Table 1 Abdominopelvic vascular compression syndromes
Compression syndrome | Cause | Clinical features | CT key findings | Treatment |
|---|---|---|---|---|
Median arcuate ligament syndrome | Compression of the celiac artery by the median arcuate ligament | Chronic postprandial epigastric pain, nausea and loss of weight | The hooked appearance of the celiac artery in the absence of atherosclerotic plaques; post-stenotic dilatation; collateral vessels; true pancreaticoduodenal arteries aneurysms | Endovascular: embolization of pancreaticoduodenal aneurysms and celiac artery revascularization with stent placement; surgical: transection of the median arcuate ligament, celiac ganglionectomy and bypass surgery |
Nutcracker syndrome | Anterior NCS: compression of the LRV between the aorta and the SMA | Hematuria, gonadal vein reflux, and pelvic varices | “Beak sign” of LRV; AMA lower than 35°; AMD from 2 to 8 mm | Conservative: in patients with tolerable symptoms. Surgical for anterior NCS: transposition of LRV or left gonadal vein, saphenous vein cuff or vein patch; for posterior NCS: anterior reimplantation of retroaortic LRV; endovascular: LRV stenting for the treatment of NCS associated with pelvic congestion |
Posterior NCS: compression of the LRV between the aorta and vertebral body | ||||
May-Thurner syndrome | Compression of the left common iliac vein between the overlying right common iliac artery and the V lumbar vertebra | Left lower extremity swelling, edema, varicose veins, venous ulcers, acute pulmonary embolism or phlegmasia cerulea dolens | Iliac vein compression and adjacent deep vein thrombosis | Conservative: in absence of deep venous thrombosis. Endovascular: stent placement with thrombolysis or anticoagulation therapy in patients with acute venous thrombosis; surgical: thrombectomy, vascular transposition, venous bypass, and venoplasty |
Superior mesenteric artery syndrome | Compression of the third portion of the duodenum between the abdominal aorta and the SMA | Postprandial abdominal pain, loss of weight, nausea, and vomiting | Compression of the third portion of the duodenum, with upstream severe dilatation of proximal duodenum and stomach; AMA lower than 22°; AMD shorter than 8 mm | Conservative: decompression through nasogastric tube placement; surgical: duodeno-jejunostomy for patients with severe symptoms |
Ureteropelvic junction obstruction | Compression of the ureteropelvic junction by “crossing vessels” (i.e. lower pole segmental renal vessels) | Flank pain, hematuria, urolithiasis, urinary tract infections or pyelonephritis | Hydronephrosis; renal pelvis with inverted “teardrop” appearance, which typically “drapes” over the lower pole segmental vessel | Surgical: endopyelotomy, pyeloplasty and vessel transposition |
Ureteral vascular compression syndromes | Compression of the ureter by adjacent common iliac artery aneurysm or dilated or aberrant ovarian vein | Flank pain, hematuria or pyelonephritis | Hydronephrosis and ureter dilatation by common iliac artery aneurysm or a dilated ovarian vein in absence of urinary calculi or tumoral strictures | Endovascular: transcatheter ovarian vein embolization; surgical: laparoscopic uretero-ureterostomy, ovarian vein ligation |
Portal biliopathy | Compression of biliary ducts by “portal cavernoma” | Chronic cholestasis, jaundice, choledocholithiasis, cholangitis, and secondary biliary cirrhosis | Bile duct dilatation; the presence of portal cavernoma; acute angulation of the common bile duct forming a “kinking”, “scalloping” or “wavy” delineation of the extrahepatic biliary ducts | Interventional: nasobiliary or biliary stent placement and portal vein recanalization with TIPS placement; surgical: hepaticojejunostomy or choledochoduodenostomy |