and the superior mesenteric artery sma figure 1. Unusual presentation of nutcracker syndrome in patient with prior gonadal vein embolization for pelvic congestion syndrome. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein.
Unusual presentation of nutcracker syndrome in patient with prior. The diagnosis of ovarian varices is confirmed by selectively catheterizing specific veins and injecting contrast dye i. The nutcracker syndrome usually affects women aged between 2040 years. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence. Abnormal pelvic varices were discovered, and she was referred to vascular surgery for treatment of nutcracker syndrome causing ovarian vein reflux and abnormal engorgement of pelvic varices. Intravascular ultrasound revealed 75% compression of the left renal vein by the superior mesenteric artery, also known as nutcracker syndrome. The clinical syndrome caused by impingement of the left renal vein lrv between the superior mesenteric artery sma and abdominal aorta has been termed nutcracker syndrome. The important role of incompetent pelvic and ovarian veins in the etiology of pelvic congestion syndrome has emerged in recent decades thanks to the increasing number of reports dealing with this peculiar clinical condition. Embolization of the ovarian and iliac veins for pelvic.
Pelvic congestion syndrome is a condition of vascular engorgement of the ovarian veins or internal iliac veins that leads to pelvic pain. Two patients had gluteal varices localized to the left side and underwent. New procedure offers speedier recovery for patients with nutcracker syndrome. In addition, filling of the pelvic veins, vulvar varices, and occasionally even the. Pelvic congestion syndrome pcs, also known as pelvic vein incompetence or pelvic vein reflux, is a chronic medical condition in women caused by varicose veins in the lower abdomen. Early resolution of pelvic venous collaterals after endovascular. Pelvic congestion syndrome pcs is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging. Women with pcs are usually of menstruating age who report pelvic heaviness and pain that is. Although often asymptomatic, it may result in varicocele, ovarian vein syndrome, haematuria, flank or abdominal pain, lrv hypertension, and pelviureteral varices.
Chronic pelvic pain due to ovarian vein and pelvic varices varicose veins is treated using nonsurgical, minimally invasive, transcatheter techniques. Pelvic congestion syndrome ultrasound exam, risk factors. Nutcracker phenomenon ncp, also known as left renal vein entrapment, is characterized by impeded outflow from the left renal vein lrv into the inferior vena cava ivc due to extrinsic lrv compression, often accompanied by demonstrable lateral hilar dilatation and medial mesoaortic narrowing schematic representation of ncp nutcracker syndrome ncs in figure 1. Pelvic congestion syndrome, also known as pelvic vein incompetence, is a long term condition in women believed to be due to enlarged veins in the lower abdomen. Assess the scrotum for varicocele in the case of male patients and ovarian vein incompetence in. The ovs was first reported and described by clark in 1964, yet its existence as a true pathophysiological entity remains controversial. Duplex ultrasound investigation in pelvic congestion. The hemodynamic status of the gonadal vein allows the type of varicose vein to be defined. Ovarian vein valves may be absent or incompetent due to venous dilation, pelvic vein kinking, external compression, or secondary causes such as nutcracker syndrome, maythurner syndrome, portal hypertension, and acquired inferior vena cava syndrome. Google scholar see all references entrapment of the vein can occur at this point because of an abnormal superior mesenteric artery origin.
Treatmentrefractory vulvodynia from nutcracker syndrome. Ovs should be distinguished from pelvic congestion syndrome pcs. The diagnosis of pelvic congestion syndrome is established by the demonstration of multiple dilated, tortuous parauterine veins with a width 4 mm or an ovarian vein diameter greater than 56 mm 4. The nutcracker syndrome journal of vascular surgery. Ovarian and other pelvic varices such as in the distribution of the internal iliac veins are not an infrequent finding in adult women, and particularly those who have previously had at least one pregnancy associated with a vaginal delivery or at least a significant trial of labour. Ovarian vein syndrome ovs is a rare condition caused by varicose, dilated ovarian veins inducing chronic ureteral obstruction. Renal vein entrapment the nutcracker syndrome brandon t.
Pelvic congestion syndrome pcs is an underdiagnosed condition causing chronic pelvic pain. This condition results in chronic pelvic pain, estimated to affect onethird of women in the united states pelvic congestion syndrome is caused by dilatation of the ovarian andor. Pelvic congestion syndrome some prefer pelvic venous insufficiency 9 is a condition that results from retrograde flow through incompetent valves in ovarian veins. Dilated left gonadal vein and pelvic varices indicate left renal vein lrv ouflow obstruction by the superior mesenteric artery sma i ordered a renal duplex and a ct venogram for procedural planning. Our reflux series had ct findings similar to those found in the nutcracker syndrome. In addition the patient had dilated gonadal and pelvic collaterals. The diagnosis is established using duplex ultrasonography followed by selective venography according to an investigation algorithm, in order to obtain anatomic and hemodynamic information. This vascular compression may lead to hypertension of the left renal vein and a possible emergence of collateral veins 4. This leads to lrv varices, left gonadal vein varices and therefore, the pelvic congestion syndrome. Insufficiency and varicose veins embolization of the ovarian and iliac veins for. Another clinical study has shown that nutcracker syndrome is a frequent finding in varicoceleaffected patients and possibly, nutcracker syndrome should be routinely excluded as a possible cause of varicocele and pelvic congestion.
Pelvic congestion syndrome is a common cause of chronic pelvic pain in women caused by abnormal ovarian and pelvic varices. My nephrologist believes i may have nutcracker syndrome. An unusual manifestation of ncs includes varicocele formation and varicose veins in the lower limbs. Ovarian vein syndrome relation of arteries and veins to ureters, view from the back in medicine, ovarian vein syndrome is a rare possibly not uncommon, certainly underdiagnosed condition in which a dilated ovarian vein compresses the ureter the tube that brings the urine from the kidney to the bladder.