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A and B) Laparoscopic images revealing substantial pelvic and abdominal vascularisation on the left, especially in the infundibulum and inferior vena cava, with engorged veins (white arrows) despite intra-abdominal hypertension caused by the pneumoperitoneum. C) Abdominal computed tomography scan, axial view, showing left renal vein compression by the superior mesenteric artery and aorta, with common "bird's beak" sign (circled). D) Diagnostic computed tomography angiography with coronal reconstruction showing left renal vein and gonadal vein, both dilated.
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A previous laparoscopy (Fig. 1A, B) revealed substantial pelvic and abdominal vascularisation on the left in the infundibulum and inferior vena cava, excluding the diagnosis of endometriosis. Two imaging tests (Fig. 1C, D) demonstrated compression of the LRV between the SMA and the aorta, suggesting reflux to the left ovarian vein, which was significantly dilated, and explaining the pelvic varices secondary to renal vein compression visible on laparoscopy.
A) Intra-operative phlebography revealing competent gonadal veins and the compressed area of the left renal vein, which is dilated and has slow flow. B) Final venogram demonstrating stent placement. C) Three dimensional reconstruction of computed tomography angiogram after the surgical procedure revealing the intravascular stent properly placed in the left renal vein.
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Because the diagnostic hypothesis was pelvic congestion secondary to NCS, the chosen approach was intravascular stent placement (Zilver Vena stent, 16 mm x 60 mm, Cook Medical, US) and balloon angioplasty (ATB Advance, 14 mm x 40 mm, Cook Medical, US) (Fig. 2A, B).
A) Three dimensional reconstruction of post-operative computed tomography angiogram revealing a properly placed stent and no significant nephroptosis on the right kidney. B) Doppler ultrasound after the first procedure revealing good venous flow in the left renal vein between the superior mesenteric artery and the aorta. C) Confirmation image, sagittal view, demonstrating an angle of 59  between the superior mesenteric artery and the aorta.
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Doppler ultrasound (Fig. 3B) and post-operative computed tomography (CT) angiography confirmed that the device was properly placed and the LRV compression was resolved (Fig. 3A, C). Doppler ultrasound (Fig. 6A), magnetic resonance imaging, and excretion urography revealed nephroptosis of the right kidney (Fig. 6B) that had been previously undetected (Fig. 3A).
A) Magnetic resonance image, axial view, revealing decompression of the left renal vein between the superior mesenteric artery and the aorta. B) Left renal vein stenosis by the portal vein, proximal to the vena cava, ultrasound image revealing the area compressed by the portal vein (circled).
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Doppler ultrasound and magnetic resonance angiography (Fig. 4A) confirmed that the stent was correctly placed, and a patent LRV suggested that the NCS was resolved. This examination revealed extrinsic compression of the LRV proximal to the vena cava, now by the portal vein (Fig. 4B).
Intravascular ultrasound performed during the second procedure. A) Two dimensional reconstruction showing segment with extrinsic compression. B) Pressure gradient measurement.
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Following sedation, an intravascular ultrasound (Fig. 5A) was performed, and measurement of intravascular LRV pressure before and after stent placement (Fig. 5B) showed pressure differences and extrinsic vein compression, suggestive of significant stenosis.
A) Ultrasound image after the second procedure showing proper stent coverage, preventing left renal vein compression by the portal vein. B) Nephroptosis of the right kidney, previously undetected on imaging.
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Doppler ultrasound (Fig. 6A), magnetic resonance imaging, and excretion urography revealed nephroptosis of the right kidney (Fig. 6B) that had been previously undetected (Fig. 3A).