E2743. An Anomalous Renopelvic Connection via Adrenal and Ovarian Anastamoses in the Workup of Lower Pelvic Pain
  1. Brenden Maag; The University of Central Florida
  2. Taylor Wolfe; The University of California Irvine
  3. Roozbeh Houshyar; The University of California Irvine
  4. Simon Long; The University of California Irvine
Atypical anatomy is important to characterize as it influences the approach to clinical and procedural management of disease. Here, we review a case of an anastomosis between the left adrenal vein and peri-uterine venous plexus via left gonadal vein and phrenic vasculature in a 28-year-old female during evaluation for pelvic congestion syndrome. With further developments in angiography and 3D vascular modeling, an expansion of common knowledge regarding anastamotic possibilities is important to characterize and treat these vascular diseases.

Educational Goals / Teaching Points
The educational goals of this are to describe the presentation of pelvic congestion syndrome and May-Thurner syndrome as it relates to complex pelvic anatomy. This educational presentation will overview the common etiology, signs, and symptoms of these pelvic vascular diseases. Additionally, this presentation will describe the variant anatomy that can complicate the presentation of these diseases, and additionally describe anatomic variants that may act to mimic these diseases. The discussion will focus on thorough characterization of the lesions and anastamoses in question as it relates to the timing and approach to therapy. This will include a discussion of the imaging findings, appropriate angiographic technique, and supplemental imaging methods.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The key anatomic issue presented in this project involves a reno-pelvic anastamosis secondary to May-Thurner syndrome and imaging-confirmed Nutcracker syndrome that developed by way of an anomalous connection between the left adrenal/phrenic vein and ipsilateral ovarian vein. This is demonstrated on imaging findings as an unobstructed pathway between the left renal vein and left pelvic vein by way of the aforementioned anastamosis. An included transvaginal ultrasound shows confirmation of dilated pelvic venous architecture that becomes more conspicuous upon initiation of the Valsalva maneuver. Although pelvic anastamoses to the inferior vena cava and other pelvic vessels have been identified in the literature, to the author's knowledge this is the first recorded example of a collateral anatomic pathway between the pelvic vessels and renal vein by way of adrenal ad ovarian vessels. Magnetic Resonance Imaging (MRI) was additionally obtained which confirmed an overlying right common iliac artery which suggests obstruction of pelvic drainage, likely resulting in the described anastamosis.

Imaging is an important tool that allows clinicians to correlate an underlying disease process with a known clinical syndrome. In the case of this patient, venogram of the abdomen and pelvis characterized an atypical connection between the renal vein and pelvic varices that was difficult to ascertain on MRI. The importance of this finding is that it alters our therapeutic approach to addressing the underlying problem, pelvic pain in the setting of pelvic varices and venous incompetence. It is common practice to supplement unspecific MRI findings with venography; in this case, this step was able to improve diagnosis and direct treatment of the patient’s underlying syndrome.