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. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months. Apr 15, 2019 percutaneous endovascular stenting of the lrv has shown longterm symptom resolution as well. Nutcracker syndrome ncs was first described in the medical literature in 1950 11. To place the stent in your vein, your surgeon will. Endovascular treatment of nutcracker syndrome scielo. 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. Stent migration after endovascular stenting in patients. It is characterized by left renal vein entrapment between the abdominal aorta and the superior mesenteric artery causing renal venous hypertension. Doppler ultrasound, computed tomography ct and selective left renal vein phlebography are useful to. Endovascular stenting in the treatment of pelvic vein congestion. We describe the case of a 43yearold woman with a duplicated inferior vena cava who was found to have lrv compression on magnetic. May 29, 2019 chronic pelvic pain is a debilitating disease that directly impacts on quality of life and generates costs for health services.
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 allows time for the body to accept the stent and for new tissue to surround it. This is because both mts and pcs are anatomic variants in the structure of abdominal veins that predispose the patient to all three issues. Thoracoabdominal aneurysm surgery, thoracic endovascular aneurysm repair, carotid artery reconstruction, carotid endar.
Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. That journey always begins with a medical consultation. Nutcracker syndrome is a rare vascular disorder that involves compression of the left renal vein lrv, most often at the level of the aortomesenteric angle. Mesenteric ischemia doctors and departments mayo clinic. At the upmc heart and vascular institute, our surgeons in the division of vascular surgery are experts in treating nutcracker syndrome. 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.
Endovascular stent placement for nutcracker phenomenon. Cgsurg106 venous angioplasty with or without stent. In this study, we sought to investigate the incidence of stent migration after endovascular stenting evs in patients with nutcracker syndrome ncs and to discuss the related factors. Nutcracker syndromean unusual case of chronic left upper ab. We report on the case of a 51yearold woman successfully treated with embolization of the ovarian vein and insertion of a self expandable stent in the left renal. Renal nutcracker syndrome genetic and rare diseases. Pelvic congestion syndrome pcs is a disease that is often undiagnosed in women with pelvic pain. Significant pain relief from a diagnostic celiac plexus block as well as the signs symptoms seen in nutcracker syndrome can help us lead to an earlier diagnosis and treatment. Introduction nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily overlooked condition. 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. The name derives from the fact that, in the sagittal plane andor transverse plane, the sma and. Following are the common symptoms that have been studied in the nutcracker syndrome.
Mayo clinic has one of the largest and most experienced practices in the united states, with campuses in arizona, florida and minnesota. 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. Surgical and endovascular interventions for nutcracker. 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. Your doctor will take a thorough history and physical examination looking specifically for signs of chronic venous insufficiency. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. The nutcracker syndrome is a vascular disorder, but the signs and symptoms are mainly urological or gynecological.
Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. 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. Minimally invasive treatments for venous compression syndromes. The nutcracker syndrome is an emerging indication for venous endovascular stenting. Percutaneous endovascular stenting of the lrv has shown longterm symptom resolution as well. Endovascular treatment of deep vein thrombosis associated. The mild nutcracker syndrome can be witnessed in children during the changes their body undergoes due to growth. We present a case of a 54yearold female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Endovascular stenting in the treatment of pelvic vein. Endovascular stent placement for nutcracker phenomenon ios. 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. It is characterized by external compression of the out.
Staff skilled in dozens of specialties work together to ensure quality care and successful recovery. Nutcracker syndrome wikimili, the free encyclopedia. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. It occurs when arteries compress the left renal kidney vein, often causing intermittent hematuria blood in the urine. Endovascular angioplasty with stenting cas treatment. 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. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. Left renal venography considered to be the gold standard test.
The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement. However, it is estimated to be relatively more common in females and usually presents in the 3rd or 4th decade of life. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. 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. It was described for the first time in 1996 by nesteet al. Nutcracker syndrome is an easily missed cause of hematuria in children. 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.
Hansraj n, hamdi a, khalifeh a, wise e, sarkar r, toursavadkohi s. 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. Endovascular treatment of posterior nutcracker syndrome. Endovascular stent placement for the treatment of nutcracker. In addition, failure to achieve pain relief with a paravertebral block made somatic abdominal wall pain less likely as the cause of pain. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. 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. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. Some people may not have symptoms, while others develop severe and. Posts about nutcracker syndrome written by docpark. Nutcracker syndrome surgery recovery time can last 3 months while the vein andor artery heals. Common treatments for nutcracker syndrome include stenting, surgery, and routine urine. Endovascular stenting for 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. The severity of nutcracker syndrome is variable, and affected individuals may be completely asymptomatic or, in the most extreme. Although uncommon, it is still an important diagnosis due to the high morbidity associated with the risk of secondary anaemia from haematuria, from longterm left renal vein hypertension, vascular thrombosis, and even blood clots in the urinary system. 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.
As pain management specialists, we should include nutcracker syndrome in the differential when the symptoms indicate, and not simply assume atypical left flank pain is chronic myofascial or due to lower rib pathology. She underwent successful extravascular stenting with complete symptom resolution. Results of endovascular treatment for patients with. Maythurner syndrome mts is an entity caused by the compression of the left iliac vein that predispose to acute deep vein thrombosis dvt of left lower limb. The lack of diagnosis seems to be related to limited awareness of this disease process by both physicians and.
In women, the hypertension in the left gonadal vein can also cause increased pain during menses. Posterior nutcracker syndrome pncs is the entrapment of the left renal vein between the aorta and the vertebral column. 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. Its development is usually ascribed to the abnormal branching of the superior mesenteric artery from the. The exact prevalence of nutcracker syndrome is unknown, likely because of the variable presenting features. 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. A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months.
Hematuria, pelvic or back pain and left varicocele are the most commonly symptoms. Nutcracker syndrome, endovascular stent, hematuria. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Endovascular treatment of posterior nutcracker syndrome with a new. Jul 14, 2017 posts about nutcracker syndrome written by docpark. Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years.
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. Imaging findings and clinical features of abdominal. Venous compression treatment adelaide, sa may thurner. The compression of the left renal vein between the aorta and superior mesenteric artery was described to resemble a nut trapped between the nutcracker by the anatomist, john c. Endovascular stenting of the renal vein has been reported for nutcracker syndrome with a promising safety and efficacy profile. Nutcracker syndrome servier phlebolymphologyservier. A rare condition due to compression of the left renal vein and impaired flow can cause flank pains, and blood in the urine. Endovascular treatment of posterior nutcracker syndrome with. Endovascular stenting for treatment of nutcracker syndrome. 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. We retrospectively evaluated the data of all patients with ncs who were treated by evs at our single center between january 2004 and october 2014. A case report of a young girl with recurrent hematuria. 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. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein.
Stenting can be used, provided that the same techniques as those in the maythurner syndrome are used, that is, the stent should protrude into the inferior vena cava. Nutcracker syndrome is an important cause of pelvic pain and consists of a set of signs secondary to compression. Extravascular stent management for migration of left renal. 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. In some cases, this compression syndrome arises in the setting of unusual vascular anatomic variants. Ncs, while rare, should be suspected in patients of both sexes with persistent pain or hematuria. Cases of nutcracker syndrome are unique and no two are exactly alike. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. Therapy for renal vein nutcracker syndrome can be completed via stenting or surgery.
Renal vein stenting for nutcracker syndrome endovascular. Learn about the symptoms and treatments for this vascular disease. Nutcracker syndromean unusual case of chronic left upper. Nyc surgical associates is committed to helping our patients receive the best care possible. 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. Intermittent hematuria and orthostatic proteinuria with or without abdominal or flank pain are the common clinical manifestations. Doppler ultrasound, computed tomography ct and selective left renal vein phlebography are useful to confirm. Pdf endovascular stenting for nutcracker syndrome researchgate. Extravascular stent management for migration of left renal vein. The extravascular stenting is an alternative option after migration of left renal vein endovascular stenting. Nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Although surgical repair has been the standard of care, more recently endovascular stenting of the renal vein has been proposed. May thurner syndrome and nutcracker syndrome are examples of venous compression and are discussed below. Recovery time for nutcracker syndrome stenting can last 23 months.
Treatment remains controversial and varies depending on the patients clinical severity. Endovascular treatment of posterior nutcracker syndrome with a new autoexpandable stent. Results are encouraging at followup periods beyond two. The computed tomographic imaging was closely correla ted to therapeutic interventions and stent migration. Renal vein stenting for nutcracker syndrome endovascular today. Data collection included details on clinical findings. Some people may not have symptoms, while others develop severe and persistent symptoms. Endovascular therapy provides an alternative therapy with satisfactory longterm clinical and imaging results for symptomatic patients with nutcracker syndrome. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of. Symptoms were hematuria, proteinuria or flank pain. 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. The internet journal of pediatrics and neonatology. The patient was diagnosed with nutcracker syndrome and underwent endovascular.
We report a case of migration of a laparoscopically. Imaging findings and clinical features of abdominal vascular. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the lrv. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. Nutcracker syndrome is another rare example of venous compression. This only slightly invasive treatment can eliminate the symptoms of the condition. Although endovascular stenting is well accepted for iliocaval occlusive disease, it has been poorly evaluated in this indication. Abdominal ultrasonography not definitive but has been found to be useful. Chronic pelvic pain affects approximately 15% of premenopausal women in the united states. Endovascular management of nutcracker syndrome after. Nutcracker syndrome ns is a welldefined pathologic process in which the therapeutic approach of first choice, although not globally accepted, is currently stenting of the left renal vein lrv with a selfexpanding stent, which may be associated with left gonadal vein lgv embolization.
Nutcracker syndrome, also called renal nutcracker syndrome is a rare vascular condition. Typically, a selfexpanding nitinol or stainless steel stent is used. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Nutcracker syndrome is characterized by a set of signs and symptoms secondary to compression of the left renal vein lrv either in the acute anatomic angle between the abdominal aorta aa and the origin of the superior mesenteric artery sma known as anterior ncs 2,3,4,5 or in a retroaortic position between aa and vertebral column, which. A case of nutcracker syndrome managed by endovascular stenting. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Management of renal nutcracker syndrome by retroperitoneal. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup.
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