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. Cae e urg naie roe 21 oue 1 ue 5 the diagnosis of nutcracker syndrome is difficult to establish with routine diagnostic methods 11. The compression of the left renal vein between the aorta and superior mesenteric artery was described to resemble a nut trapped between the nutcracker by the anatomist, john c. Intravascular stenting is the implantation of metallic stents performed with the guidance of digital subtraction angiography under a local anesthesia. Endovascular stenting in the treatment of pelvic vein congestion. She had surgery, which is left renal vein transposition, where her symptoms resolved for about two weeks. A novel hybrid left renal vein transposition and endovascular. Park yb1, lim sh, ahn jh, kang e, myung sc, shim hj, yu sh. Meissner the nutcracker syndrome is characterized by entrapment and compression of the left renal vein between the abdominal aorta and the superior mesenteric artery sma figure 1.
The indications for surgical management with the nutcracker syndrome depend on the severity of the symptoms, and laparoscopic extravascular stent placement in the renal vein is a feasible approach for reestablishing free renal venous outflow. Laparoscopic extravascular renal vein stent placement for. The symptoms vary from asymptomatic hematuria to severe pelvic congestion. 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.
Intravascular ultrasoundguided endovascular stenting of renal vein in nutcracker syndrome show details. The indications for surgical management with the nutcracker syndrome depend on the severity of the symptoms, and laparoscopic extravascular stent placement in the renal vein is a feasible approach. Endovascular stenting for nutcracker syndrome kuokang feng, chunyang huang, chenyuan hsiao, tsunghsing lee, tzuting kuo. The retroaortic or circumaortic renal vein may be compressed between the aorta and the vertebral body, which is called posterior nutcracker. It is characterized by external compression of the outflow from the left renal vein lrv into the inferior vena cava ivc. 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. Extravascular stent management for migration of left renal. Extravascular stent management for migration of left renal vein. The stent is introduced in the femoral artery going to the lrv. The authors advocate for abdominal ultrasound to evaluate for nutcracker syndrome when hematuria or persistent severe varicocele are present and a conservative approach to management in nearly all patients. Nutcracker phenomenon and nutcracker syndrome ncbi. Nutcracker syndrome is a venous entrapment phenomenon characterized by the compression of the left renal vein lrv between the superior mesenteric artery and abdominal aorta.
Jan 01, 2000 surgical approaches for nutcracker syndrome include nephrectomy, nephropexy, renocaval reimplantation, or autotransplantation. Endovascular treatment of nutcracker syndrome journal of. A 52yearold woman who had a history of hematuria two years previously was admitted to another hospital for treatment of recurrent hematuria. Treatment options for pelvic congestion syndrome servier. 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 ncpnutcracker syndrome ncs in figure 1. Cgsurg106 venous angioplasty with or without stent. Although both terms are clinically equivalent, the latter is used for patients who are manifesting the characteristic clinical symptoms of the disorder 2. Left renal vein to vena cava bypass autologous or ptfe sma transposition. Renal vein stenting for nutcracker syndrome endovascular. Both balloonexpandable and selfexpanding stents have been used in adult and pediatric patients. Aug 25, 2016 renal vein entrapment the nutcracker syndrome brandon t. Renal vein stenting for nutcracker syndrome endovascular today.
Intravascular stenting with expandable metallic stents is performed under local anesthesia utilizing digital subtraction. Endovascular treatment of nutcracker syndrome scielo. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and testicular swelling. Several treatment options have been described to relieve associated symptoms. Endovascular stenting for nutcracker syndrome sciencedirect. Loin pain and hematuria are common symptoms, presenting in patients of all ages. 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. Endovascular stenting for treatment of nutcracker syndrome. Results of endovascular treatment for patients with. I just want to let everyone know that i have vericose veins in my uterus. Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome. Pcs could also derive from a venous compression, such as that observed in the nutcracker or maythurner syndromes. Aug 31, 2017 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome.
More recently, endovascular approaches have been reported for this uncommon problem. Nutcracker phenomenon and nutcracker syndrome undiagnosed. Expanding metallic stent placement for nutcracker phenomenon. We satisfactorily treated a middleaged man with nutcracker syndrome accompanied by renal enlargement, persistent haematuria, proteinuria and hypertension with a new intravascular stent. Nutcracker syndrome servier phlebolymphologyservier. Nutcracker phenomenon and nutcracker syndrome are sometimes used interchangeably in literatures. Surgical approaches reported include venolysis and anterior nephropexy, renal vein bypass or interposition grafting, renocaval reimplantation, and autotransplantation. Although the use of stents within the venous circulation bears potential risks, such as in stent stenosis and occlusion, experience gained in treating superior vena caval syndrome and buddchiari syndrome, 10 x 10 segawa, n. Postsurgical followup for a repaired nutcracker syndrome. Nutcracker syndrome symptoms, treatment, causes, surgery. Nutcracker syndrome is a venous entrapment phenomenon characterized by the impingement of the left renal vein between the superior mesenteric artery and abdominal aorta.
Just 2 patients 1 renal vein stent, 1 transposition and autotransplantation required intervention to directly address renal vein compression. 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. Renal nutcracker syndrome genetic and rare diseases. Nutcracker syndrome ncs was first described in the medical literature in 1950 11. Current trends in the diagnosis and management of renal. Nutcracker syndrome, or mesoaortic compression of the left. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications.
Despite potential serious consequences, diagnosing ncs is often challenging, circuitous and commonly delayed. I have had pain since i was a child, i am now 29 and after years of searching, going from doc to doc, i finally found out that i had something called nutcracker syndrome which is a clinically manifest variant of nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein. We report a case of migration of a laparoscopically. Application of extravascular stenting for nutcracker. 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.
Left renal vein transposition for nutcracker syndrome. Medical therapy aimed at decreasing renal venous hypertension for hematuria renal autotransplantation. Clinical and surgical data and shortterm outcomes were analyzed retrospectively. Laparoscopic extravascular stent placement for nutcracker. She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. It can be assimilated using the technique recommended by raju et al to stent cases of maythurner syndrome, that is a stent largely protruding into the ivc. 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 clinical syndrome caused by impingement of the left renal vein lrv between the superior mesenteric artery sma and abdominal aorta has been termed. The nutcracker phenomenon left renal vein lrv entrapment syndrome refers to compression of the lrv most commonly between abdominal aorta and superior mesenteric artery. Renal venous hypertension baishideng publishing group. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches.
Endovascular stent placement as a treatment for renal venous hypertension. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months. Some people may not have symptoms, while others develop severe and. Nutcracker syndrome ncs is the most common term for compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. Patients with left renal vein compression nutcracker syndrome can be referred for ovarian vein transposition. The development of ncs is associated with the formation of the left renal vein lrv from the aortic collar during the sixth to eighth week of gestation and abnormal angulation of the superior mesenteric artery from the aorta. Endovascular management of nutcracker syndrome after. We report the case of a 59 yearold female treated by endovascular repair with. Endovascular management of recurrent stenosis following left renal vein transposition for the treatment of nutcracker syndrome donald t. 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. Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome.
A rare and potentially under diagnosed cause of haematuria. Posts about nutcracker syndrome written by docpark. Nutcracker syndrome is an entity resulting from left renal vein compression by. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. Nutcracker syndrome ncs is a rare pathology manifested by pain or. 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. This is a vascular territory where i tread lightly with a conservative approach. Placement of left renal venous stent for nutcracker syndrome. Nutcracker syndrome is an important cause of pelvic pain and consists of a set of signs secondary to compression of the left renal vein, most commonly between the superior mesenteric artery and the aorta.
Embolization is typically performed using mechanical devices, such as coils, in combination with liquid sclerosants. Figure 5 placement of the stent in the left renal vein. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. This slightly invasive treatment can eliminate the symptoms of the condition. Endovascular management of recurrent stenosis following. My daughter has nutcracker syndrome testicular disorders. If embolization of incompetent pelvic veins is performed without stenting, embolization will fail because the outflow of these incompetent veins remains obstructed. Since some of these causes are potentially serious and may be treatable if identified early, it is important to establish a. We present a case of a 54yearold female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Placement of intravascular stent on the left renal vein discussion nutcracker syndrome ncs was first described in the medical literature in 1950 11. Therefore, anterior nutcracker is analogous to and may cooccur with compression of the duodenum by the sma, known as the superior mesenteric artery syndrome wilkie syndrome. We report the first case of extravascular stent placement using the robotic approach for the treatment of nutcracker syndrome. Images c and d show stent placement ct images in the axial and coronal plane, respectively. Nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily overlooked condition.
It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Nutcracker syndrome and radiographic evaluation of loin. 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. Surgical approaches for nutcracker syndrome include nephrectomy, nephropexy, renocaval reimplantation, or autotransplantation. Its development is usually ascribed to the abnormal branching of the superior mesenteric artery from the. The metallic stent is placed in the narrowed portion of the vein 1. Hybrid intervention for treatment of the nutcracker syndrome. Both open and endovascular approaches to the treatment of this condition have been described in the literature.
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 occurs more frequently in women by the 3rd or 4th decades, although cases have been reported in children. 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. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. 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 ncs, also known as left renal vein lrv entrapment syndrome, was first defined anatomically by grant in 1937 as follows. 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. After a successful endovascular stenting and a 6month period of antiplatelet and. Nutcracker syndrome european journal of vascular 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. 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 can present with a multitude of symptoms, both sonographically and clinically. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Intravascular stenting approaches in ncs were extrapolated from the stenting experience in maythurner and superior vena cava syndromes. However, further followup and investigation will be required to determine if the durability of this approach compares favorably to current open options for this rare condition. I prefer to use the smart control stent cordis, a cardinal health company or other stents with segmental independence, which extend from the renal hilum to just beyond the site where the renal vein passes under the superior mesenteric artery. Expandable metallic stent placement for nutcracker.
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. With respect to the high number of patients in our study, we recommend that these parameters be routinely examined in patients with varicocele to confirm or exclude nutcracker syndrome as the direct cause of varicocele and to evaluate the anatomic characteristics of the patients to be able to predict possible reoccurrence of varicocele or treatment such as a renal vein stent. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. 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. It was described for the first time in 1996 by nesteet al. The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. We finally went to mayo clinic and she was diagnosed there. This study included nutcracker syndrome patients who were treated by laparoscopic extravascular stent placement from june 2009 to august 20. Endovascular management of recurrent stenosis following left. 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. Symptoms were hematuria, proteinuria or flank pain. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis.
There are different approaches that will be discussed in this article, according to the need of every case. Obstruction of lrv occasionally causes clinically significant venous hypertension resulting in unexplained left flank, gross haematuria, with formation of periureteric and gonadal varices and varicocele in relatively young and. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. The described treatment options for nutcracker syndrome include ref 1. 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. In certain situations, the syndrome can result from a retroaortic or circumaortic left renal vein 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. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Management of renal nutcracker syndrome by retroperitoneal. Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years.
Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. The best treatment is still elusive, but there are several surgical approaches, such as intravascular stenting. We reported a case of successful endovascular stenting of the left renal vein for nutcracker syndrome. Nutcracker syndrome ncs is caused by compression of left renal vein lrv, usually between the aorta and the superior mesenteric artery sma. Treatment of nutcracker syndrome is controversial, with a wide array of therapeutic options. Nutcracker syndrome ncs describes left renal vein compression. 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 ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. The first case report of endovascular stent placement for renal vein. Robotassisted laparoscopic extravascular stent for.
This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. To report our techniques and experience of laparoscopic extravascular stent placement for nutcracker syndrome. Endovascular treatment of circumaortic nutcracker syndrome. 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. We describe five patients who were treated for nutcracker syndrome by using stenting and analyze the nine cases previously reported. Term of nutcracker syndrome ncs is used for patients with clinical symptoms associated with nutcracker anatomy. The nutcracker syndrome refers to compression of the lrv between the superior mesenteric artery and abdominal aorta. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. Most reports consist of small case series, and longterm results are limited. Current management approach for left renal vein entrapment.