VCI 1. Is the Nutcracker Syndrome the Most Important Actor in the Presence and Presentation of the Pelvic Congestion Syndrome?

Abstract

The objective of this study was to show a discrepancy in the real causes of the pelvic congestion syndrome. In our experience obtained in the Central Military Hospital, Mexico City, a hospital of the highest level in the Mexican armed forces with >700 hundred beds, we have found a great discrepancy in what has been published around the world concerning the nutcracker syndrome as the main cause of the pelvic congestion syndrome. Our experience is with 29 patients who were treated with an endovascular procedure in a period of 3 years to correct a well-studied and diagnosed congestive pelvic syndrome. We found four main patterns of occlusion and reflux of this pathologic process. These four patterns describe the majority of reflux caused by the pelvic congestion syndrome because they compromised the pelvic venous drain. However, we identified that the nutcracker syndrome is by far the rarest etiologic origin for the pathologic process in contrast to when we compare our results with the published results. The four major occlusion and reflux behaviors that affected the pelvic venous drain system and caused congestion in our series are the following: 19 cases of pelvic congestion syndrome caused by a stenosis or occlusion of the iliocaval union (May-Thurner syndrome); 7 cases of pelvic congestion syndrome caused by a stenosis or occlusion of the iliocaval union (May-Thurner syndrome) plus reflux of the left gonadal vein without clamping of the renal vein (nutcracker syndrome); 3 cases of pelvic congestion syndrome caused by reflux of the left gonadal vein without clamping of the renal vein (nutcracker syndrome) or occlusion of the ilio caval union; and 0 cases of pelvic congestion syndrome by compression of the renal vein alone (nutcracker syndrome). We have found a strong association between May-Thurner syndrome and gonadal vein reflux without clamping of the renal vein as the main cause of pelvic congestion syndrome in nearly 89% (the first two groups) and no presentation of the nutcracker syndrome, making it a rare condition yet to be found in our series. The nutcracker syndrome has been described in several publications as the origin of the pelvic congestion syndrome, and in some publications it is referred to as the main actor. However, in our series, there is clearly a great discrepancy related to what has been published compared with our findings.