Cyclical Menstrual Pain Due To Nutcracker Syndrome: Atypical Presentation Of Nutcracker Syndrome
Amandeep Juneja, MD, Sneha Subramaniam, Melissa Garuthara, MD, Mihai Rosca, MD.
Long Island Jewish Medical Center, New Hyde Park, NY, USA.
History We present a case of a 34-year-old African American female with history of chronic abdominal pain for 6 years. Patient presented with intermittent cramping abdominal pain associated with her menses . She had occasional left flank pain but denied hematuria and other urinary symptoms. She was treated for this pain for 5 years with pain medication and oral contraceptive pills as workup with imaging failed to reveal a cause of the pain and it was thought to be of adnexal origin. A year ago, patient presented to the emergency department with abdominal pain and a computed tomography (CT) of the abdomen and pelvis showed evidence of left renal vein compression by the SMV and dilated left ovarian vein and para-uterine vessels. She subsequently underwent a renal venogram with pressure measurement that showed a gradient of 4mm of mercury along with findings consistent with the CT scan (Image A). Given the atypical nature of presentation she was given a trial of non-operative management with aspirin and pain management, however she continued to have pain and was offered a renal vein transposition Plan Patient underwent an exploratory laparotomy through a midline incision. and found to have dilated and engorged para-uterine vessels and left ovarian vein. A retroperitoneal exploration was performed and left renal vein(LRV) was identified. The inferior vena cava(IVC) was exposed for a length of 8cm starting from above the left renal vein origin distally. The LRV was divided. and transposed to the IVC approximately 3cm distal to its original location (Image B and C). After releasing the clamps significant decompression of the para-uterine vessels was noted. The patient received a follow up CT venogram that showed patent anastomosis. The dilated LOV and para-uterine vessels were not visible. Discussion Nutcracker syndrome is a rare condition resulting from compression of the LRV between the abdominal aorta and the superior mesenteric artery. Typical symptoms include flank pain and hematuria. Endovascular LRV stenting has been described as a treatment option for these patients, however, open surgery with LRV to IVC transposition is preferred. Other surgical options include LOV transposition or SMA transposition.
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