Current results of left gonadal vein transposition to treat nutcracker syndrome

Published:March 14, 2021DOI:



      Nutcracker syndrome can cause disabling chronic pain requiring surgical intervention. At present, data describing a straightforward management approach are lacking. Transposition of the left gonadal vein is one of the surgical therapeutic alternatives. The aim of the present study was to describe our clinical results with gonadal vein transposition.


      All 11 patients from three centers who had undergone left gonadal vein transposition for nutcracker syndrome from 2016 to 2019 were retrospectively included. The surgical cases were mainly selected according to the morphologic criteria of the left gonadal vein. The diameter and length dictated the type of approach (laparotomy or retroperitoneal) and the transposition level. A minimally invasive retroperitoneal approach was preferred. Pain was assessed using a numeric rating scale.


      We included 11 patients (10 women) with a median age of 35 years (range, 25-69). Preoperative computed tomography angiography showed anterior nutcracker syndrome in 10 patients (91%). All 11 patients had experienced lower back and/or pelvic pain, which was associated with pelvic congestion syndrome in 6 patients (55%) and hematuria in 5 patients (45%). The median preoperative numeric rating scale score for pain was 7.0 (range, 3.5-10.0) and 6.0 (range, 3.5-8.0) for lower back pain and pelvic pain, respectively. At the level of the iliac vein crossing (external or common), the median diameter of the left gonadal vein was 7.87 mm (range, 6.45-11.28). The left gonadal vein was transposed to the inferior vena cava in one case (9%), the left external iliac vein in five (45%), and the left common iliac vein in five cases (45%). The median in-hospital stay was 4 days (range, 2-20 days). Two early complications (18%) requiring surgical revision occurred: one of active bleeding and one hematoma. The median follow-up was 15 months (range, 6-44 months). The median postoperative pain score was 1.0 (range, 0.0-4.0) and 0.0 (range, 0.0-6.0) for lower back and pelvic pain, respectively. Incisional and/or neuropathic pain was noted, with a median score of 3.5 (range, 1.0-6.0) in seven patients (64%). Two late complications (18%) were observed: one case of thrombosis and one case of anastomotic stenosis. The hematuria had disappeared in all patients who had presented with it initially.


      Left gonadal vein transposition can be proposed as a first approach if the diameter of the left gonadal vein is sufficient to perform the anastomosis. It is an easily achievable, minimally invasive alternative that achieves satisfactory results without the use of foreign material.


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        • Ananthan K.
        • Onida S.
        • Davies A.H.
        Nutcracker syndrome: an update on current diagnostic criteria and management guidelines.
        Eur J Vasc Endovasc Surg. 2017; 53: 886-894
        • de Macedo G.L.
        • dos Santos M.A.
        • Sarris A.B.
        • Gomes R.Z.
        Diagnóstico e tratamento da síndrome de quebra-nozes (nutcracker): revisão dos últimos 10 anos.
        J Vasc Bras. 2018; 17: 220-228
        • Velasquez C.A.
        • Saeyeldin A.
        • Zafar M.A.
        • Brownstein A.J.
        • Erben Y.
        A systematic review on management of nutcracker syndrome.
        J Vasc Surg Venous Lymphat Disord. 2018; 6: 271-278
        • Gilmore B.F.
        • Benrashid E.
        • Geersen D.
        • Shortell C.K.
        Gonadal vein transposition is a safe and effective treatment of nutcracker syndrome.
        J Vasc Surg Venous Lymphat Disord. 2020 Sep 8; ([E-pub ahead of print])
        • Salehipour M.
        • Rasekhi A.
        • Shirazi M.
        • Haghpanah A.
        • Jahanbini S.
        • Eslahi S.A.
        The role of renal autotransplantation in treatment of nutcracker syndrome.
        Saudi J Kidney Dis Transpl. 2010; 21: 237-241
        • Hao J.
        • Shi H.
        • Xu H.
        • Zhu J.
        • Zhou J.
        • Du T.
        Ultrasound-assisted microsurgical left spermatic-inferior epigastric vein anastomosis for treating nutcracker syndrome-associated varicocele.
        Int Urol Nephrol. 2019; 51: 1925-1932
        • Kurklinsky A.K.
        • Rooke T.W.
        Nutcracker phenomenon and nutcracker syndrome.
        Mayo Clin Proc. 2010; 85: 552-559
        • Hartung O.
        • Azghari A.
        • Barthelemy P.
        • Boufi M.
        • Alimi Y.S.
        Laparoscopic transposition of the left renal vein into the inferior vena cava for nutcracker syndrome.
        J Vasc Surg. 2010; 52: 738-741
        • Thaveau F.
        • Nicolini P.
        • Lucereau B.
        • Georg Y.
        • Lejay A.
        • Chakfe N.
        Associated Da Vinci and Magellan robotic systems for successful treatment of nutcracker syndrome.
        J Laparoendosc Adv Surg Tech. 2015; 25: 60-63
        • Erben Y.
        • Gloviczki P.
        • Kalra M.
        • Bjarnason H.
        • Reed N.R.
        • Duncan A.A.
        • et al.
        Treatment of nutcracker syndrome with open and endovascular interventions.
        J Vasc Surg Venous Lymphat Disord. 2015; 3: 389-396
        • Miler R.
        • Shang E.K.
        • Park W.M.
        Gonadal vein transposition in nutcracker syndrome.
        Ann Vasc Surg. 2018; 46: 205.e3-205.e6
        • Wang S.Z.
        • Zhang W.X.
        • Meng Q.J.
        • Zhang X.P.
        • Wei J.X.
        • Qiao B.P.
        Laparoscopic extravascular stent placement for nutcracker syndrome: a report of 13 cases.
        J Endourol. 2015; 29: 1025-1029
        • Chen S.
        • Zhang H.
        • Shi H.
        • Tian L.
        • Jin W.
        • Li M.
        Endovascular stenting for treatment of nutcracker syndrome: report of 61 cases with long-term followup.
        J Urol. 2011; 186: 570-575
        • Hartung O.
        • Grisoli D.
        • Boufi M.
        • Marani I.
        • Hakam Z.
        • Barthelemy P.
        • et al.
        Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: lessons learned from the first five cases.
        J Vasc Surg. 2005; 42: 275-280
        • Gong X.Y.
        • Zheng W.
        • Du H.
        • Lei Y.
        • Xue Y.H.
        • Xue C.H.
        • et al.
        Treatment of nutcracker syndrome with spermatic vein ligation and iliac vein anastomosis: case report of three cases.
        Asian Pac J Trop Med. 2012; 5: 923-924
        • Rosas S.
        • Paço M.
        • Lemos C.
        • Pinho T.
        Comparison between the visual analog scale and the numerical rating scale in the perception of esthetics and pain.
        Int Orthod. 2017; 15: 543-560
        • Bookwalter C.A.
        • VanBuren W.M.
        • Neisen M.J.
        • Bjarnason H.
        Imaging appearance and nonsurgical management of pelvic venous congestion syndrome.
        Radiographics. 2019; 39: 596-608
        • Shin J.I.
        • Baek S.Y.
        • Lee J.S.
        • Kim M.J.
        Follow-up and treatment of nutcracker syndrome.
        Ann Vasc Surg. 2007; 21: 402
        • He Y.
        • Wu Z.
        • Chen S.
        • Tian L.
        • Li D.
        • Li M.
        • et al.
        Nutcracker syndrome—how well do we know it?.
        Urology. 2014; 83: 12-17
        • Boyer T.
        • Ejargues M.
        • Hartung O.
        • Bonnabel J.
        • Marechal M.
        • Boufi M.
        • et al.
        Value of direct stenting of the left common iliac vein to treat a nutcracker syndrome (NCS) associated with a Cockett's syndrome (CS).
        Ann Vasc Surg. 2020; 68: P106
        • Meneses L.
        • Fava M.
        • Diaz P.
        • Andía M.
        • Tejos C.
        • Irarrazabal P.
        • et al.
        Embolization of incompetent pelvic veins for the treatment of recurrent varicose veins in lower limbs and pelvic congestion syndrome.
        Cardiovasc Intervent Radiol. 2013; 36: 128-132
        • Hartung O.
        Embolization is essential in the treatment of leg varicosities due to pelvic venous insufficiency.
        Phlebol J Venous Dis. 2015; 30: 81-85
        • White J.V.
        • Ryjewski C.
        • Messersmith R.N.
        • Sbrana F.
        • Schwartz L.B.
        Left ovarian to left external iliac vein transposition for the treatment of nutcracker syndrome.
        J Vasc Surg Venous Lymphat Disord. 2016; 4: 114-118