We report a case of migration of a laparoscopically. Loin pain and hematuria are common symptoms, presenting in patients of all ages. There are various underlying pathologic causes, including renal or ureteric calculi or tumors, intrinsic kidney disease including glomerulonephritis, and loin pain hematuria syndrome. 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. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. 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. Materials and methods we retrospectively evaluated the endovascular stenting experience with 61 patients with a median age of 26 years. Endovascular stenting for nutcracker syndrome sciencedirect. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Endovascular stenting of the renal vein has been reported for nutcracker syndrome with a promising safety and efficacy profile. 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. 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. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and testicular swelling.
Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. Although it is in its infancy, endovascular therapy for nutcracker syndrome is a viable option that may circumvent more invasive procedures. Nutcracker syndrome ncs describes left renal vein compression. A rare and potentially under diagnosed cause of haematuria. Endovascular management of nutcracker syndrome after.
Scvs endovascular treatment of nutcracker syndrome. While an attempt at medical management works for some, others experience ongoing symptoms. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Endovascular stenting for the nutcracker phenomenon. Although endovascular stenting is an attractive option, it is not without complications. 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. More recently, endovascular approaches have been reported for this uncommon problem.
Nassiri n 1, shafritz r 1, rahimi s 1, pate l pb 2, araujo l 2 and thomas j 3 1 department of surgery, rutgers robert wood johnson medical school, usa 2 department of general surgery, rutgers robert wood johnson medical school, usa 3 medical student, rutgers robert wood. Left renal vein to vena cava bypass autologous or ptfe sma transposition. If hematuria is not present it is termed 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. Nutcracker syndrome is a rare diagnosis and may manifest in unusual ways. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months. Nov 22, 2017 although endovascular stenting is an attractive option, it is not without complications. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Nutcracker syndrome servier phlebolymphologyservier. Nutcracker syndrome and radiographic evaluation of loin.
Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years. The nutcracker syndrome ncs is a rare cause of haematuria. We recently treated a young woman incapacitated by left flank pain and hematuria with a new external stenting procedure, which relieved the nutcracker syndrome. Endovascular treatment of nutcracker syndrome scielo. Surgical and endovascular interventions for nutcracker syndrome. As more cases are reported, endovascular repair is becoming an alternative treatment for nutcracker syndrome. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Pdf nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in.
Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches. Diagnosis and treatment of subclavian artery occlusive disease. 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. Diagnosing nutcracker syndrome and pelvic congestion syndrome. Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria.
Endovascular stenting in the treatment of pelvic vein congestion. The described treatment options for nutcracker syndrome include ref 1. It embraces an extended nonpathognomonic spectrum of symptoms that imply a difficult diagnosis. Looking at it from a transverse plane both sma and aorta. Cgsurg106 venous angioplasty with or without stent. It was described for the first time in 1996 by neste et al. 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. Research article left renal vein balloon venoplasty without stenting for management of symptomatic nutcracker syndrome. April 2018 endovascular treatment of pelvic congestion 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. 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. Renal vein stenting for nutcracker syndrome endovascular today. We satisfactorily treated a middleaged man with nutcracker syndrome accompanied by renal enlargement, persistent haematuria, proteinuria and hypertension with a new intravascular stent. In cases of nutcracker syndrome, the left renal vein was stenosed between the.
Robotassisted laparoscopic extravascular stent for. Left renal vein balloon venoplasty without stenting for. 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 finally went to mayo clinic and she was diagnosed there. The authors also found that the thrombosis was 8 times more common on the left side due to anatomic differences. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Minimally invasive treatments for venous compression syndromes. Endovascular stent placement for nutcracker phenomenon ios. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. 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. Results are encouraging at followup periods beyond 2 years.
Pdf endovascular stenting for nutcracker syndrome researchgate. Cases of nutcracker syndrome are unique and no two are exactly alike. The first case report of endovascular stent placement for renal vein. 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. Management of renal nutcracker syndrome by retroperitoneal. Medical therapy aimed at decreasing renal venous hypertension for hematuria renal autotransplantation. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. After a successful endovascular stenting and a 6month period of antiplatelet and. 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.
Although surgical repair has been the standard of care, more recently endovascular stenting of the renal vein has been proposed. May 03, 2017 the term syndrome refers to a group of signs and symptoms primarily occurring together, characteristic of a specific condition. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. 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. 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. Extravascular stent management for migration of left renal vein. Results of endovascular treatment for patients with. To present a case highlighting the efficacy of stent implantation for left renal vein lrv entrapment, otherwise known as the nutcracker phenomenon. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications. She had surgery, which is left renal vein transposition, where her symptoms resolved for about two weeks. Our case report confirms nutcracker syndrome may be treated through endovascular means, eliminating symptoms and providing a. Jan 01, 2000 surgical approaches for nutcracker syndrome include nephrectomy, nephropexy, renocaval reimplantation, or autotransplantation. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy. Ncs, while rare, should be suspected in patients of both sexes with persistent pain or hematuria.
Figure 5 placement of the stent in the left renal vein. 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. Endovascular stenting randwick angioplasty sydney nsw. Although endovascular stenting is well accepted for iliocaval occlusive disease. It was described for the first time in 1996 by nesteet al. Pcs remains underdiagnosed and undertreated, but recognizing this condition and providing endovascular treatment can benefit women with chronic pelvic pain. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup. Renal nutcracker syndrome genetic and rare diseases. Endovascular treatment of nutcracker syndrome request pdf. Endovascular stenting and angioplasty is a new and evolving minimally invasive method to treat circulatory disorders caused by diseased arteries. Endovascular angioplasty with stenting cas treatment. The alternative option of endovascular or extravascular stenting is very.
Symptoms were hematuria, proteinuria or flank pain. Management options can range from conservative to surgical, with the endovascular approach becoming an increasingly common one. We present a case of a 54yearold female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Posterior nutcracker syndrome with left renal vein.
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. Left renal vein transposition for nutcracker syndrome. Endovascular treatment of nutcracker syndrome sciencedirect. Single center experience with open and endovascular. The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. Endovascular treatment of pelvic congestion syndrome. The nutcracker syndrome in a venous or even broader scope, vascular compression syndromes is based upon decreased space between the superior mesenteric artery and the aorta in the area of the left renal vein. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. 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. That journey always begins with a medical consultation. The endovascular therapy of the nutcracker syndrome ncs.
Certainly, more studies have to be done before such a treatment can be validated as superior to endovascular stenting and left renal vein transposition. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma. She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of surgical procedures. We report a rare cause if a 12yearold boy who presented with a history of frequent intermittent episodes of painless constant haematuria. Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of. Ultimately it may be associated with substantial morbidity and even lifethreatening events. 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.
Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome. A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal. Treatment of nutcracker syndrome with open and endovascular interventions, j vasc surg. Nutcracker syndrome symptoms, treatment, causes, surgery. Aug 31, 2017 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Endovascular stenting for treatment of nutcracker syndrome. At the threeweek followup, she reported near resolution of nausea and abdominal pain. Application of extravascular stenting for nutcracker. 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. Nutcracker syndrome, or mesoaortic compression of the left. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. Several treatment options have been described to relieve associated symptoms. 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.
After failed conservative approach, she underwent endovascular stenting. Finally, we examined our own experience with a 9year followup of primary stenting, which is one of the longest to date. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis. Further studies should report if this approach has adverse effects and if such a. The nutcracker syndrome ncs is a described as a mesoaortic compression of the left renal vein between the abdominal aorta and the superior mesenteric artery together with hematuria. Nutcracker syndrome, caused by left renal vein lrv compression as it passes between the superior mesenteric artery and aorta, causes ongoing symptoms ranging from hematuria and orthostatic proteinuria to pelvic congestion syndrome. Current management approach for left renal vein entrapment. Although the nutcracker syndrome represents a form of vascular compression, no previous reports have appeared in the vascular surgical literature. Nutcracker syndrome ncs is a rare pathology manifested by pain or. Kirby sebro 1, lester goetz 1, satyendra persaud 2 1 division of surgical sciences, university of the west indies, st augustine, trinidad and tobago.
Conclusion nutcracker syndrome is a rare diagnosis and may manifest in unusual ways. Follow up computed tomography with intravenous contrast showed a widely patent stent. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. 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. Nutcracker syndrome ncs may present with just leftsided flank pain. We report the first case of extravascular stent placement using the robotic approach for the treatment of nutcracker syndrome. Extravascular stent management for migration of left renal. Aug 25, 2016 renal vein entrapment the nutcracker syndrome. Jul 14, 2017 nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle.
Typically, a selfexpanding nitinol or stainless steel stent is used. 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. Posts about nutcracker syndrome written by docpark. My daughter has nutcracker syndrome testicular disorders. The renal venous hypertension caused by ncs can be severe enough to lead to formation of an aneurysm and development of hydronephrosis. Results are encouraging at followup periods beyond two.
She underwent successful extravascular stenting with complete symptom resolution. Mesoaortic compression of the left renal vein the socalled. 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. Endovascular stent placement for nutcracker phenomenon. Longterm followup after endovascular stent placement for. Since some of these causes are potentially serious and may be treatable if identified early, it is important to establish a.
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. We take a team approach to diagnose your condition and design a treatment plan thats right for you. Nyc surgical associates is committed to helping our patients receive the best care possible. Hybrid intervention for treatment of the nutcracker syndrome. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal 20. Nutcracker syndrome european journal of vascular and. 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. San raffaele scientific institute vascular surgery vitasalute university. 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.