Left Gonadal Vein to Inferior Vena Cava transposition for Pelvic Congestion Syndrome caused by variant gonadal vein anatomy.

Pelvic congestion syndrome is commonly identified as a constellation of symptoms that include chronic pelvic pain that is not associated with the patient’s menstrual cycle, flank pain, and dyspareunia. The underlying etiology is multi-factorial. Pelvic vein congestion can be caused by valvular insufficiency, obstruction, and/or hormones. The left gonadal vein (LGV) drains into the left renal vein (LRV) normally at a 90-degree angle. Variations in gonadal vein anatomy and valvular incompetence are known risk factors that exacerbate pelvic congestion.

Methods or Case Description:

The patient is a 24-year-old female that presented to Vascular surgery clinic with worsening dyspareunia, dull left lower quadrant pain, and chronic pelvic pain. She had a past medical history significant for HIV on anti-retroviral therapy and had never had previous abdominal surgery. Given her symptoms, patient underwent venography, and was found to have significant gonadal vein reflux. On fluoroscopy, the LGV appeared to be dilated with a significant gradient between the gonadal vein and the proximal LRV of about 25 mmHg. The patient was then taken to the operating theater for a left renal vein transposition, possible gonadal vein transposition. We performed a midline laparotomy, mobilized the ligament of Treitz, entered the retroperitoneum, and exposed the abdominal aorta, inferior vena cava (IVC), LRV, and LGV. The SMA was identified above the LRV at the base of the transverse mesocolon and was not causing compression. The gonadal vein was identified to be taking an abnormal course into the superior and posterior aspect of the LRV. The proximal LRV, when crossing over the abdominal aorta, was noted to scarred and dilated, yet widely patent. To address this abnormal vein reflux, we ligated the gonadal vein in the pelvis and transposed the proximal left gonadal vein to the IVC. 

Outcomes:

The patient did well post-operatively and was discharged on post-operative day 3 with a daily aspirin. Patient had follow-up mesenteric venous duplex that showed a patent left gonadal vein transposition. She has followed up in Vascular clinic post operatively and has had resolution of her symptoms.

Conclusion:

Variant gonadal vein anatomy such as duplicated left gonadal veins, presence of duodenal/suprarenal veins, drainage into the common iliac veins, and both gonadal veins draining into the LRV are common findings. The termination angle of the left gonadal vessels into the LRV is almost always at a right angle. Graif et al documented that blood flow in the left gonadal system is impaired as the blood flow has a take a “double 90-degree turn” prior to reaching the IVC. The right gonadal vein (RGV) drains directly into the IVC at an acute angle and in < 15% of cases, the RGV drains into the right renal vein at a right angle. In this patient, however, the abnormal insertion of the LGV at the posterosuperior aspect of the LRV has not been thoroughly documented and created pelvic congestion symptoms for the patient. This case represents the successful management for a patient with anomalous LGV drainage causing pelvic congestion with anastomosis of the LGV to the IVC.