Endovascular Management of Renal Arteriovenous Fistula Associated with Nutcracker Syndrome

Renal arteriovenous fistulae (AVFs) and Nutcracker syndrome (NCS) are rare vascular anomalies. This report describes the case of a renal AVF associated with NCS presenting as pelvic congestion syndrome (PCS).

A 62 year old woman presented with chronic pelvic pain and exertional dyspnoea. Imaging revealed a large left renal AVF draining into the left ovarian vein, associated with NCS. The patient underwent two stage endovascular treatment: embolisation of the left renal artery using Amplatzer Vascular Plugs (Abbott; Abbott Park, IL, USA), followed nine months later by embolisation of pelvic varices using glue. Symptoms resolved completely and were sustained at the four year follow up.

The co-existence of renal AVFs and NCS may exacerbate venous hypertension and aggravate PCS symptoms. Endovascular embolisation offers a safe, minimally invasive, and effective therapeutic option in anatomically complex cases, avoiding the morbidity of open surgery. This case highlights the need to consider vascular anomalies such as AVFs and NCS in women with PCS. Staged endovascular embolisation can provide excellent outcomes in select patients.