Although surgical repair has been the standard of care, more recently endovascular stenting. It can be preferred to open surgery because of the long period of renal congestion, additional anastomoses and extensive dissection requirement of the open surgery. Conclusion nutcracker syndrome is a rare diagnosis and may manifest in unusual ways. Endovascular management of recurrent stenosis following left renal vein transposition for the treatment of nutcracker syndrome donald t. Endovascular treatment of nutcracker syndrome journal of. The nutcracker syndrome ncs results most commonly from the compression of the left renal vein lrv between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. Imaging findings and clinical features of abdominal. Venous angioplasty with or without stent placement in adults. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures.
The nutcracker syndrome is a rare clinic condition associated with severe hematuria and left flank pain due to the entrapment of the left renal vein between the superior mesenteric artery and the aorta. Nutcracker syndrome, caused by left renal vein lrv compression as it passes between the superior mesenteric artery and aorta, causes. Stents in the renal vein can cause fibromuscular hyperplasia. The first case report of endovascular stent placement for renal vein hypertension was in 1996 by neste et al who described a 58yearold man successfully treated with a wallstent boston scientific corporation, natick, ma. D baylor university medical center, dallas, tx, usa. Treatment of nutcracker syndrome with open and endovascular interventions journal of vascular surgery. Nutcracker syndrome is a rare vascular disorder that involves compression of the left renal vein lrv, most often at the level of the aortomesenteric angle. As more cases are reported, endovascular repair is becoming an alternative treatment for nutcracker syndrome. We recommend endovascular stenting as primary option for nutcracker syndrome. Extravascular stent management for migration of left renal. The computed tomographic imaging was closely correla ted to therapeutic interventions and stent migration. This can lead to renal venous hypertension, resulting in rupture of thinwalled veins into. Left renal vein entrapment syndrome, also known as nutcracker syndrome, involves compression of the left renal vein and can present with abdominopelvic pain, hematuria, and symptoms of pelvic congestion syndrome. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal.
Endovascular stenting for treatment of nutcracker syndrome. Peak velocity in the aortomesenteric portion, and the anteroposterior diameter ratio of the renal hilum and the aortomesenteric portion of the left renal vein on duplex ultrasound after stenting was significantly decreased compared to that on duplex ultrasound before stenting p endovascular stenting is a safe, effective procedure in select adults. Its diagnostic criteria are not well defined, often causing delayed or misdiagnosis. Hartung o, grisoli d, boufi m, marani i, hakam z, et al. The stent will be placed in your vein by the surgeon after the surgeon makes a small puncture in the leg. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures.
Scvs endovascular treatment of nutcracker syndrome. Noninvasive ultrasound and crosssectional imaging can show the anatomic abnormality. Symptoms were hematuria, proteinuria or flank pain. The exact prevalence of nutcracker syndrome is unknown, likely because of the variable presenting features. The patient was diagnosed with nutcracker syndrome and underwent endovascular stent.
We explain the underlying pathophysiology that results in these clinical syndromes so that the patient subset. Staff skilled in dozens of specialties work together to ensure quality care and successful recovery. In most cases, compression of the left renal vein is between the abdominal aorta the main artery in the abdomen and the superior mesenteric artery, which brings blood. Nutcracker syndrome is best diagnosed with ultrasound. Both open and endovascular approaches to the treatment of this condition have been described in the literature. Nutcracker syndrome ncs refers to the clinical manifestations of ncp. Current trends in the diagnosis and management of renal nutcracker syndrome. Renal nutcracker syndrome ncs is a condition that occurs when the left renal vein the vein that carries blood purified by the left kidney becomes compressed. In some cases, this compression syndrome arises in the setting of unusual vascular anatomic variants. Some people may not have symptoms, while others develop severe and persistent symptoms. A stent is a small mesh tube which is used to hold the left renal vein open so that there is proper blood flow. Common signs and symptoms when the condition shows no symptoms, its usually known.
Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the superior mesenteric artery, which leads to symptoms of hematuria or left flank pain. At the threeweek followup, she reported near resolution of nausea and abdominal pain. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal 20. Nutcracker syndrome got its name because the compression of the renal vein is like a nutcracker cracking a nut. Unusual confluence of two rare syndromes results in. Mayo clinic has one of the largest and most experienced practices in the united states, with campuses in arizona, florida and minnesota. Followup was completed by clinical exams and duplex ultrasound at. A rare condition due to compression of the left renal vein and impaired flow can cause flank pains, and blood in the urine.
However, it is estimated to be relatively more common in females and usually presents in the 3rd or 4th decade of life. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. Renal vein stenting for nutcracker syndrome endovascular. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. The patient was treated with stenting of her left renal vein.
Mesenteric ischemia doctors and departments mayo clinic. Our protocol for transabdominal pelvic vein duplex ultrasound. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Nutcracker syndrome is a variation of nutcracker phenomenon or renal vein entrapment syndrome, in which the arteries near the kidney compress the left renal kidney vein. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma.
Thrombosis, stent migration, fracture and restenosis are the complications of the endovascular stenting but they are rare. Nutcracker phenomenon ncp, also known as left renal vein entrapment, is characterized by impeded outflow from the left renal vein lrv into the inferior vena cava ivc due to extrinsic lrv compression, often accompanied by demonstrable lateral hilar dilatation and medial mesoaortic narrowing schematic representation of ncp nutcracker syndrome ncs in. Nutcracker syndrome is a very common condition that is present in almost 50% of women with other forms of pelvic vein disease, such as may thurner syndrome mts and pelvic congestion. Nutcracker syndrome, first reported in 1972, is characterized by hematuria and back pain caused by increased pressure in the lrv as a result of compression between the aorta and the sma. The name nutcracker syndrome comes from the image of the left renal vein being compressed, or cracked, between the aorta and superior mesenteric arteries. Endovascular management of nutcracker syndrome after. Left renal vein lrv compression by the aorta and the superior mesenteric artery sma leading to symptoms of hematuria or left flank pain has been classically described as nutcracker syndrome ncs 1, 2. Nutcracker syndrome is a vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric artery sma and aorta, although other variations can exist 1.
Developed by renowned radiologists in each specialty, statdx provides comprehensive decision support you can rely on nutcracker syndrome. Endovascular stenting is an alternative treatment option. Endovascular treatment of nutcracker syndrome request pdf. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup. Criteria for defining significant central vein stenosis with duplex ultrasound. Therapy for renal vein nutcracker syndrome can be completed via stenting or surgery. The extravascular stenting is an alternative option after migration of left renal vein endovascular stenting. Images c and d show stent placement ct images in the axial and coronal plane, respectively. Minimal invasive management includes both endovascular stenting and extravascular stenting 1, 2. The severity of nutcracker syndrome is variable, and affected individuals may be completely asymptomatic or. Venous angioplasty with or without stent placement in an adult. This is because both mts and pcs are anatomic variants in the structure of abdominal veins that predispose the patient to all three issues. Endovascular venous stenting in maythurner syndrome.
Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. Results are encouraging at followup periods up to 2 years. A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months. Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome. Endovascular management of recurrent stenosis following. Clinicians place an endovascular stent in the left renal vein. We reported a teaching case with ncs who underwent endovascular stenting. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta.
We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and. Treatment of nutcracker syndrome florida surgical clinic. Hybrid intervention for treatment of the nutcracker syndrome. Renal nutcracker syndrome genetic and rare diseases. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. Abstract we report a case of dunbar syndrome, maythurner syndrome and. Although endovascular stenting is an attractive option, it is not without complications. Nutcracker syndrome is a rare diagnosis and may manifest in unusual ways. Symptoms of nutcracker syndrome include hematuria blood in the urine, left flank pain, left lower quadrant pain in women and left testicular swelling or pain in men. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery and the aorta, leading to symptoms of hematuria and left flank pain. The name derives from the fact that, in the sagittal plane andor transverse plane, the sma and aa with some imagination appear to be a nutcracker crushing a nut the.
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