Nutcracker syndrome is increasingly recognized as a cause of chronic pelvic pain in women due to reflux down the left ovarian vein into the pelvis. However, treatment has been challenging. Left renal vein transposition is a major, technically challenging procedure that is associated in some cases with inadequate relief if the vein is not moved sufficiently distally and restenosis in others due to tension when moved too far. Renal vein stenting also provides adequate relief but has the inherent low risk of stent migration with catastrophic consequences. Since the left ovarian vein (LOV) crosses over and touches the left iliac vein, we have used a simple method of LOV transposition to the left iliac vein to preserve renal outflow and eliminate reflux into pelvic collaterals.1,2 This study is an analysis of the impact of Nutcracker Syndrome and its treatment on quality of life using prospectively collected SF-36 surveys.

Women who had noncyclic pelvic pain for greater than 12 months, an unremarkable gynecologic evaluation, and appropriate symptoms were evaluated for Nutcracker Syndrome with complete renal and pelvic venography, IVUS, and CT venography. Nutcracker Syndrome was diagnosed based upon the presence of ALL of the following imaging criteria: CT and IVUS confirmed compression of at least 70% of the left renal vein, reflux through the LOV, flow into smaller pelvic collaterals, and cross pelvic venous flow. If Nutcracker Syndrome was documented and the LOV demonstrated continuous reflux into the pelvis and was at least 5 mm in diameter throughout in the absence of left iliac vein compression, the patient was considered a candidate LOV transposition. The procedure was performed through a small left lower quadrant incision using a retroperitoneal approach to the left iliac and distal LOV. A 1.5 cm anastomosis between the ovarian and iliac vein was created. Follow-up venograms were obtained after 1 month. Pre-procedure and post-treatment SF-36 surveys were prospectively completed. The surveys were scored and subscale values calculated. Pre and post-op subscale values were compared for statistical significance using T-test.

Of 190 patients evaluated, 22 were found to have clinically significant Nutcracker Syndrome and 12 were considered appropriate candidates and underwent LOV transposition to the left iliac vein. The average age was 39.9 years (21-53). The procedure was technically successful in all patients. There was only 1 complication which was bleeding from an ovarian vein tributary treated by immediate return to the operating room for ligation. There were no delayed complications. All patients did well and were discharged to home after an average length of stay of 1.67 days (1-4). There were no episodes of hematuria, flank pain, or decreased renal function post-operatively. There were no episodes of iliac vein thrombosis or left leg edema. Patients were therapeutically anticoagulated for 3 months and then converted to clopidogrel. Mean follow-up was 44.5 months (8-101). Venograms (standard or CT) between 1 month and 1 year confirm patency of the ovarian vein with flow into the iliac vein in 11 of the 12 patients (92%) (Fig1). All women reported a significant improvement of chronic pelvic pain. Comparison of pre and post-procedure SF-36 scores confirm a significant improvement in quality of life after LOV transposition (Fig 2). The improvement was highly statistically significant for health change (p=0.006), role limitations due to physical disability (p=0.007), energy (p=0.01), and pain (p=0.0008).

Nutcracker Syndrome has a significant negative impact upon the quality of life of otherwise healthy women. In appropriately selected patients, LOV transposition to the left iliac vein is a simple and effective procedure for the treatment of Nutcracker Syndrome and significantly reduces or eliminates chronic pelvic pain, improves health-related quality of life, and preserves left renal function with minimal risk.

1. White JV, Ryjewski CE, Messersmith R, Sbrana F, Schwartz LB. Left ovarian to left external iliac vein transposition for the treatment of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord; 4:114-118 2. White JV, Ryjewski CE. A simple surgical approach for left ovarian vein transposition for the treatment of pelvic venous disease from nutcracker syndrome. J Vasc Surg Cases Innov Tech 2021; 7:411-414