Scultetus A H, Villavicencio J L, Gillespie D L
Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814-4799, USA.
J Vasc Surg. 2001 Nov;34(5):812-9. doi: 10.1067/mva.2001.118802.
Symptoms of pelvic venous congestion (chronic pelvic pain, dyspareunia, dysuria, and dysmenorrhea) have been attributed to massive gonadal reflux. 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. We describe the diagnosis and management of nine patients studied in our institutions.
From a group of 51 female patients with pelvic congestion symptoms studied at our institutions, there were nine patients with symptoms of pelvic congestion, microscopic hematuria, and left-sided flank pain. The diagnosis of the nutcracker syndrome was suspected based on clinical examination, Doppler scan, duplex ultrasound scan, computed tomography scan, and magnetic resonance imaging. The diagnosis was confirmed by retrograde cine-video-angiography with renocaval gradient determination and catheterization of both internal iliac venous systems. All patients had a renocaval pressure gradient >4 mm Hg (normal, 0-1 mm Hg). Renal compression was relieved by external stent (ES) in two patients, internal stent (IS) in one patient, and gonadocaval bypass (GCB) in three. GCB was preceded by coil embolization of internal iliac vein tributaries connecting with lower-extremity varicose veins in three patients. Three patients deferred surgery and are under observation. Mean follow-up time was 36 months (range, 12-72 months).
Hematuria disappeared postoperatively in all patients. ES and IS normalized the renocaval gradient and resulted in significant alleviation of symptoms (90% improvement on a scale of 0-10 where 0 = no improvement and 10 = greatest improvement). Two patients with GCB had a residual gradient of 3 mm Hg. The third patient normalized the gradient. In this group, improvement of symptoms was 60%. Patients awaiting surgery are being treated conservatively (elastic stockings, hormones, and pelvic compression). They have shown only moderate improvement.
The nutcracker syndrome should be considered in women with symptoms of pelvic venous congestion and hematuria. The diagnosis is suspected by compression of the left renal vein on magnetic resonance imaging or computed tomography scan and confirmed by retrograde cine-video-angiography with determination of the renocaval gradient. Internal and external renal stenting as well as gonadocaval bypass are effective methods of treatment of the nutcracker syndrome. IS and ES were accompanied by better results than GCB. Surgical and radiologic interventional methods should be guided by the clinical, radiologic, and hemodynamic findings.
盆腔静脉淤血的症状（慢性盆腔疼痛、性交困难、排尿困难和痛经）一直被认为是大量性腺反流所致。然而，性腺流出道梗阻也可能产生类似症状。左肾静脉的中主动脉压迫（胡桃夹综合征）会导致梗阻和反流，从而引发盆腔淤血症状。我们描述了在我们机构研究的9例患者的诊断和治疗情况。
在我们机构研究的一组51例有盆腔淤血症状的女性患者中，有9例出现盆腔淤血、镜下血尿和左侧胁腹疼痛症状。基于临床检查、多普勒扫描、双功超声扫描、计算机断层扫描和磁共振成像怀疑胡桃夹综合征的诊断。通过逆行电影血管造影测定肾腔静脉梯度并对双侧髂内静脉系统进行插管来确诊。所有患者的肾腔静脉压力梯度均>4 mmHg（正常为0 - 1 mmHg）。2例患者通过外置支架（ES）缓解了肾压迫，1例通过内置支架（IS），3例通过性腺腔静脉分流术（GCB）。3例患者在进行GCB之前，先行线圈栓塞与下肢静脉曲张相连的髂内静脉分支。3例患者推迟手术并接受观察。平均随访时间为36个月（范围为12 - 72个月）。
所有患者术后血尿消失。ES和IS使肾腔静脉梯度恢复正常，症状明显缓解（在0 - 10分的评分中改善了90%，其中0分表示无改善，10分表示改善最大）。2例行GCB的患者残余梯度为3 mmHg。第3例患者梯度恢复正常。在这组患者中，症状改善为60%。等待手术的患者正在接受保守治疗（弹力袜、激素和盆腔压迫）。他们仅表现出中度改善。
有盆腔静脉淤血和血尿症状的女性应考虑胡桃夹综合征。通过磁共振成像或计算机断层扫描上左肾静脉受压怀疑诊断，并通过逆行电影血管造影测定肾腔静脉梯度来确诊。肾内外置支架以及性腺腔静脉分流术是治疗胡桃夹综合征的有效方法。IS和ES的效果优于GCB。手术和放射介入方法应以临床、放射和血流动力学检查结果为指导。
