I report on a female patient who was diagnosed by functional colour Doppler sonography with the following abdominal vascular compression syndromes:

1. Celiac artery compression syndrome (MALS)
2. Lordogenetic left renal vein compression (erroneously aka nutcracker syndrome)
3. May Thurner syndrome

Indication for operation was excruciating post-prandial pain and vomiting with substantial weight loss.

The patient opted against a decompression of the left common iliac vein and was thus operated with an excision of the median arcuate ligament to reduce her celiac artery compression and with a shielding of the left renal vein by a PTFE sheath surrounding the vein to prevent further compression.

The PixelFlux measurements clearly show an effect of the protection of the left renal vein by the PTFE sheath covering onto the left renal perfusion.

Preoperative PixelFlux measurement of the renal perfusion in a horizontal posture:

PixelFlux measurements of the renal perfusion in various postures 19 months after external PTFE shielding of the left renal vein

The ratio of peripheral to deep cortical perfusion of the left kidney in the supine position improved from 0.42 to 0.55 – all related symptoms disappeared.

The celiac trunk decompression was successful with respect to the complete disappearance of all symptoms, the weight gain, and a complete relief of abdominal pain.

Nevertheless, the patient now developed a posture dependent compression of the splenic vein by the common hepatic artery only whith an upright trunk – standing or sitting. This compression syndrome has not been described before in medical literature.

Stretching of the splenic vein while standing produces a hemodynamically relevant splenic vein compression by the common hepatic artery. The venous flow velocity peaks at 360 cm/s.

Comporession of the splenic vein by the common hepatic artery only while standing

Localized flow acceleration at the compression site to now 284 cm/s in the splenic vein – only while standing

Enlarging gap between the splenic vein and the common hepatic artery in a supine position with subsequent drop of venous flow velocity to 78 cm/s and pain relief

PixelFlux measurements of splenic tissue perfusion clearly demonstrate dropping perfusion while standing – a sign of painful splenic congestion due to splenic vein compression

The diagram above compares splenic tissue perfusion subcapsular layers at different depths. The location of the tissue examined is 4 cm cranial to the lower pole of the spleen. It can be clearly shown that while standing there is a significant perfusion reduction especially of the pressure-sensitive subcapsular vessels which show a perfusion suppression by nearly 50%. This reflects the increasing back pressure due to the orthostatic compression of the splenic vein this way underscoring the haemodynamic significance of this compression and explaining the gradually increasing left flank pain in the patient while standing due to increasing tissue turgor of the spleen.

Comparison of splenic tissue perfusion while supine and standing

The splenic vein was compressed from behind by the common hepatic artery resulting in a massive flow acceleration to 360 cm/s at the compression site. With the PixelFlux measurement of the splenic perfusion it became evident that the congestion of the spleen is related to the simultaneously increasing left flank pain.

This way the so far undescribed mechanism of left flank pain could be elucidated.