Left renal vein lrv compression by the aorta and the superior mesenteric artery sma leading to symptoms of hematuria or left flank pain has been classically described as nutcracker syndrome ncs 1, 2. 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. Renal vein stenting for nutcracker syndrome endovascular. Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of surgical procedures. Savs endovascular treatment of nutcracker syndrome. Following the diagnosis of nutcracker syndrome, she underwent endovascular treatment with renal vein. Roboticassisted laparoscopic placement of extravascular stent for nutcracker syndrome. Ivc at the level between the aorta and the superior mesenteric artery was 4 mm. Its diagnostic criteria are not well defined, often causing delayed or misdiagnosis.
Background retrograde type a aortic dissection has been deemed a rare complication after endovascular stent graft placement for type b dissection. 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. The stent fits inside the aorta, creating a safe tunnel through which blood can pass, thereby allowing the aneurysm to shrink. 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. A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months. Developed by renowned radiologists in each specialty, statdx provides comprehensive decision support you can rely on nutcracker syndrome.
Endovascular stenting for nutcracker syndrome core. Endovascular management of ascending aortic pathology by ralf kolvenbach the incidence of thoracic aortic aneurysms is estimated to be as high as six cases per 100,000 personyears, and replacement of the ascending aorta accounts for the majority of cardiothoracic aortic procedures. Endovascular repair of the descending thoracic aorta. Review of the current literature, primarily case studies, case series, and retrospective studies indicates that angioplasty has also been used with mixed results. The phenomenon is so named because of fact that in the sagittal view, the sma and aa appear to be a nutcracker. 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. Jan 01, 20 read endovascular stent placement for nutcracker phenomenon, journal of xray science and technology on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips.
However, this is only one case, with shortterm followup, and the longterm patency and complications of this procedure are unknown. Endovascular stent placement for nutcracker phenomenon ios. Nutcracker syndrome refers to the clinical manifestations of left renal vein compression between the superior mesenteric artery and the abdominal aorta, causing urinary changes and low back pain. Nutcracker phenomenon and nutcracker syndrome undiagnosed. Treatment of nutcracker syndrome by retroperitoneal laparoscopic extravascular stent placement is a safe and feasible procedure, especially for youngsters in the period of physical. Surgical treatment of posterior nutcracker syndrome presented.
Nutcracker syndrome ncs, also known as left renal vein lrv. The surgery for nutcracker syndrome is not inconsequential, and it is important to link the objective radiologic findings with the critical clinical findings before performing surgery. Compression of the left renal vein between the aorta and the superior mesenteric. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta. The nutcracker phenomenon results from the partial obstruction of the distal segment of the lrv as it passes between the abdominal aorta and the superior mesenteric artery. Endovascular therapy, specifically catheterdirected thrombolysis followed by stent placement, is the current primary intervention for maythurner syndrome moudgill, 2009. The aorta exits the heart and carries blood to all the organs and the rest of the body. Extravascular stent management for migration of left renal vein.
However, this lifethreatening event appears to be underrecognized and is worth being investigated further. Jun 22, 2017 on the other hand, while lessinvasive endovascular stent placement appears to offer good results in the short term, longterm outcomes in a more diverse population are still being studied, and stents have a risk of migration. Endovascular stent placement for nutcracker phenomenon. Endovascular stent placement as a treatment for renal venous hypertension. Longterm followup after endovascular stent placement for treatment of nutcracker syndrome. 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 therapy for thoracic aortic aneurysms and. The lrv may also be compressed by nearby neoplasms, lymphadenopathy, or an enlarged abdominal aortic aneurysm.
This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. Background nutcracker syndrome, caused by left renal vein compression as it passes between the superior mesenteric artery and aorta, causes ongoing symptoms ranging from hematuria and orthostatic proteinuria to pelvic congestion syndrome. 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. Discussion the first report of nutcracker syndrome was published in 1950 by elsadr, who described compression of the left renal vein along its route between the abdominal aorta and the superior mesenteric artery. Endovascular stent placement for the treatment of nutcracker phenomenon in three pediatric patients article in journal of vascular and interventional radiology 1611.
With respect to diseases of the descending thoracic aorta, the indications for stent graft placement are generally the same as those for surgical treatment, 1, 3. The nutcracker syndrome managed by autotransplantation. We reported a teaching case with ncs who underwent endovascular stenting. Pdf endovascular stenting for nutcracker syndrome researchgate. 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. The relationship between the abdominal aorta, sma, lrv v, and duodenum d. In women, the hypertension in the left gonadal vein can also cause increased pain during menses.
Retrograde type a aortic dissection after endovascular. Herein, the authors report three pediatric cases with successful followup for 2 or 3 years after intravenous stent placement with nutcracker syndrome. Left renal vein lrv compression by the aorta and the superior. Although two stents migrated into the inferior vena cava in this study, early researchers had reported that migrated stents were left in the inferior vena cava without adverse effect after longterm followup. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma. Thoracic endovascular aortic repair tevar is a minimally invasive procedure to repair the major blood vessel in the body, called the aorta. Endovascular stent placement for nutcracker phenomenon article in journal of xray science and technology 211. Left renal vein transposition for nutcracker syndrome. 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 first reported case of endovascular stent placement for nutcracker syndrome was in 1996 by neste et al, 10 and a survey of the published english literature revealed 83 cases treated in this manner with satisfactory results.
After the procedure, we arbitrarily chose to treat this patient. Lin md, mba buddima ranasinghe md, phd amit patel mbbs craig g. To present a case highlighting the efficacy of stent implantation for left renal vein lrv entrapment, otherwise known as the nutcracker phenomenon. Several case reports have proved the usefulness of endovascular stent placement in adults with nutcracker syndrome since 1996 2, 3, 4, 6. Endovascular techniques are very efficient not only to treat pcs derived from reflux, but also to treat pcs derived from compressive etiologies, such as the nutcracker syndrome left renal compression between the aorta and the superior mesenteric artery, the maythurner syndrome nonthrombotic compression of the common iliac vein by an iliac. 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. This can lead to renal venous hypertension, resulting in rupture of thinwalled veins into. Endovascular stenting for nutcracker syndrome sciencedirect. Endovascular stent placement for the treatment of nutcracker phenomenon in three pediatric patients. Extravascular stent management for migration of left renal. As with any endovascular stent graft, the abdominal stent graft comes with risks. In anterior nutcracker syndrome, the left renal vein is compressed between the aorta and another abdominal artery.
Treatment of renal vein stenosis by endovascular stent placement may be an appropriate therapeutic option in select cases of nutcracker phenomenon. 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. Endovascular treatment for this syndrome with stent graft placement has recently been reported, 57, 58. 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. Endovascular management of ascending aortic pathology cx. The nutcracker phenomenon, or entrapment of the left renal vein lrv between the aorta and superior mesenteric artery sma, was first described by grant in 1937.
Stent graft placement for the treatment of thoracic aortic. In cases of nutcracker syndrome, the left renal vein was stenosed between the. 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. Entrapment of the left renal vein lrv between the abdominal aorta and. Longterm followup after endovascular stent placement for. We report a case of successful percutaneous lrv stenting for treating nutcracker syndrome and. Diagnosis of nutcracker phenomenon should be considered in cases in which the anteroposterior diameter and peak velocity at these two points exceeds the norm by a factor of four. Anterior nutcracker syndrome is caused by abnormal branching of the superior mesenteric artery that decreases the aortamesenteric angle to below 90, and posterior nutcracker syndrome is caused by the compression of the left renal vein between the abdominal aorta and the vertebral body. Three patients two men and one woman between the ages of 20 and 35 years mean 25. Surgeons, researchers and innovators are increasingly looking towards new. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Learn about the symptoms and treatments for this vascular disease. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. The development of endovascular stent grafts in the descending aorta has significantly reduced the number of open surgical repairs being performed.
Some people may not have symptoms, while others develop severe and. Endovascular management of nutcracker syndrome after. The alternative option of endovascular or extravascular stenting is very. Endoleaks an endoleak is the leaking of blood around the graft into the aneurysm. Endovascular management of recurrent stenosis following. Nutcracker syndrome ncs is caused by compression of left renal vein lrv, usually between the aorta and the superior mesenteric artery sma. Treatment remains controversial and varies depending on the patients clinical severity. Thoracic endovascular aortic repair society for vascular. Endovascular stenting for the nutcracker phenomenon. Aneurysms of the thoracic aorta can be effectively treated by endovascular stent grafting, but this approach requires suitable lengths of normal aorta proximal and distal to the defect for device fixation. The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. Laparoscopic extravascular renal vein stent placement for. 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. In most cases, youll stay in the hospital overnight after the procedure.
Several treatment options have been described to relieve associated symptoms. In 1994, dake first reported the initial stanford experience with patients undergoing endovascular therapy for descending thoracic aortic aneurysms. Read endovascular stent placement for nutcracker phenomenon, journal of xray science and technology on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. Cgsurg106 venous angioplasty with or without stent. Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. This syndrome causes impaired blood flow, along with swelling of the distal area of the vein. Rare causes of hematuria associated with various vascular. Endovascular treatment in the aortic arch vascular news. Thoracic endovascular aneurysm repair tevar involves the percutaneous placement of a stent graft in the descending thoracic or thoracoabdominal aorta. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Roboticassisted laparoscopic placement of extravascular.
Mayo clinic vascular and endovascular surgeons develop and use advanced diagnostic techniques and surgical treatments, such as balloon angioplasty and stenting, bypass surgery, and carotid endarterectomy. Request pdf endovascular stent placement for nutcracker phenomenon the nutcracker syndrome is a rare clinic condition associated with severe hematuria and left flank pain due to the entrapment. Treatment options for pelvic congestion syndrome servier. In most cases, compression of the left renal vein is between the abdominal aorta the main. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in. Endovascular stent placement for decompression of an entrapped left renal vein lrv between the aorta and superior mesenteric artery is an alternative to surgical decompression for treating the nutcracker syndrome.
Endovascular repair of the thoracic aorta uptodate. The first case report of endovascular stent placement for renal vein hypertension was in 1996 by neste et al who described a 58yearold man successfully treated with a wallstent boston scientific corporation, natick, ma. Methods and results eleven of 443 patients developed retrograde type a aortic dissection during or after stent grafting for type b. Jan 11, 2019 they showed that placement of thoracic stent grafts, otherwise known as thoracic endovascular aortic repair tevar, could be performed from a technical standpoint with relatively low morbidity. Nutcracker syndrome encompasses classical symptoms of hematuria and flank pain resulting from the compression of the left renal vein between the aorta and the superior mesenteric artery. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. Nutcracker syndrome, caused by left renal vein lrv compression as it passes between the superior mesenteric artery and aorta, causes ongoing symptoms ranging from. A 44 year old woman presented with low back and pelvic pain. Major risks associated with abdominal endovascular stent grafts include, but are not limited to. D baylor university medical center, dallas, tx, usa. Surgical and endovascular interventions for nutcracker.
Endovascular stent grafts for disorders of the thoracic aorta. Nov 22, 2017 endovascular stenting was followed by complete resolution of symptoms. Vascular and endovascular surgery overview mayo clinic. Endovascular treatment of nutcracker syndrome scielo. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. A minimally invasive alternative for the treatment of nutcracker. The nutcracker syndrome ncs is the clinical equivalent of. Expanding metallic stent placement for nutcracker phenomenon. Scvs endovascular treatment of nutcracker syndrome.
Endovascular stent placement as a treatment for renal venous. Despite potential serious consequences, diagnosing ncs is often challenging, circuitous and commonly delayed. Endovascular extraction of a migrated large selfexpanding. Renal vein stenting for nutcracker syndrome endovascular today. The nutcracker syndrome or nutcracker phenomenon is, basically, the compression of the left renal vein, usually between the superior mesenteric artery and the aorta. Although the contraindication for surgery is often the poor medical condition of the patient, the contraindication for endovascular treatment is most often related to anatomic considerations. Common treatments for nutcracker syndrome include stenting, surgery, and routine. We report a case of migration of a laparoscopically. This is the most common type of 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. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. No intraoperative or postoperative complications occurred. Although endovascular stenting is well accepted for iliocaval occlusive disease. 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. The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement.
Endovascular repair of the thoracic aorta, also referred to as thoracic endovascular aortic repair tevar, refers to a minimally invasive approach that involves placing a stent graft in the thoracic or thoracoabdominal aorta for the treatment of a variety of thoracic aortic pathologies. Nutcracker syndrome servier phlebolymphologyservier. Renal nutcracker syndrome genetic and rare diseases. 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. While an attempt at medical management including aspirin and angiotensin converting enzyme inhibitors works. Li h 1, sun x, liu g, zhang y, chu j, deng c, zhou b, chen w, yang j. The nutcracker syndrome is a rare clinic condition associated with severe hematuria and left flank pain due to the entrapment of the left renal vein 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. Pdf nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria. Hybrid intervention for treatment of the nutcracker syndrome. The large arrow indicates stent placement and the smaller arrow indicates placement of the springs. However, the ascending aorta may be considered one of the last frontiers of endovascular aortic treatment, and encompasses the most challenging anatomy and contraindications. This prevents entrapment of the lrv, coursing between the anterior sma and the posterior aorta. Minimal invasive management includes both endovascular stenting and extravascular stenting 1, 2. Endovascular treatment of nutcracker syndrome sciencedirect. The retroaortic renal vein may be compressed between the aorta and the. 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.
Nutcracker syndrome is an entity resulting from left renal vein. In addition to traditional methods of aneurysm repair, which involve extensive surgery, a large incision, and a long recovery time, stony brook medicine can perform this procedure endovascularly. Results of endovascular treatment for patients with. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. The first case report of endovascular stent placement for renal vein. Li h1, sun x, liu g, zhang y, chu j, deng c, zhou b, chen w, yang j. Nutcracker syndrome encompasses classical symptoms of hematuria and flank pain resulting from the compression of the left renal vein between the aorta. Endovascular stenting in the treatment of pelvic vein congestion.