The symptoms vary from asymptomatic hematuria to severe pelvic congestion. Additionally, this method can be successfully used in the treatment of posterior nutcracker syndrome. Superior mesenteric artery sma syndrome is a gastrovascular disorder in which the third and final portion of the duodenum is compressed between the abdominal aorta aa and the overlying superior mesenteric artery. Pelvic congestion syndrome pcs is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging. The traditional clinical manifestations of nutcracker syndrome is usually accompanied with abdominal pain, hematuria, orthostatic proteinuria, and varicocele formation, however, hypertension is rarely reported as main clinical feature. Vascular surgeons treat diseases of the blood vessels.
Nutcracker syndrome, compression of the left kidney vein. Treatment of arterial complications in thoracic outlet syndrome 61. Based on the advantages of retroperitoneal laparoscopic surgery, this approach should become a standard method for nutcracker syndrome repair. Among the causes of urological etiology, the nutcracker syndrome is very relevant, characterized by compression of the left renal vein, between the aorta and the superior mesenteric artery 2428. Looking at it from a transverse plane both sma and aorta. 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. Read the latest articles of journal of vascular surgery. Nutcracker phenomenon and nutcracker syndrome undiagnosed. Yet, over the last decade, the syndrome has become less controversial as the etiology has become better understood and as the diagnostic approach has become more specific. A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. The henry ford vein center vein diseases can range from cosmetic problems to more serious conditions causing pain, swelling and other symptoms. 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. Surgical placement of an external stent to the lrv is another surgical approach to ncs.
Using this approach we are able to treat difficult aortic aneurysm minimally invasively which may result in a shorter hospital stay and quicker recovery. Renal compression was relieved by external stent es in two patients, internal stent. Current therapy in vascular and endovascular surgery book. Acronym finder has 7 verified definitions for ptas. We report a case of migration of a laparoscopically. Multidisciplinary approach to the management of complex vascular malformations march 1415, 2016. 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. The carotid artery carries blood through the neck and into the brain. Nutcracker phenomenon ncp is caused by a compression of left renal vein between aorta and superior mesenteric artery. The patient presented with signs and symptoms suggestive of deep vein thrombosis. Extravascular stent management for migration of left renal. 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 options offer a minimally invasive approach to select. 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. Diagnosis and treatment of nutcracker syndrome grand rounds. Herein, we present a unique approach to treatment of a severely symptomatic nutcracker syndrome via left renal vein. Renal nutcracker syndrome genetic and rare diseases. From a group of 51 female patients with pelvic congestion. Radiologicallyguided treatment, including angioplasty and stenting, can be used. It also allows the senior trainees the opportunity to attend pnec, the premier endovascular meeting in the pacific northwest. Minimally invasive treatment angioplasty and stenting of the venous lesion relieves outflow obstruction and provides immediate relief of symptoms with good longterm patency rates. Vascular and endovascular surgery overview mayo clinic. The posterior nutcracker syndrome with duplication of the left renal vein is extremely rare, especially in childhood, and often misdiagnosed because it embraces an extended nonpathognomonic spectrum of symptoms that imply a difficult diagnosis. Objective to study the pathophysiology of the nutcracker syndrome and to describe a new method of treatment. Nutcracker syndrome is an entity resulting from left renal vein. Endovascular management of recurrent stenosis following left renal.
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. Clinical and surgical data and shortterm outcomes were analyzed retrospectively. 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. This report describes a case of posterior nutcracker syndrome in which the management approach chosen was open surgery, transposing the gonadal vein distally, to the inferior cava vein. We also investigated the left renal vein doppler ultrasonography dus results, to determine whether or not there was an association between clinical symptoms and dus findings among these patients. An endovascular approach to treat recurrent stenosis following left renal vein. Nutcracker syndrome refers to compression of the left renal vein by the superior mesenteric artery and aorta. Endovascular treatment of nutcracker syndrome request pdf. Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome.
The lrv transposition was the most commonly reported technique, followed by renal autotransplantation. Nutcracker phenomenon ncp, also known as left renal vein entrapment, is characterized by impeded outflow from the left renal vein lrv into the inferior vena cava ivc due to extrinsic lrv compression, often accompanied by demonstrable lateral hilar dilatation and medial mesoaortic narrowing schematic representation of ncpnutcracker syndrome ncs in figure 1. 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. Nutcracker syndrome, or mesoaortic compression of the left. For those with venous thrombosis, rates of postthrombotic syndrome are reduced with endovascular treatment. It was described for the first time in 1996 by neste et al. Herein, we present a unique approach to treatment of a severely symptomatic nutcracker syndrome via left. Aside from clinical findings and physical examination, diagnosis can be made with ultrasound, computed tomography, or magnetic resonance conventional venography.
Current management approach for left renal vein entrapment. Purpose we report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup. Supraclavicular operative approach for thoracic outlet syndrome 60. Additionally, endovascular approaches, primarily via renal vein stenting, have. Baishideng publishing group inc, 7041 koll center parkway, suite 160, pleasanton, ca 94566, usa. Left renal vein lrv compression, commonly referred to as the nutcracker syndrome or renal vein entrapment syndrome, is a rare and often overlooked condition. Kraiss, md vicechair of research, department of surgery chief, division of vascular surgery university of utah medical center salt lake city, ut.
Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Endovascular treatment of nutcracker syndrome journal of. Modern imaging methods show that some degree of left renal vein obstruction may be a common incidental finding in asymptomatic patients so it is better described as nutcracker phenomenon, ncp. Peter gloviczki is a vascular surgeon in rochester, minnesota. She also serves as the coeditor of the thoracic section of the endovascular today journal. The patient was treated with stenting of her left renal vein. A key challenge for these systems is to provision shared resources on demand to meet service quality targets continue reading. The summit provides senior cardiovascular trainees a forum to learn advanced endovascular techniques for the management of aortic dissection and ruptured aaa raaa. Pdf left renal vein balloon venoplasty without stenting for. Endovascular treatment of nutcracker syndrome sciencedirect. Transperitoneal versus retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular national surgical quality improvement program. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Although surgical repair has been the standard of care, more recently endovascular stenting of the renal vein has been proposed. Nutcracker syndrome and phenomenon oxford medicine.
Venous angioplasty with or without stent placement in adults. 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. Laparoscopic extravascular renal vein stent placement for. Peter gloviczki, vascular surgeon in rochester, mn. Oct 27, 2009 with no accepted protocol for nutcracker syndrome repair, retroperitoneal laparoscopic donor nephrectomy and renal autotransplantation should be determined on a casebycase basis. The causes of gynecological origin include adherences, endometriosis, salpingo. We report the first case of mts in a previously healthy adolescent female associated with a large intraabdominal cyst arising from the right ovary. Ptas percutaneous angioplasty and stenting acronymattic. The purpose of this study was to evaluate the clinical characteristics of 44 pediatric patients who were diagnosed as having nutcracker syndrome ncs. Expanding metallic stent placement for nutcracker phenomenon. Indications and patient selection for mesenteric artery stenting were covered previously here. Fatima performs the whole spectrum of vascular surgery both open and endovascular procedures including treatment of mesenteric disease, peripheral vascular disease, and. Since the first issue was released in 1984, the goal of the journal has been to improve the management of patients with vascular diseases by publishing relevant papers that report important.
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. Endovascular stenting of the renal vein has been reported for nutcracker. 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. This study included nutcracker syndrome patients who were treated by laparoscopic extravascular stent placement from june 2009 to august 20. If hematuria is not present it is termed nutcracker phenomenon. This includes aortic aneurysms and dissections, carotid artery disease, peripheral vascular disease, limb salvage, and venous insufficiency.
Nutcracker syndrome servier phlebolymphologyservier. Erben is a vascular surgeon in jacksonville, florida and is affiliated with one hospital. Nutcracker syndrome ncs is a rare vascular anomaly involving left renal vein outflow. After failed conservative approach, she underwent endovascular stenting and. Nutcracker syndrome describes symptomatology associated with obstruction to the left renal vein caused by pressure from the overlying superior mesenteric artery. 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. Robotassisted laparoscopic extravascular stent for. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. Endovascular stenting for nutcracker syndrome sciencedirect. Renal vein stenting for nutcracker syndrome endovascular.
Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. 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. Modern imaging methods show that some degree of left renal vein obstruction may be a common incidental finding in asymptomatic patients so it is better described as nutcracker. Renal venous hypertension usually seen in young, otherwise healthy individuals and can lead to significant overall morbidity. Laparoscopic extravascular renal vein stent placement for nutcracker syndrome article in journal of endourology endourological society 2410. Full text posterior nutcracker syndrome with left renal. Veins henry ford health system henry ford health system. Application of extravascular stenting for nutcracker. Pacific northwest endovascular conference program 2019.
Although there are multiple treatment options, current techniques aim to relieve the symptoms and reduce venous pressure on the left renal vein. It was described for the first time in 1996 by nesteet al. Vulvovaginal varicosities and pelvic congestion syndrome. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. In women, it is an important cause of pelvic congestion syndrome 1, 5, 8. We retrospectively evaluated the endovascular stenting experience with 61 patients with a. Endovascular angioplasty and stenting for proximal subclavian artery stenoses 43. To report our techniques and experience of laparoscopic extravascular stent placement for nutcracker syndrome. Aug 31, 2017 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Several anatomical anomalies can result in deep vein thrombosis dvt. Several treatment options have been described to relieve associated symptoms. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome.
Pdf nutcracker syndrome ncs is a rare vascular anomaly involving left renal vein. Endovascular stent placement as a treatment for renal venous hypertension. An incidental detection of nutcracker phenomenon in an. Minimally invasive treatments for venous compression syndromes. Materials and methods we retrospectively evaluated the endovascular stenting experience with 61 patients with a median age of 26 years. Oclcs webjunction has pulled together information and resources to assist library staff as they consider how to handle.
The nutcracker syndrome journal of vascular surgery. Similarly, the right common iliac artery can compress the left common iliac vein. This article will outline technical aspects of mesenteric artery stenting. Buddchiari syndrome bcs is a rare, lifethreatening disorder caused by obstruction of hepatic venous outflow andor the inferior vena cava. Endovascular stenting for treatment of nutcracker syndrome. Surgical treatment of posterior nutcracker syndrome. Maythurner syndrome mts usually presents with signs and symptoms of deep vein thrombosis or chronic venous insufficiency. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis. She underwent successful extravascular stenting with complete symptom resolution.
Threedimensional volumerendered computed tomographic ct angiography represents an increasingly important clinical tool that, in many institutions, is replacing conventional angiography in the depiction of normal vascular anatomy and the diagnosis of vascular disorders. Left renal vein transposition for nutcracker syndrome. Maythurner syndrome also known as iliac vein compression syndrome is one of them. Jul 24, 2015 a 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. Laparoscopic extravascular stent placement for nutcracker. Endovascular management of nutcracker syndrome after. An eightyearold boy with a history of left varicocele treated by palomo technique one year ago, presented with intermittent painless hematuria. The management of ncs depends upon the clinical presentation and the severity of the lrv hypertension. Venous revascularization to treat posterior nutcracker.
Threedimensional volumerendered ct angiography of the. Endovascular stent placement for nutcracker phenomenon ios. This allow the graft to seal without shutting off blood supply to the kidneys. Endovascular treatment of deep vein thrombosis associated.
Subjects and methods computerized tomography ct was used to compare the anatomical rel. Clinical vignette a 74yearold gentleman with a history of antiphospholipid syndrome and celiac artery stenosis. 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. Hybrid intervention for treatment of the nutcracker syndrome. 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. Many of these treatments take an endovascular approach, meaning doctors work inside the veins to fix the problem. Nutcracker syndrome describes signs and symptoms related to renal venous. Results are encouraging at followup periods up to 2 years. Endovascular angioplasty with stenting cas treatment. Gonadal vein transposition in the treatment of nutcracker syndrome ehsan benrashid, ryan s. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Your surgeons discuss with you all suitable treatment options, which may include traditional open surgery and minimally invasive techniques. Left renal vein balloon venoplasty without stenting for. Compression of the left renal vein between the aorta and superior mesenteric artery causes left renal venous hypertension and symptoms collectively known as nutcracker syndrome 8, 9.
In women, the hypertension in the left gonadal vein can also cause increased pain during menses. The pelvic venous syndromes, which include pelvic congestion syndrome and vulvar varicosities, are poorly understood disorders of the pelvic venous circulations. The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. Surgical and endovascular interventions for nutcracker syndrome. Term of nutcracker syndrome ncs is used for patients with clinical symptoms associated with nutcracker anatomy. Surgical treatment of posterior nutcracker syndrome presented. Current trends in the diagnosis and management of renal. Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome.
Current therapy in vascular and endovascular surgery. As a vascular surgeon, she uses medical treatments, endovascular or minimally invasive techniques, as well as open surgical techniques to manage and treat diseases of the vascular system. Results of endovascular treatment for patients with. 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 treatment of deep vein thrombosis associated with maythurner syndrome. Results are encouraging at followup periods beyond two. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. As more cases are reported, endovascular repair is becoming an alternative treatment for 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. 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. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications. Current therapy in vascular and endovascular surgery is an ideal medical reference book to consult for information in this everchanging field. Nutcracker syndrome is an entity resulting from left renal vein compression by the. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup.
The endovascular therapy of the nutcracker syndrome ncs. Management of renal nutcracker syndrome by retroperitoneal. Pelvic congestion syndrome is a poorly understood and underdiagnosed disease. 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. Endovascular today issn 15511944 print and issn 2689792x online is a publication dedicated to bringing you comprehensive coverage of all the latest technology, techniques, and developments in the endovascular field. At the threeweek followup, she reported near resolution of nausea and abdominal pain. Thoroughly revised to reflect the most recent innovations in vascular and endovascular surgery, it features more than 150 chapters on topics new to this edition, and equips residents and practitioners alike with the latest procedures and techniques in. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. Extravascular stent management for migration of left 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. 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. Sep 30, 2019 although there are multiple treatment options, current techniques aim to relieve the symptoms and reduce venous pressure on the 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. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed.
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