Kirby sebro 1, lester goetz 1, satyendra persaud 2 1 division of surgical sciences, university of the west indies, st augustine, trinidad and tobago. Nutcracker syndrome, caused by left renal vein lrv compression as it passes between the superior mesenteric artery and aorta, causes. Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome. Nutcracker syndrome, also called renal nutcracker syndrome is a rare vascular condition. Extravascular stent management for migration of left renal vein. Renal vein stenting for nutcracker syndrome a potentially lessinvasive treatment for a rare but debilitating condition. 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.
Our case report confirms nutcracker syndrome may be treated through endovascular means, eliminating symptoms and providing a durable. It is characterized by external compression of the outflow from the left renal vein lrv into the inferior vena cava ivc. Vena cava filter placement, venous stent procedure, venous angioplasty, venous thrombolysis, varicose vein, deep vein t. Endovascular stenting for nutcracker syndrome nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily overlooked condition. It is characterized by external compression of the. Endovascular stent placement as a treatment for renal venous hypertension. Common treatments for nutcracker syndrome include stenting, surgery, and routine urine. Despite potential serious consequences, diagnosing ncs is often challenging, circuitous and commonly delayed. Longterm followup after endovascular stent placement for. This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. Savs endovascular treatment of nutcracker syndrome. Left renal vein compression nutcracker syndrome left renal vein compression, also known as nutcracker syndrome, occurs when the vein that that carries blood filtered by the left kidney is pinched. Symptoms of nutcracker syndrome include hematuria blood in the urine, left flank pain, left lower quadrant pain in women and left testicular swelling or pain in men.
Pitfalls and bailouts of endovascular stenting for iliac. Venous compression treatment adelaide, sa may thurner. Endovascular stenting for iliac and renal vein obstructions. Posts about nutcracker syndrome written by docpark. Coronary artery stenting, which supports blood flow to the heart muscles. The name derives from the fact that, in the sagittal plane andor transverse plane. D baylor university medical center, dallas, tx, usa. 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 syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. This is because both mts and pcs are anatomic variants in the structure of abdominal veins that predispose the patient to all three issues. 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 is a clinical entity leading to renal venous hypertension due to extrinsic compression of the left renal vein by the superior mesenteric artery.
Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and. Background nutcracker syndrome ncs is caused by left renal vein lrv entrapment, most commonly between the aorta and superior mesenteric artery sma. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches.
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. To place the stent in your vein, your surgeon will. A rare and potentially under diagnosed cause of haematuria. At the upmc heart and vascular institute, our surgeons in the division of vascular surgery are experts in treating nutcracker syndrome. Endovascular stenting for nutcracker syndrome sciencedirect. Renal vein stenting for nutcracker syndrome endovascular today. The nutcracker phenomenon left renal vein lrv entrapment syndrome refers to compression of the lrv most commonly between abdominal aorta and superior mesenteric artery. The patient was treated with stenting of her left renal vein. Extravascular stent management for migration of left renal vein endovascular stent in nutcracker syndrome lu tian, shanwen chen, gaoyue zhang, hongkun zhang, wei jin, and ming li department of vascular surgery, the first affiliated hospital of medical college, zhejiang university, hangzhou, 33 china.
Current trends in the diagnosis and management of renal. Outcomes of left renal vein stenting in patients with nutcracker. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. We describe endovascular stenting of the left renal vein to treat nutcracker syndrome accompanied by gross hematuria. It is due to the compression of the distal segment of the left renal vein lrv between the superior mesenteric artery sma and the aorta also called left renal vein entrapment. 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. Renal nutcracker syndrome genetic and rare diseases. Nutcracker syndrome is an entity resulting from left renal vein. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Show more areas of focus for haraldur bjarnason, m. Division of vascular and endovascular surgery, mayo clinic, rochester, mn, usa january 1921, 2017 paris, france. A novel hybrid left renal vein transposition and endovascular stenting technique for the treatment of posterior nutcracker syndrome kristin stawiarski, md,a matthew wosnitzer, md,b andyoung erben, md,c bridgeport, fair. Venous stenting, which supports blood flow through vessels affected by deep vein thrombosis or chronic venous insufficiency.
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. The nutcracker syndrome causes compression of the left renal vein by the arteries near the kidney. Nutcracker syndrome wikimili, the free encyclopedia. The stent will be placed in your vein by the surgeon after the surgeon makes a small puncture in the leg. A novel hybrid left renal vein transposition and endovascular. Extravascular stent management for migration of left renal. Entrapment of the left renal vein lrv between the abdominal aorta and superior mesenteric artery sma causing the classic clinical triad of hematuria, varicocele, and left abdominal or flank pain was first described in 1950. The name nutcracker syndrome comes from the image of the left renal vein being compressed, or cracked, between the aorta and superior mesenteric arteries. Nutcracker syndrome is a variation of nutcracker phenomenon or renal vein. 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. 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.
Endovascular management of recurrent stenosis following left. Endovascular treatment of nutcracker syndrome request pdf. We report the case of a young patient with nutcracker syndrome who underwent left renal vein transposition and subsequently developed recurrent symptoms and restenosis 10 months postoperatively. 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 ncs, or renal vein entrapment syndrome, is a rare and easily overlooked condition. Hematuria is frequently present, and vulvar or lower extremity varices are seen in a subset of patients. It is characterized by external compression of the out.
The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement. Treatment remains controversial and varies depending on the patients clinical severity. A rare condition due to compression of the left renal vein and impaired flow can cause flank pains, and blood in the urine. Inguinal microscopic varicocelectomy with spermatic vein. 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 ncs is the name given to entrapment of the left renal vein lrv between the aorta and superior mesenteric artery sma. Nutcracker syndrome treated by endovascular stenting of the left. Nutcracker syndrome refers to compression of the left renal vein by the superior mesenteric artery and aorta. As more cases are reported, endovascular repair is becoming an alternative treatment for nutcracker syndrome. Renal vein stenting for nutcracker syndrome endovascular. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and testicular swelling. 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 diagnosis of left renal vein entrapment nutcracker syndrome, ncs was. Developed by renowned radiologists in each specialty, statdx provides comprehensive decision support you can rely on nutcracker syndrome.
Jun 21, 2012 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. The lrv may also be compressed by nearby neoplasms, lymphadenopathy, or an enlarged abdominal aortic aneurysm. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the lrv. It may coincide with sma syndromecompression of the third portion of the duodenum by the abdominal aorta and the sma. 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. Results of endovascular treatment for patients with. Medstar heart and vascular institute stenting medstar. Results are encouraging at followup periods beyond 2 years. Nutcracker syndrome is another rare example of venous compression. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the.
At the threeweek followup, she reported near resolution of nausea and abdominal pain. Nutcracker syndrome, or mesoaortic compression of the left. Despite modern imaging modalities, the diagnosis of nutcracker syndrome is difficult and requires a high index of suspicion. Most often, it implies compression of the lrv between the aorta and the superior mesenteric artery sma, known as the. Early resolution of pelvic venous collaterals after endovascular. 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. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Patients typically present with left flank pain and associated symptoms of pelvic congestion. We report on 3 patients who presented with nutcracker syndrome, including one patient with a circumaortic lrv resulting in posterior nutcracker syndrome, who underwent successful endovascular treatment with renal vein stenting. Nutcracker syndrome is a very common condition that is present in almost 50% of women with other forms of pelvic vein disease, such as may thurner syndrome mts and pelvic congestion.
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. Endovascular management of nutcracker syndrome after. Learn about the symptoms and treatments for this vascular disease. Most common symptoms are hematuria, pain, and severe pelvic congestion. Angioplasty, stenting, atherectomy, bypass surgery. We describe the case of a 20yearold female with haematuria, abdominal pain and weight loss. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Endovascular treatment with renal vein stenting is safe. Endovascular management of recurrent stenosis following. A case report patients with nutcracker syndrome ncs associated left varicocele are at high risk of varicocele recurrence when treated only with routine surgical approach for varicocele.
Nutcracker syndrome servier phlebolymphologyservier. Jul 14, 2017 posts about nutcracker syndrome written by docpark. Flank pain resolved immediately and postoperative computed tomography with intravenous contrast revealed only a small focus of thrombus in the left upper pole renal vein and a widely patent stent. Endovascular stent placement for the treatment of nutcracker. Nutcracker syndrome treated by endovascular stenting of the left renal vein. Current surgical therapy involves placement of an oversized renal vein stent with partial protrusion into the inferior vena cava ivc to relieve stenosis and prevent stent migration. 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. Endovascular treatment of nutcracker syndrome sciencedirect. 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. Nutcracker syndrome ncs is a rare condition that can pre sent with. Renal nutcracker syndrome rns is characterized by the compression of the left renal vein between the superior mesenteric artery sma and the aorta or between the aorta and vertebral body. Entrapment of the left renal vein lrv between the abdominal aorta and superior mesenteric artery sma causing the classic clinical triad of hematuria.
Scvs robotic assisted left renal vein transposition. Nov 16, 2011 doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. 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. Renal artery stenting, which improves blood flow through the arteries that supply blood to the kidneys. 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 florida surgical clinic. However, endovascular treatment with renal vein stenting has achieved excellent results. Although it is in its infancy, endovascular therapy for nutcracker syndrome is a viable option that may circumvent more invasive procedures.
A stent is a small mesh tube which is used to hold the left renal vein open so that there is proper blood flow. Term of nutcracker syndrome ncs is used for patients with clinical symptoms associated with nutcracker anatomy. Some people may not have symptoms, while others develop severe and persistent symptoms. Mesoaortic compression of the left renal vein the socalled nutcracker syndrome. Therapy for renal vein nutcracker syndrome can be completed via stenting or surgery. Here, the left renal vein which drains the blood from the left kidney is compressed like a nutcracker between the abdominal aorta behind and the superior mesenteric artery in front. Current management approach for left renal vein entrapment. 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. Inguinal microscopic varicocelectomy with spermatic vein inferior epigastric vein anastomosis in a child with nutcracker syndrome. Results are encouraging at followup periods beyond two. This can obstruct venous return into the inferior vena cava ivc and lead to hypertension.
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