4:03 PM Abstract No. 368 Nutcracker syndrome as a cause of recurrent symptoms in pelvic congestion syndrome patients who underwent gonadal vein embolization

Abstract

Left renal vein compression by the SMA (nutcracker syndrome) prevents normal flow from the left renal vein into IVC and can divert flow into the left ovarian vein in women, resulting in pelvic congestion syndrome symptoms. In these patients, embolization of the left ovarian vein result in renal venous hypertension, which may predispose patients to new or recurrent symptoms. The purpose of this study was to investigate the clinical implications of left renal vein compression in patients who underwent left ovarian vein embolization. In this retrospective study, 79 patients underwent left ovarian vein embolization. Of these, 40 females (mean age 44.5 years) had a contrast-enhanced CT or MRI prior to the procedure and adequate clinical follow-up. Electronic medical records were reviewed to capture clinical symptomology before and after embolization. On preprocedural CT or MRI, the percent compression of the left renal vein (LRV) by the SMA was measured, as was the diameter of the left lumbar vein at the level of the LRV. Categorical variables were compared with the chi square test. Left ovarian vein embolization was performed due to pelvic pain in 33 patients. In 7 patients, embolization was performed due to leg pain, swelling, or varicosities without pelvic pain. Of the patients with pelvic pain, 75% had improvement in symptoms. Overall, 27 patients reported recurrent, new, or unimproved pelvic pain or flank pain at a median of 159 days. In patients with 60% or greater narrowing of the LRV at the level of the SMA, 80% had recurrent/new/unchanged symptoms compared to 28% in patients without LRV compression (p = 0.003). The presence of a prominent left lumbar vein was significantly associated with LRV compression (p<0.001). The presence of both LRV compression and a prominent left lumbar vein had a 100% positive predictive value for recurrent/new/unimproved symptoms. The presence of nutcracker syndrome correlated significantly with recurrent or new symptoms after left ovarian vein embolization. Assessing its presence prior to embolization may be important to optimize outcomes; an alternative therapy may be warranted.