Left Ovarian Vein Transposition to Restore Renal Venous Outflow in a Patient With Severe Pelvic Congestion After Multiple Endovascular and Failed Open Procedures for Nutcracker Syndrome.

Introduction: Nutcracker syndrome (NCS) results from compression of the left renal vein between the superior mesenteric artery and aorta, leading to impaired venous outflow. This rare condition may cause a spectrum of symptoms, including haematuria, abdominal or pelvic pain, and features of pelvic congestion. Although endovascular stenting is a common treatment, it carries the risk of significant complications. Report: A 29 year old woman presented with severe pelvic pain, left flank discomfort, and lower extremity oedema. Her history included a diagnosis of NCS treated by left renal vein (LRV) stenting, which was complicated by stent migration into the inferior vena cava that required open surgical removal and LRV re-implantation. This procedure was further complicated by retroperitoneal bleeding that necessitated surgical evacuation. At presentation, imaging revealed thrombosis of the reconstructed LRV and a markedly dilated left ovarian vein (LOV), which had become the main renal outflow pathway. Endovascular recanalisation of the reconstruction was attempted but failed. The patient subsequently underwent open surgical transposition of the LOV to the left external iliac vein via an extraperitoneal approach. Post-operative imaging confirmed patency of the transposed vessels and the patient experienced significant symptom relief. Discussion: Nutcracker syndrome can present diagnostic and therapeutic challenges, especially in patients with previous failed interventions. While endovascular techniques are less invasive, they may be associated with serious complications, including stent migration. In selected cases, open surgery remains a valuable option. Transposition of the LOV to the external iliac vein may represent a feasible and effective alternative in patients with suitable anatomy and failure of other options.