Conservative, open and endovascular options exist for treatment, however patient treatment must be individualized. Treatment of nutcracker syndrome with open and endovascular interventions, j vasc surg. We report the first case of extravascular stent placement using the robotic approach for the treatment of nutcracker syndrome. Endovascular stenting randwick angioplasty sydney nsw. Fatima performs the whole spectrum of vascular surgery both open and endovascular procedures including treatment of mesenteric disease, peripheral vascular disease, and. The small intestines hang like baggy sausages off the branched stems of the superior mesenteric artery sma, and in some individuals, the sma compresses the left renal vein against the aorta. The alternative option of endovascular or extravascular stenting is very. Nutcracker syndrome got its name because the compression of the renal vein is like a nutcracker cracking a nut. Pelvic congestion syndrome, which is a cause of chronic pelvic pain in women, may be due to nutcracker syndrome. 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.
The patient self referred because she had read multiple reports of cardioembolization on internet support group comments. Endovascular stent placement for nutcracker phenomenon ios. 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. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Mesoaortic compression of the left renal vein the socalled. Nutcracker syndrome ncs may present with just leftsided flank pain.
I have nutcracker syndrome also and i am so happy i found this site. She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. A diagnosis of left renal vein entrapment nutcracker syndrome, ncs was supported. The small intestines hang like baggy sausages off the branched stems of the superior mesenteric artery sma, and in some individuals, the sma. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the lrv.
Results are encouraging at followup periods beyond 2 years. Since some of these causes are potentially serious and may be treatable if identified early, it is important to establish a. Ultimately it may be associated with substantial morbidity and even lifethreatening events. The endovascular therapy of the nutcracker syndrome ncs. Endovascular stenting for nutcracker syndrome kuokang feng, chunyang huang, chenyuan hsiao, tsunghsing lee, tzuting kuo, chunche shih, chiaopo hsu division of cardiovascular surgery, department of surgery, taipei veterans general hospital and national yangming university school of medicine, taipei, taiwan, roc. 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 is an entity resulting from left renal vein. Endovascular angioplasty with stenting cas treatment. Results of endovascular treatment for patients with. It was described for the first time in 1996 by neste et al. It is characterized by external compression of the outflow from the left renal vein lrv into the inferior vena cava ivc. 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 renal vein. We present a patient whose complaint of flank pain led to the diagnosis of a renal vein thrombosis.
Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. We recently treated a young woman incapacitated by left flank pain and hematuria with a new external stenting procedure, which relieved the nutcracker syndrome. We present a case of a 54yearold female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications. The nutcracker syndrome ncs is a rare cause of haematuria. Nutcracker syndrome, caused by compression of the left renal vein lrv between the superior mesenteric artery and the aorta, results in left renal and gonadal venous hypertension. We report on the case of a 51yearold woman successfully treated with embolization of the ovarian vein and insertion of a self expandable stent in the left renal. 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. A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. 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 risks of stent. Hybrid intervention for treatment of the nutcracker syndrome.
Intravenous stent placement for the treatment of nutcracker syndrome. Endovascular stent placement for nutcracker phenomenon. Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. San raffaele scientific institute vascular surgery vitasalute university. Endovascular treatment of nutcracker syndrome scielo. Common signs and symptoms when the condition shows no.
Current management approach for left renal vein entrapment. Loin pain and hematuria are common symptoms, presenting in patients of all ages. Although endovascular stenting is an attractive option, it is not without complications. 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.
Oct 27, 2009 nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Dec 01, 20 read surgical and endovascular interventions for nutcracker syndrome, seminars in vascular surgery on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Research article left renal vein balloon venoplasty without stenting for management of symptomatic nutcracker syndrome.
Materials and methods we retrospectively evaluated the endovascular stenting experience with 61 patients with a median age of 26 years. Thoracoabdominal aneurysm surgery, thoracic endovascular aneurysm repair, carotid artery reconstruction, carotid endar. Popliteal artery aneurysm doctors and departments mayo. There are many modalities of treatment of nutcracker syndrome.
Nutcracker syndrome treated by endovascular stenting of the left renal vein. Single center experience with open and endovascular. Extravascular stent management for migration of left renal vein. Nutcracker syndromean unusual case of chronic left upper. Nutcracker syndrome treated by endovascular stenting of the left. I have 2 children, but suffered multiple misscarrages, but thinking they were related to my bloodclotting disorder. Endovascular treatment of carotid blowout syndrome. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches. Several treatment options have been described to relieve associated symptoms. Management options can range from conservative to surgical, with the endovascular approach becoming an increasingly common one.
You need to send a request to join, as this will keep it private for anybody sharing medical information. We report a rare cause if a 12yearold boy who presented with a history of frequent intermittent episodes of painless constant haematuria. She underwent successful extravascular stenting with complete symptom resolution. Endovascular treatment of nutcracker syndrome is a new tool for treating the syndrome offering the advantages of being less invasive and causing less morbidity and mortality. 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. Endovascular stenting for nutcracker syndrome nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily overlooked condition. Approximately forty cases of stenting for ncs have been reported in the. The pain is severe around the week before my monthly and the week after. With the combination of extensive correlation of scans, cytology and frozen section with differential diagnosis, and analysis of the information crucial to the neurosurgeon in a casebased approach and with a special.
Posterior nutcracker syndrome with left renal vein. Endovascular approaches offer multiple modalities for treatment to prevent morbidity and death. To place the stent in your vein, your surgeon will. I also have a blood clotting disorder on top of the ncs. Endovascular treatment of nutcracker syndrome request pdf. Another clinical study has shown that nutcracker syndrome is a frequent finding in varicoceleaffected patients and possibly, nutcracker syndrome should be routinely excluded as a possible cause of varicocele and pelvic congestion. 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 this can lead to renal venous hypertension, resulting in rupture of thinwalled veins into the collecting system with resultant hematuria. 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. Who to treat and what works best ucsf vascular symposium 2019. Nutcracker syndrome, or mesoaortic compression of the left. Left renal vein balloon venoplasty without stenting for.
Management of renal nutcracker syndrome by retroperitoneal. Moreover, the presence of a stent increases the risk of surgical intervention and consequently the endovascular approach is paramount in those situations. The largest nitinol stent self expanding available is 14mm. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. Endovascular stenting for nutcracker syndrome sciencedirect. Nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup. Application of extravascular stenting for nutcracker. Nutcracker syndrome symptoms, treatment, causes, surgery.
Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years. We satisfactorily treated a middleaged man with nutcracker syndrome accompanied by renal enlargement, persistent haematuria, proteinuria and hypertension with a new intravascular stent. Similar to stents in the heart to treat a heart attack, stents and balloons are used by endovascular surgeons to treat blocked arteries throughout the body. Renal nutcracker syndrome genetic and rare diseases.
While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. We report the case of a 59 yearold female treated by. Extravascular stent management for migration of left renal. Endovascular stenting for the nutcracker phenomenon.
Nutcracker syndrome is the term used to describe the patient with clinical symptoms of entrapment of the left renal vein between the aorta and the superior mesenteric artery. Exovascular stenting wrap of renal vein with ringed ptfe graft endovascular stenting. Books lane medical library stanford university school. Nutcracker syndrome complicated by left renal vein thrombosis. Pelvic congestion syndrome in a nutcracker patient the endovascular therapy of the nutcracker syndrome ncs. A, diagramatic representation of the nutcracker syndrome with extrinsic compression of the left renal vein lrv by the superior mesenteric artery sma at its junction with the inferior vena cava ivc, causing dilatation of the peripheral lrv. However, studies show that among these diagnostic tools, doppler ultrasonography which is a noninvasive modality should be the initial assessment tool after nutcracker syndrome is suspected clinically, or when there is an increased diameter ratio between the distended and narrow portions on ct scan and mr imaging 2. In women, the hypertension in the left gonadal vein can also cause increased pain during menses. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of. Nutcracker syndrome is a rare diagnosis and may manifest in unusual ways. My daughter has nutcracker syndrome testicular disorders. Conclusion nutcracker syndrome is a rare diagnosis and may manifest in unusual ways.
Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. Although surgical repair has been the standard of care, more recently endovascular stenting of the renal vein has been proposed. The volume uses a casebased approach to show correlation between scan, history, frozen section and cytologic preparations. 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. 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. 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. I am not in favor of primary endovascular stenting based on risk of migration, timing of migration, and uncertainty of longterm patency thank you. Although it is in its infancy, endovascular therapy for nutcracker syndrome is a viable option that may circumvent more invasive procedures. However, endovascular treatment with renal vein stenting has achieved excellent results.
It embraces an extended nonpathognomonic spectrum of symptoms that imply a difficult diagnosis. Renal vein stenting for nutcracker syndrome endovascular today. Some people may not have symptoms, while others develop severe and. 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. Endovascular stenting for treatment of nutcracker syndrome. Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of surgical procedures. Looking at it from a transverse plane both sma and aorta appear to create a nutcracker crushing the left renal vein imitating a nut. Jun 22, 2017 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.
Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Endovascular therapy is the treatment of choice for in stent restenosis because it is less invasive. We finally went to mayo clinic and she was diagnosed there. Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of. Endovascular treatment of nutcracker syndrome sciencedirect.
Although the nutcracker syndrome represents a form of vascular compression, no previous reports have appeared in the vascular surgical literature. Aug 31, 2017 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Endovascular therapy is one of the greatest achievements of modern medicine because it has made it possible to treat various complex vascular problems safely and effectively without any surgery. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis. The renal venous hypertension caused by ncs can be severe enough to lead to formation of an aneurysm and development of hydronephrosis. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience.
Nutcracker syndrome servier phlebolymphologyservier. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal 20. It was described for the first time in 1996 by nesteet al. Symptoms were hematuria, proteinuria or flank pain. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein.
Nov 24, 20 isolated renal vein thrombosis is a rare entity. 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. Endovascular stenting for nutcracker syndrome core. In this case, abdominal computed tomography angiography was helpful in diagnosing the nutcracker syndrome complicated by the renal vein thrombosis. A high index of suspicion is required so that appropriate imaging may be requested. Carotid blowout syndrome cbs is a highrisk condition associated with significant morbidity and mortality that may result from invasion and destruction of the cervical carotid vasculature from head and neck squamous cell carcinoma. Jan 01, 2000 surgical approaches for nutcracker syndrome include nephrectomy, nephropexy, renocaval reimplantation, or autotransplantation. Early resolution of pelvic venous collaterals after endovascular.
She had surgery, which is left renal vein transposition, where her symptoms resolved for about two weeks. Cgsurg106 venous angioplasty with or without stent. Endovascular stenting and angioplasty is a new and evolving minimally invasive method to treat circulatory disorders caused by diseased arteries. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the.
The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. Renal vein stenting for nutcracker syndrome endovascular. Stenting for nutcracker syndrome your surgeon may choose to treat your nutcracker syndrome using a stent a small mesh tube to hold your left renal vein open and allow for proper blood flow. Nutcracker syndrome an unusual case of chronic left upper abdominal pain. Current trends in the diagnosis and management of renal. Jul 14, 2017 nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle.
Left renal vein transposition for nutcracker syndrome. Challenging concepts in interventional radiology 1st. Surgical and endovascular interventions for nutcracker syndrome. Nutcracker syndrome is an entity resulting from left renal vein compression by. Fatima performs the whole spectrum of vascular surgery both open and endovascular procedures including treatment of mesenteric disease, peripheral vascular disease, and carotid disease, among others. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. Anticoagulation was started and three weeks later, cta showed complete disappearance of the renal. 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. She also serves as the coeditor of the thoracic section of the endovascular today journal. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria.
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. 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. Nutcracker syndrome and radiographic evaluation of loin. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. 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. We report a case of migration of a laparoscopically. Nutcracker syndrome with pelvic congestion treated by balloon. Robotassisted laparoscopic extravascular stent for. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months.