Nutcracker syndrome treatment is very safe, benign, with almost no longterm consequences or lifestyle alterations needed. In some cases we will delay treatment for other reasons, like in a woman expecting to have more children, which may put pressure on an endovascular stent. Hybrid intervention for treatment of the nutcracker syndrome. Thoracoabdominal aneurysm surgery, thoracic endovascular aneurysm repair, carotid artery reconstruction, carotid endar. Following are the common symptoms that have been studied in the nutcracker syndrome. Conservative management with routine urinalysis is proposed for mild hematuria, since the development of collateral veins may resolve the hypertension in the left renal vein and alleviate symptoms.
Jun 22, 2017 endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. Extravascular stent management for migration of left renal. Vascular and endovascular surgery overview mayo clinic. 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. Endovascular technology has evolved as a potential minimally invasive therapy for relief of symptoms caused by this compression syndrome. Surgical options include nephrectomy, variceal ligation, nephropexy, and renocaval reimplantation.
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, caused by left renal vein lrv compression as it passes between the superior mesenteric artery and aorta, causes ongoing symptoms ranging from. In this article, we refer to this heterogeneous group of. Each of these interventions has strengths and weaknesses. Policha a, lamparello p, sadek m, berland t, maldonado t 2016 endovascular treatment of nutcracker syndrome. Endovascular treatment of nutcracker syndrome request pdf. Nutcracker syndrome treatments can vary based on your age, symptoms, and the severity of your condition. Nutcracker syndrome is a rare anomaly resulting from compression of the left renal vein between the aorta and the superior mesenteric artery. A rare and potentially under diagnosed cause of haematuria. 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. 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. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Staff skilled in dozens of specialties work together to ensure quality care and successful recovery.
A diagnosis of left renal vein entrapment nutcracker syndrome, ncs was. While an attempt at medical management works for some, others experience ongoing symptoms. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. Conservative, open and endovascular options exist for treatment, however patient treatment must be individualized. Nutcracker syndrome is a rare entity, and in the majority of cases is the result of extrinsic compression of the left renal vein between the superior mesenteric artery and the aorta, associated with functional stenosis. Controversy also exists regarding treatment of nutcracker syndrome. Both open and endovascular approaches to the treatment of this condition have been described in the literature. 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. Ab minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome.
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. 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. 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. 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. Open and endovascular interventions have both been performed to relieve the compression.
In some cases, you may not need treatment, particularly if youre. An adult with mild symptoms of nutcracker syndrome. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the lrv. Endovascular treatment of posterior nutcracker syndrome with a new. Endovascular stenting for treatment of nutcracker syndrome. 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. Nutcracker syndrome is diagnosed through imaging such as doppler ultrasound dus, computed tomography ct, magnetic resonance imaging mri, and venography. Early resolution of pelvic venous collaterals after endovascular. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures.
Symptoms of nutcracker syndromes may include intermittent left flank pain associated with hematuria, proteinuria, and sometimes with symptoms of pelvic congestion. Gonadal vein transposition for the treatment of nutcracker syndrome. 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. Nov 22, 2017 conservative, open and endovascular options exist for treatment, however patient treatment must be individualized. Renal nutcracker syndrome genetic and rare diseases. 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. 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. Macroscopic hematuria secondary to nutcracker syndrome. Multidetector ct of vascular compression syndromes in the. D baylor university medical center, dallas, tx, usa.
Nutcracker syndrome got its name because the compression of the renal vein is like a nutcracker cracking a nut. Mayo clinic has one of the largest and most experienced practices in the united states, with campuses in arizona, florida and minnesota. This is a minimally invasive method with encouraging results. Nutcracker syndrome ncs is caused by compression of left renal vein lrv, usually between the aorta and the superior mesenteric artery sma. Takayasus arteritis doctors and departments mayo clinic.
There are currently no well performed studies to help guide when to treat patients with nutcracker anatomy. 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. As more cases are reported, endovascular repair is becoming an alternative treatment for nutcracker syndrome. Common signs and symptoms when the condition shows no.
Endovascular treatment of nutcracker syndrome sciencedirect. 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. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Endovascular treatment of nutcracker syndrome journal of. Treatment options for pelvic congestion syndrome servier.
The endovascular treatment of nutcracker syndrome is currently considered by some to be the preferred treatment option in this pathologic. Endovascular management of recurrent stenosis following left renal vein transposition for the treatment of nutcracker syndrome journal of vascular surgery, vol. Hartung o, grisoli d, boufi m, marani i, hakam z, et al. Despite potential serious consequences, diagnosing ncs is often challenging, circuitous and commonly delayed. The nutcracker syndrome is a vascular disorder, but the signs and symptoms are mainly urological or gynecological. May 29, 2019 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. Your surgeons discuss with you all suitable treatment options, which may include traditional open surgery and minimally invasive techniques. Nutcracker syndrome can be treated with observation, endovascular techniques or surgery. 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.
We report two patients in whom a hybrid approach was adopted in the process combining the strengths of each. Herein we report three patients who presented with nutcracker syndrome, including one patient with posterior nutcracker syndrome due to a retroaortic lrv who underwent successful endovascular treatment with renal vein stenting. The available options are subdivided into four groups, namely surveillance, open surgical procedures, intra or extra vascular stents, and lastly intrapelvic chemical cauterisation 1. Scvs endovascular treatment of nutcracker syndrome. The iliocaval confluence is relatively static with some movement of the lumbosacral joints and well suited for treatment with the relatively nonconforming wall stents. At the threeweek followup, she reported near resolution of nausea and abdominal pain. Minimally invasive treatments for venous compression syndromes the management of venous compression syndromes has historically been reliant on surgical treatment when conservative measures fail. When symptomatic, such compressions can result in a variety of uncommon syndromes in the abdomen and pelvis, including median arcuate ligament syndrome mals, maythurner syndrome, nutcracker syndrome, superior mesenteric artery sma syndrome, upj obstruction, ovarian vein syndrome ovs, and other forms of ureteral compression. 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 selection of the imaging modality is a stepwise process. Jun 12, 2016 the difference between maythurner syndrome and nutcracker syndrome isnt merely the size of the veins and stents. The difference between maythurner syndrome and nutcracker syndrome isnt merely the size of the veins and stents.
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. Endovascular treatment of nutcracker syndrome scielo. Cgsurg106 venous angioplasty with or without stent. Oct 04, 20 treatment options for nutcracker syndrome. 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. To present the case of a 19yearold female with no significant medical history with confirmed diagnosed of nutcracker syndrome treated successfully by endovascular means. Results of endovascular treatment for patients with nutcracker. Endovascular as well as open therapies are available for the treatment of nutcracker syndrome. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Endovascular therapy involves stent placement in the left renal vein.
Treatment of nutcracker syndrome has been evolving in the last four decades ranging from observation to nephrectomy, depending on the severity of symptoms 3. Renal vein stenting for nutcracker syndrome endovascular today. Results of endovascular treatment for patients with. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. Renal vein stenting for nutcracker syndrome endovascular. Nutcracker syndrome refers to signs and symptoms secondary to compression of the left renal vein, most commonly between the superior mesenteric artery and. Treatment remains controversial and varies depending on the patients.
There are, however, several settings in which endovascular therapy can play a significant role as an adjunct or even a replacement to more invasive. Developed by renowned radiologists in each specialty, statdx provides comprehensive decision support you can rely on nutcracker syndrome. It was described for the first time in 1996 by neste et al. The posterior nutcracker syndrome is very rare and is considered when the left renal vein is compressed between the aorta and vertebral column. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of. Nutcracker syndrome servier phlebolymphologyservier.
Treatment of nutcracker syndrome florida surgical clinic. Common signs and symptoms when the condition shows no symptoms, its usually known. Additionally, the authors stated further experience and followup are needed before accepting such a procedure for the superior choice of the treatment for nutcracker. Nutcracker phenomenon and nutcracker syndrome mayo clin proc. A surgeons notes to cut is to cure a vascular surgery blog. The authors concluded that endovascular treatment is a safe, effective, and minimally invasive technique that provides good longterm patency rates for nutcracker syndrome. This test also demonstrates anatomy and allows the surgeon to determine the most ideal treatment. Results are encouraging at followup periods beyond 2 years. This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. Robotassisted laparoscopic extravascular stent for.
Savs endovascular treatment of nutcracker syndrome. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid. Treatment remains controversial and varies depending on the patients clinical severity. The most common treatments for nutcracker syndrome are. To retrospectively assess the therapeutic value of endovascular stenting for treatment of the nutcracker syndrome ncs in longterm followup and to explore. Jenna kazil is a skilled expert vascular surgeon in bradenton, fl, who sees west florida patients from sarasota to tampa at various hospitals. In these cases, a metal stent is placed in the area compressed by the superior mesenteric artery. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and testicular swelling. Research reporting standards for endovascular treatment of pelvic venous insufficiency.
Jul 14, 2017 posts about nutcracker syndrome written by docpark. The patient was treated with stenting of her left renal vein. This study reports the effect of blood transfusion and blood product ratios on outcome in massively transfused mt patients treated for ruptured. If patients are suffering from nutcracker syndrome, it is important that they locate an acquainted vascular surgeon to carry out the treatment of nutcracker syndrome. Left renal vein transposition has remained the treatment of choice although endovascular left renal vein stent placement has been advocated in some series with variable success and some complications including stent migration. Satyendra persaud department of urology san fernando general hospital san fernando trinidad and tobago tel. Mesenteric ischemia doctors and departments mayo clinic. Endovascular treatment of nutcracker syndrome article pdf available in jornal vascular brasileiro 123. The mild nutcracker syndrome can be witnessed in children during the changes their body undergoes due to growth. Currently, many patients are treated with endovascular stenting. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis. 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.