Although it is in its infancy, endovascular therapy for nutcracker syndrome is a viable option that may circumvent more invasive procedures. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. Kirby sebro 1, lester goetz 1, satyendra persaud 2 1 division of surgical sciences, university of the west indies, st augustine, trinidad and tobago. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. Imaging findings and clinical features of abdominal vascular compression syndromes. Medstar heart and vascular institute stenting medstar. It is caused when the left iliac or other veins are compressed btween the right iliac or other arteries and the spine, which also increases the risk of deep vein. 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.
Engorged left renal and gonadal veins white arrow in a and b before stenting. Imaging findings and clinical features of abdominal. Endovascular stenting is an alternative treatment option. Nutcracker syndrome, or mesoaortic compression of the left renal. Endovascular stent placement for nutcracker phenomenon. Cgsurg106 venous angioplasty with or without stent.
Thrombosis, stent migration, fracture and restenosis are the complications of the endovascular stenting but they are rare. Figure 2 demonstrates her stent within a now patent renal vein. Longterm followup after endovascular stent placement for. At the upmc heart and vascular institute, our surgeons in the division of vascular surgery are experts in treating nutcracker syndrome. Computed tomography ct imaging revealed compression of the left renal vein between the aorta and the superior mesenteric artery and cystoscopy revealed. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Computed tomography findings were consistent with posterior nutcracker syndrome. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Endovascular stenting for treatment of nutcracker syndrome. Hybrid intervention for treatment 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.
Nutcracker syndrome ncs is a rare entity defined by the symptomatic hypertension of the left renal vein lrv compressed in the majority of cases between the superior mesenteric artery and the aorta. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Discussion the term nutcracker syndrome is reserved for patients with both clinical and radiological nutcracker features 2. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Venous compression treatment adelaide, sa may thurner. The criteria of duplex scan and computed tomography ct scan for ncs is stenosis of the lrv with proximal distention and the presence of collateral pathways. Maythurner syndrome affects the iliac or femoral veins, vascular structures containing internal and external veins that have several connections in the pelvic and abdominal region. A ct scan and occasionally a venography may be required. Endovascular management of recurrent stenosis following. 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.
Doppler ultrasound, computed tomography ct and selective left renal vein phlebography are useful to. He subsequently underwent left renal vein stent insertion with improvement of both fatigue and abdominal pain. Nutcracker syndrome european journal of vascular and. Maythurner syndrome refers to a chronic compression of the left common iliac vein civ against the lumbar vertebrae by the overlying right common iliac artery cia, with or without deep venous thrombosis 2 although both left and right civs lie deep to the right common iliac artery, the left civ has a more transverse course and is predisposed to compression whereas the right civ ascends. The haematuria disappeared 2 weeks after an endovascular stent implantation of the lrv.
This can lead to renal venous hypertension, resulting in rupture of thinwalled veins into. Lrv and gonadal veins with decreased diameter white arrow in c and d. Although surgical repair has been the standard of care, more recently endovascular stenting of the renal vein has been proposed. Nutcracker syndrome is a rare anomaly resulting from compression of the left renal vein between the aorta and the superior mesenteric artery. Endovascular treatment of nutcracker syndrome scielo.
Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. 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. Results of endovascular treatment for patients with. Results are encouraging at followup periods beyond 2 years. Pdf nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males.
Endovascular treatment of nutcracker syndrome sciencedirect. This inturn prevents the compression of the vein between the arteries. Posts about nutcracker syndrome written by docpark. Dus is the initial choice after clinical suspicion based on symptoms. Computed tomography ct eventually revealed engorged left renal, gonadal, and uterine veins due to compression between the superior mesenteric artery sma. Developed by renowned radiologists in each specialty, statdx provides comprehensive decision support you can rely on nutcracker syndrome. Open and endovascular interventions have both been performed to relieve the compression. A rational approach to imaging begins with duplex ultrasonography, followed by ct or magnetic resonance angiography and then left renal. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. 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.
A computed tomography angiography of renal vascular revealed a compression of the left renal vein lrv between the abdominal aorta aa and the superior mesenteric artery sma, figure 1. We report two patients in whom a hybrid approach was adopted in the process combining the strengths of each. Nutcracker syndrome is a vascular compression disorder that refers to the compression of. Nutcracker syndrome treated by endovascular stenting of the left. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. Lrvand gonadal veins with decreased diameter white arrow in c and d. Ct images of the lrv before and after endovascular stenting. He underwent a novel hybrid operation that included left renal vein transposition followed by endovascular stenting. She was referred to our hospital in august 2010 for further investigation and treatment for suspected nutcracker syndrome based on her medical history and the.
Nutcracker syndrome, also called renal nutcracker syndrome is a rare vascular condition. It occurs when arteries compress the left renal kidney vein, often causing intermittent hematuria blood in the urine. Abdominal ct angiography shows narrowing of left renal vein arrow. Nutcracker syndrome ncs is a syndrome caused by compression of the left renal vein lrv, between the abdominal aorta and the superior mesenteric artery, resulting in hypertension of the lrv and hematuria. Renal vein stenting for nutcracker syndrome endovascular today. Endovascular stenting for nutcracker syndrome sciencedirect. Learn more about treatment options for this aneurysm that occurs in the wall of an artery located behind the knee joint. To our knowledge, this is the first reported case of chronic fatigue syndrome attributable to ns in an adult. Computed tomography ct eventually revealed engorged left renal, gonadal, and uterine veins due to compression between the superior mesenteric artery sma and the abdominal aorta, consistent with ncs. The doctors in our interventional cardiology program and vascular and endovascular program are experts in placing various types of stents, including. Nutcracker syndrome ncs is defined by the compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma, known as anterior nutcracker syndrome fig. Nutcracker syndrome is diagnosed through imaging such as doppler ultrasound dus, computed tomography ct, magnetic resonance imaging mri, and venography.
Endovascular stenting for the nutcracker phenomenon. Renal vein stenting for nutcracker syndrome endovascular. Pdf endovascular stenting for nutcracker syndrome researchgate. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months. Symptoms were hematuria, proteinuria or flank pain. Current trends in the diagnosis and management of renal. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. A 26yearold woman with a history of hematuria and left flank pain was admitted to another hospital in january 2009. Nutcracker phenomenon, renal vein entrapment syndrome, mesoaortic compression of the left renal vein the nutcracker syndrome results from compression of the left renal vein between the aorta and the superior mesenteric artery. At 6 months follow up the patient remained symptom free. We use cookies to offer you a better experience, personalize content, tailor advertising, provide social media features, and better understand the use of our services. Carotid artery stenting, which improves blood flow through the large blood vessels in your neck that supply blood to the brain.
Computed tomography ct revealed nutcracker phenomenon. We describe endovascular stenting of the left renal vein to treat nutcracker syndrome accompanied by gross hematuria. Ct imaging findings of abdominopelvic vascular compression. Nutcracker syndrome got its name because the compression of the renal vein is like a nutcracker cracking a nut. Multidetector ct of vascular compression syndromes in the abdomen and pelvis. Intravenous stent placement for the treatment of nutcracker syndrome.
Each of these interventions has strengths and weaknesses. Here the renal vein that is compressed between the arteries is reinforced from the inside by a stent a metal scaffolding. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and testicular swelling. Coronary artery stenting, which supports blood flow to the heart. Followup after endovascular stent placement for treatment of nutcracker syndrome. A novel hybrid left renal vein transposition and endovascular stenting technique for the treatment of posterior nutcracker syndrome journal of. Hematuria, pelvic or back pain and left varicocele are the most commonly symptoms. 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. 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. Nutcracker syndrome wikimili, the free encyclopedia. Endovascular management of nutcracker syndrome after. Common signs and symptoms when the condition shows no. Multidetector ct of vascular compression syndromes in the. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration.
Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years. The ct scan identified compression of the lrv between the sma and aorta, with an abundance of venous collaterals in the retroperitoneum figure 1. A rare and potentially under diagnosed cause of haematuria. Doppler ultrasonography us has been commonly used for the diagnosis of ncs. 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. Pdf endovascular treatment of nutcracker syndrome a.
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