The nutcracker syndrome ncs is a rare cause of haematuria. 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. Nutcracker syndrome european journal of vascular and. We finally went to mayo clinic and she was diagnosed there. 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.
Other etiologies include tumor thrombosis of the inferior vena cava ivc, portal vein thrombosis, renal cell carcinoma with left renal vein thrombosis, and left renal arteriovenous fistula. Endovascular angioplasty with stenting cas treatment. 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. Other symptoms are often associated with the disorder such as.
The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis. She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. 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. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Nutcracker syndrome is the term used to describe the patient with clinical symptoms of entrapment of the left renal vein between the aorta and the superior mesenteric artery. External stenting of the lrv with this shield technique is.
We reported a case of successful endovascular stenting of the left renal vein for nutcracker syndrome. Endovascular management of nutcracker syndrome after. Results are encouraging at followup periods beyond two. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. 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. Intravascular stenting is the implantation of metallic stents performed with the guidance of digital subtraction angiography under a local anesthesia. 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. Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome. Endovascular treatment of nutcracker syndrome request pdf. Technical variations of twostent bifurcation treatment. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. Current management approach for left renal vein entrapment. Ultimately it may be associated with substantial morbidity and even lifethreatening events. Endovascular treatment of nutcracker syndrome pubmed.
There are many modalities of treatment of nutcracker syndrome. Nutcracker syndrome refers to the complex of clinical symptoms caused by the compression of the left renal vein lrv between the abdominal aorta and the superior mesenteric artery, leading to stenosis of the aortomesenteric portion of the lrv and dilatation of the distal portion. The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. I reached out on instagram and found many others with this disease. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches. The nutcracker syndrome ncs is the clinical equivalent of nutcracker phenomenon characterized by a complex of symptoms with substantial variations. The endovascular therapy of the nutcracker syndrome ncs. 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. It was described for the first time in 1996 by neste et al. Some people may not have symptoms, while others develop severe and. Endovascular stenting for nutcracker syndrome sciencedirect.
Left renal vein transposition for nutcracker syndrome. 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. Nutcracker syndrome had been confirmed by conventional venography until recent years.
The left kidney vein has to cross over the left sided aorta to get to the right sided vena cava. Nutcracker syndrome ncs is caused by compression of the left renal vein. 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. I have had pain since i was a child, i am now 29 and after years of searching, going from doc to doc, i finally found out that i had something called nutcracker syndrome which is a clinically manifest variant of nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein. Although endovascular stenting is well accepted for iliocaval occlusive disease. Nutcracker syndrome ncs is a rare pathology manifested by pain or. Several treatment options have been described to relieve associated symptoms.
A 52yearold woman who had a history of hematuria two years previously was admitted to another hospital for treatment of recurrent hematuria. It embraces an extended nonpathognomonic spectrum of symptoms that imply a difficult diagnosis. Pelvic congestion syndrome, which is a cause of chronic pelvic pain in women, may be due to nutcracker syndrome. The small intestines hang like baggy sausages off the branched stems of the superior mesenteric artery sma, and in some individuals, the sma. We explain the underlying pathophysiology that results in these clinical syndromes so that the patient subset who will benefit from treatment can be identified. Nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle. Results of endovascular treatment for patients with nutcracker. 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.
This article describes the typical imaging findings and clinical features that are associated with four abdominal vascular compression syndromes. Anticoagulation was started and three weeks later, cta showed complete disappearance. Although it is in its infancy, endovascular therapy for nutcracker syndrome is a viable option that may circumvent more invasive procedures. Superior vena cava svc syndrome is caused by obstruction of the flow of venous blood from the upper body into the right atrium. The left gonadal vein is approached through the transverse mesocolon similar to the exposure used for lrv transposition. Elective stenting of unprotected left main coronary artery stenosis. Renal vein entrapment the nutcracker syndrome brandon t. Further studies should report if this approach has adverse effects and if such a. Secondary pevd is due to venous compression of the iivs or left renal veins, as seen in maythurner syndrome and nutcracker syndrome, respectively. Although the nutcracker syndrome represents a form of vascular compression, no previous reports have appeared in the vascular surgical literature. Nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Endovascular stent placement for nutcracker phenomenon. Extravascular stent management for migration of left renal vein. Nowadays, with the development of imaging techniques, color doppler sonogram and 3d cta are replacing venography for the diagnosis of nutcracker.
Moussa, md division of cardiology nyph associate professor of medicine weill medical college of cornell university, new york. The clinical syndrome caused by impingement of the left renal vein lrv between the superior mesenteric artery sma and abdominal aorta has been termed. Intravascular stenting approaches in ncs were extrapolated from the stenting experience in maythurner and superior vena cava syndromes. This patient may be the first reported case of ncs treated with endovascular stenting in taiwan. Endovascular stenting for treatment of nutcracker syndrome. In this case, abdominal computed tomography angiography was helpful in diagnosing the nutcracker syndrome complicated by the renal vein thrombosis.
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 case report of endovascular stent placement for renal vein. It should not be confused with with superior mesenteric artery syndrome aka wilkie syndrome which although also a superior mesenteric artery compression disorder, the sma compresses the. 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. Obstruction of the svc causes congestion and edema of the face and upper thorax 1, 2. Nutcracker syndrome is an entity resulting from left renal vein compression by. After a successful endovascular stenting and a 6month period of antiplatelet and. I just recently had a major surgery for something called nutcracker syndrome. We report a case of migration of a laparoscopically. If hematuria is not present it is termed nutcracker phenomenon. Endovascular stenting as the first step in the overall. On rare occasions the kidney vein will go behind the aorta. Nutcracker syndrome complicated by left renal vein thrombosis. The stent is introduced in the femoral artery going to the lrv.
We report a rare cause if a 12yearold boy who presented with a history of frequent intermittent episodes of painless constant. In cases of nutcracker syndrome, the left renal vein was stenosed between the. After failed conservative approach, she underwent endovascular stenting. It was described for the first time in 1996 by nesteet al. My daughter has nutcracker syndrome testicular disorders. 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. Nutcracker phenomenon and nutcracker syndrome ncbi. Nutcracker syndrome and hypertension radiology case. This case illustrates the features of nutcracker syndrome, also known as renal vein entrapment syndrome, and an uncommon cause of secondary hypertension. Robotassisted laparoscopic extravascular stent for. We recently treated a young woman incapacitated by left flank pain and hematuria with a new external stenting procedure, which relieved the nutcracker syndrome. We present a patient whose complaint of flank pain led to the diagnosis of a renal vein thrombosis.
This syndrome results most commonly from the compression of the left renal vein between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. Mesoaortic compression of the left renal vein the so. Figure 5 placement of the stent in the left renal vein. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications. Meissner the nutcracker syndrome is characterized by entrapment and compression of the left renal vein between the abdominal aorta and the superior mesenteric artery sma figure 1.
Terms in this set 69 nutcracker syndrome is the result of extrinsic compression of what. Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Compartment syndrome pathologic condition caused by progessive development of arterial compression and reduced blood supply secondary to increased pressure within the compartment usually caused by compressive or blunt forces. Imaging findings and clinical features of abdominal. Conflict of interest no conflict to report in relation to this presentation. Placement of left renal venous stent for nutcracker syndrome. However, in some cases, pelvic pain may persist despite removal of the obstruction to the renal venous backflow. I just want to let everyone know that i have vericose veins in my uterus. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. Nutcracker syndrome with pelvic congestion treated by. Technical variations of twostent bifurcation treatment indications and examples issam d. Posterior nutcracker syndrome with left renal vein. Renal nutcracker syndrome genetic and rare diseases. Expandable metallic stent placement for nutcracker phenomenon.
Endovascular stenting in the treatment of pelvic vein congestion. Although surgical repair has been the standard of care, more recently endovascular stenting of the renal vein has been proposed. We report a case of nutcracker syndrome diagnosed with 3dimensional computed tomography angiography 3d cta. Nutcracker syndrome, first reported in 1972, is characterized by hematuria and back pain caused by increased pressure in the lrv as a result of compression between the aorta and the sma. More recently, endovascular approaches have been reported for this uncommon problem. She had surgery, which is left renal vein transposition, where.
Is a complex of clinical symptoms that results from nutcracker phenomenon ncp ncs can be found any time from childhood to old age, with a relatively high prevalence in young and middleaged adults no difference between the sexes. The metallic stent is placed in the narrowed portion of the vein 1. Extravascular stent management for migration of left renal. Nutcracker syndrome ncs describes left renal vein compression.
Park yb1, lim sh, ahn jh, kang e, myung sc, shim hj, yu sh. 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. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. When the kidney vein goes in front of the aorta, it may be pinched by the intestinal artery sma superior mesenteric artery anterior nutcracker syndrome.
Depending on specific manifestations, ncs may be encountered by different medical specialists. Complex bifurcation stenting approach bests provisional stenting double kissing crush technique cut target lesion failure and thrombosis. In 95% of the cases, the obstruction is due to an underlying malignant disease, usually advancedstage lung cancer. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or embolization. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. Management of renal nutcracker syndrome by retroperitoneal. Nutcracker syndrome symptoms, treatment, causes, surgery.
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