Endovascular treatment of nutcracker syndrome journal of. Endovascular stenting for nutcracker syndrome sciencedirect. Renal nutcracker syndrome genetic and rare diseases. Additionally, this method can be successfully used in the treatment of posterior nutcracker syndrome. 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. Hansraj n, hamdi a, khalifeh a, wise e, sarkar r, toursavadkohi s.
Pdf nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria. Hybrid intervention for treatment of the nutcracker syndrome. Minimally invasive treatments for venous compression syndromes. Extravascular stent management for migration of left renal vein endovascular stent in nutcracker syndrome lu tian1, shanwen chen2, gaoyue zhang3, hongkun zhang1, wei jin1 and ming li1 abstract background. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Current management approach for left renal vein entrapment. Jun 22, 2017 endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. Jan 01, 20 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.
Although both terms are clinically equivalent, the latter is used for patients who are manifesting the characteristic clinical symptoms of the disorder 2. Management options can range from conservative to surgical, with the endovascular approach becoming an increasingly common one. Nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and. Nutcracker syndromean unusual case of chronic left upper. We opted for the endovascular approach as it is was the least invasive option and is of proven efficacy in addition to the fact that our patient was opposed to the idea of surgical intervention. The renal venous hypertension caused by ncs can be severe enough to lead to formation of an aneurysm and development of hydronephrosis. 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. 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. The first case report of endovascular stent placement for renal vein. Endovascular stenting is an alternative treatment option. Some people may not have symptoms, while others develop severe and. Although endovascular stenting is well accepted for iliocaval occlusive disease. The severity of nutcracker syndrome is variable, and affected individuals may be completely asymptomatic or, in the most extreme. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis.
Nutcracker syndrome, or mesoaortic compression of the left. Renal vein stenting for nutcracker syndrome endovascular. Endovascular angioplasty with stenting cas treatment. Nov 22, 2017 although endovascular stenting is an attractive option, it is not without complications. Although endovascular stenting is an attractive option, it. Endovascular stenting in the treatment of pelvic vein congestion. 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.
Results are encouraging at followup periods up to 2 years. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. Further studies should report if this approach has adverse effects and if such a. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months. A simplified approach with gonadal vein transposition posted on june 12, 2016 june 12, 2016 by docpark the patient is a young woman in her twenties who developed severe right sided abdominal and back pain about 4 months prior to presentation associated with bouts of bloody urine. Though lrv transposition and now lrv stenting are commonly employed methods for treatment of nutcracker syndrome, judicious management of ncs should take into consideration patients age, severity, and chronicity of symptoms along with current lack of data regarding longterm outcomes of stent placement. Nutcracker syndrome is a rare diagnosis and may manifest in unusual ways.
Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Its diagnostic criteria are not well defined, often causing delayed or misdiagnosis. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the lrv. Jul 14, 2017 posts about nutcracker syndrome written by docpark. Hartung o, grisoli d, boufi m, marani i, hakam z, barthelemy p, et al. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. Nutcracker syndrome ncs may present with just leftsided flank pain. Chen et al have shown, in a longer followup of 61 patients, that endovascular stenting is a primary option for ncs. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal. Endovascular stent placement for nutcracker phenomenon. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully.
Posts about nutcracker syndrome written by docpark. Nutcracker syndromean unusual case of chronic left upper ab. In cases of nutcracker syndrome, the left renal vein was stenosed between the. At the threeweek followup, she reported near resolution of nausea and abdominal pain.
There are various underlying pathologic causes, including renal or ureteric calculi or tumors, intrinsic kidney disease including glomerulonephritis, and loin pain hematuria syndrome. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma. Endovascular treatment of nutcracker syndrome request pdf. Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome. Lrv transposition is the most commonly described surgical approach successfully utilized to alleviate pelvic congestion symptoms and hematuria. Left renal vein entrapment syndrome, characterized by the compression of the left renal vein lrv between the superior mesenteric artery sma and the abdominal aorta was first described in 1950. Endovascular treatment by stenting was proposed and is not very invasive, but followup is too short to establish the role of this technique in the management of the nutcracker syndrome. Since some of these causes are potentially serious and may be treatable if identified early, it is important to establish a. Nutcracker phenomenon and nutcracker syndrome are sometimes used interchangeably in literatures. Carotid artery angioplasty with stenting cas is a minimally invasive procedure in which a very small hollow tube, or catheter, is advanced from a blood vessel in the groin to the carotid arteries.
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. Results are encouraging at followup periods beyond 2 years. Nutcracker syndrome symptoms, treatment, causes, surgery. Nutcracker syndrome and radiographic evaluation of loin. Thrombosis, stent migration, fracture and restenosis are the complications of the endovascular stenting but they are rare. Extravascular stent management for migration of left renal vein. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications. Current trends in the diagnosis and management of renal. The exact prevalence of nutcracker syndrome is unknown, likely because of the variable presenting features. Although surgical repair has been the standard of care, more recently endovascular stenting of the renal. Aug 31, 2017 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome.
Symptoms were hematuria, proteinuria or flank pain. 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. We describe a case of a 28yearold man who presented with microscopic hematuria, left. Transposition of the left renal vein for treatment of the nutcracker phenomenon. However, it is estimated to be relatively more common in females and usually presents in the 3rd or 4th decade of life.
Endovascular management of nutcracker syndrome after. 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. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. Robotassisted laparoscopic extravascular stent for. Jul 24, 2015 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. Figure 5 placement of the stent in the left renal vein. Imaging findings and clinical features of abdominal.
A simplified approach with gonadal vein transposition posted on june 12, 2016 june 12, 2016 by docpark the patient is a young woman in her twenties who developed severe right sided abdominal and back pain about 4 months prior to. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Nutcracker syndrome ncs describes left renal vein compression. A novel hybrid left renal vein transposition and endovascular. More recently, endovascular approaches have been reported for this uncommon problem. Nutcracker syndrome european journal of vascular and.
After a successful endovascular stenting and a 6month period of antiplatelet and. 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. Pdf endovascular stenting for nutcracker syndrome researchgate. Although endovascular stenting is an attractive option, it is not without complications. Both open and endovascular approaches to the treatment of this condition have been described in the literature. Endovascular treatment of nutcracker syndrome scielo.
Endovascular stenting for treatment of nutcracker syndrome. Results are encouraging at followup periods beyond two. Loin pain and hematuria are common symptoms, presenting in patients of all ages. 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.
Endovascular treatment of nutcracker syndrome sciencedirect. The patient was treated with stenting of her left renal vein. Although nutcracker syndrome ns is rare, patients presenting with symptoms or signs and anatomic compression of the left renal vein lrv can be considered for intervention. Dec 21, 2009 loin pain and hematuria are common symptoms, presenting in patients of all ages. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. Renal vein stenting for nutcracker syndrome endovascular today. Nutcracker syndrome and radiographic evaluation of loin pain.
Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years. Nutcracker syndrome should not be confused with superior mesenteric artery syndrome wilkie syndrome also a superior mesenteric artery compression disorder, where the sma compresses the third part of the duodenum the two conditions, however, may be associated. Cgsurg106 venous angioplasty with or without stent. After failed conservative approach, she underwent endovascular stenting. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. To retrospectively assess the therapeutic value of endovascular stenting for treatment of the nutcracker syndrome ncs in longterm followup and to explore the selection of the size of stents in chinese patients with ncs. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of. She underwent successful extravascular stenting with complete symptom resolution. N2 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Left renal vein balloon venoplasty without stenting for.
Nutcracker syndrome is an entity resulting from left renal vein compression by. Extravascular stent management for migration of left renal. Nutcracker syndrome or mesoaortic compression of the left renal vein lrv with associated symptoms related to venous hypertension in the left kidney is a rare entity that may result in severe symptoms requiring operative intervention. A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. Endovascular stenting of the renal vein has been reported for nutcracker syndrome with a promising safety and efficacy profile. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. Patient is a 43 year old woman who had been having bouts of severe left sided abdominal pain for several years with worsening episodes of nausea and vomiting resulting in several visits to the emergency room. As more cases are reported, endovascular repair is becoming an alternative treatment for 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. Endovascular stenting for nutcracker syndrome kuokang feng, chunyang huang, chenyuan hsiao, tsunghsing lee, tzuting kuo. Typically, a selfexpanding nitinol or stainless steel stent is used. More recently, endovascular stenting of the left renal vein has been reported. Results of endovascular treatment for patients with. Nutcracker syndrome servier phlebolymphologyservier. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and testicular swelling.
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