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John G, Wilhelm F, Magnus L, Burgaud M, Leterrier T, Rouyer O, Thiel H, Nicolini P, Chabrot P, Thaveau F. Monocentric prospective study to valid multidisciplinary diagnostic and therapeutic approach for Nutcracker syndrome. Phlebology 2024:2683555241278548. [PMID: 39250305 DOI: 10.1177/02683555241278548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Background: Nutcracker syndrome (NCS) is defined as left renal vein (LRV) compression by the superior mesenteric artery. NCS diagnosis is rendered complex by confounding symptoms. The study objective was to perform a prospective observational analysis of the diagnostic and therapeutic criteria of the patients with suspected NCS. When NCS diagnosis was confirmed, transposition of the LRV was carried out by mini-invasive robotic surgery (MIRS). Method: All patients addressed to the vascular surgery department for suspicion of NCS between January 2022 and June 2023 were included in the study. Patients were subsequently assessed by means of a computed tomography scan, dynamic duplex ultrasound and phlebography associated with an occlusion test of the left gonadic vein (LGV). Diagnostic criteria included aorto-mesenteric angle, LGV diameter and reflux, velocity ratios and diameters and the reno-caval gradient. Result: Thirty two patients aged 37 ± 14 years had suspicion of NCS. Twenty presented an aorto-mesenteric angle below 20°, twenty three had a LGV diameter greater than 5 mm and twenty two of the latter patients also had LGV reflux. A significant reno-caval gradient greater than 5 mmHg was found in ten cases, thereby consolidating NCS diagnosis. Overall, thirteen patients neither presented NCS or pelvic varicosities; eight had pelvic congestion syndrome without NCS and were successfully treated by embolization. Eleven patients with confirmed NCS underwent LRV transposition in the inferior vena cava (IVC). Eight of the latter patients received a complementary pelvic varicosity embolization 2 days later. Two months post-operation 100% of transposed LRV were permeable as assessed by duplex ultrasound controls and all of these patients reported an improvement of symptoms. Conclusion: An innovative multidisciplinary decisional algorithm establishes certitude in NCS diagnosis which can subsequently be treated radically by MIRS.
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Affiliation(s)
- Gwenaël John
- Department of Vascular and Endovascular Surgery, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Frederic Wilhelm
- Department of Vascular and Endovascular Surgery, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Louis Magnus
- Department of Vascular and Endovascular Surgery, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Mathilde Burgaud
- Department of Vascular and Endovascular Surgery, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Tristan Leterrier
- Department of Vascular and Endovascular Surgery, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Olivier Rouyer
- Department of Vascular and Endovascular Surgery, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Hélène Thiel
- Department of Vascular Radiology, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Philippe Nicolini
- Department of Vascular Surgery, Medipole Medical Center, Lyon, France
| | - Pascal Chabrot
- Department of Vascular Radiology, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Fabien Thaveau
- Department of Vascular and Endovascular Surgery, Gabriel Montpied University Hospital, Clermont-Ferrand, France
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Superior mesenteric artery syndrome (Wilkie Syndrome) with unusual clinical onset: Description of a rare case. Radiol Case Rep 2021; 16:2998-3002. [PMID: 34401041 PMCID: PMC8358285 DOI: 10.1016/j.radcr.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022] Open
Abstract
Wilkie's Syndrome is a very rare disease caused by reduction of aorto-mesenteric space with consequent duodenum compression. It can combine with left renal vein stenosis which, when symptomatic, is known as "Nutcracker Syndrome". We describe a clinical onset case with epigastric pain without vomiting in a normal weight patient. 28-year-old woman who came to our observation for intense epigastric pain after a weight loss of 14 kg in 4 months. Multidetector Computed Tomography and Ultrasound revealed gastric and duodenal overdistension with hydro-air levels, severe duodenum stenosis, and left renal vein compression. Wilkie's Syndrome is common in anorexic individuals suffering from recurrent postprandial vomiting, onset with severe epigastric pain, without vomiting, is quite unusual. High-calorie diet must be first therapeutic approach, in case of failure treatment of first choice should be endovascular stenting and, only in selected cases, surgical treatment should be used because it is very invasive and burdened with numerous complications. Failure to diagnose this disease can expose patients to serious health risks.
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3
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Cronan JC, Hawkins CM, Kennedy SS, Marshall KW, Rostad BS, Gill AE. Endovascular management of nutcracker syndrome in an adolescent patient population. Pediatr Radiol 2021; 51:1487-1496. [PMID: 33704542 DOI: 10.1007/s00247-021-04986-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 12/01/2020] [Accepted: 01/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Nutcracker syndrome is defined as left renal vein compression with concomitant clinical symptoms that include flank pain and hematuria. Historically, pediatric and adolescent patients with mild symptoms of nutcracker syndrome were simply observed while those with more severe symptoms underwent left renal vein transposition. Endovascular stenting of the left renal vein is a potentially efficacious and less invasive alternative for managing nutcracker syndrome in adolescents. OBJECTIVE The purpose of this study was to investigate the technical feasibility, efficacy and safety of left renal vein stenting in adolescents with nutcracker syndrome. MATERIALS AND METHODS We conducted a retrospective review of electronic medical records and imaging archives to identify adolescents undergoing endovascular stenting for nutcracker syndrome. We reviewed patient demographics including age, gender, presenting symptoms and diagnostic imaging findings. We compared pre- and post-stent deployment intravascular ultrasound (IVUS) and venography and evaluated patient symptoms in clinic up to 6 months following stent placement. RESULTS Ten patients (average age 16 years, range 12-20 years) underwent 13 procedures. Initial symptoms included pain (n=10) and gross hematuria (n=5). Diagnostic imaging studies included CT abdomen pelvis (n=8), retroperitoneal US (n=6), MRI abdomen/pelvis (n=4), scrotal US (n=2), pelvic US (n=1) and renal Doppler US (n=2). Venography and IVUS demonstrated venous collaterals, proximal blanching at the left-renal-vein-IVC junction, pre-stenotic dilation and intraluminal compression. Most patients (n=9) experienced symptomatic resolution; however, three patients required reintervention to achieve asymptomatic status. No periprocedural complications occurred. CONCLUSION In this carefully selected adolescent cohort, left renal vein stenting for nutcracker syndrome was often technically feasible, safe and effective in symptom management.
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Affiliation(s)
- Julie C Cronan
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - C Matthew Hawkins
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
- Division of Pediatric Radiology, Department of Radiology and Imaging Science, Emory University School of Medicine, Atlanta, GA, USA
- Emory + Children's Pediatric Institute, Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Sabina S Kennedy
- Emory + Children's Pediatric Institute, Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kelley W Marshall
- Division of Pediatric Radiology, Department of Radiology and Imaging Science, Emory University School of Medicine, Atlanta, GA, USA
- Emory + Children's Pediatric Institute, Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Bradley S Rostad
- Division of Pediatric Radiology, Department of Radiology and Imaging Science, Emory University School of Medicine, Atlanta, GA, USA
- Emory + Children's Pediatric Institute, Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Anne E Gill
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
- Division of Pediatric Radiology, Department of Radiology and Imaging Science, Emory University School of Medicine, Atlanta, GA, USA
- Emory + Children's Pediatric Institute, Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
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4
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Cubberley AT, Hamandi M, Rawitscher C, Al-Azizi K, Sayfo S, Potluri S, Morales PA, Vasquez J, Dib C. The Vici venous stent for treatment of renal vein entrapment. Proc (Bayl Univ Med Cent) 2021; 34:394-396. [PMID: 33953474 DOI: 10.1080/08998280.2020.1871278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery and the aorta. We present the first reported case of symptomatic left renal vein compression treated with balloon angioplasty and stenting with the Vici stent system.
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Affiliation(s)
- Alex T Cubberley
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas
| | - Mohanad Hamandi
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas
| | - Courtney Rawitscher
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas
| | - Karim Al-Azizi
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas.,Baylor Scott and White Legacy Heart Center, Plano, Texas
| | - Sameh Sayfo
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas.,Baylor Scott and White Legacy Heart Center, Plano, Texas
| | - Srinivasa Potluri
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas.,Baylor Scott and White Legacy Heart Center, Plano, Texas
| | - Phillip A Morales
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas.,Baylor Scott and White Legacy Heart Center, Plano, Texas
| | | | - Chadi Dib
- Division of Cardiology, Baylor Scott and White The Heart Hospital - Plano, Plano, Texas.,Baylor Scott and White Legacy Heart Center, Plano, Texas
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5
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Cherfan P, Avgerinos ED, Chaer RA. Left Renal Vein Stenting in Nutcracker Syndrome: Outcomes and Implications. VASCULAR AND ENDOVASCULAR REVIEW 2020. [DOI: 10.15420/ver.2020.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Nutcracker syndrome refers to the symptomatic extrinsic compression of the left renal vein presenting most commonly as flank pain and haematuria. While surgery remains the first-line treatment, stenting is gaining more acceptance and there are now several published case series. This article highlights the outcomes of left renal vein stenting in the setting of nutcracker syndrome.
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Affiliation(s)
- Patrick Cherfan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, US
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, US
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, US
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Eighteen years of experience with pediatric nutcracker syndrome: the importance of the conservative approach. J Pediatr Urol 2020; 16:218.e1-218.e6. [PMID: 32044256 DOI: 10.1016/j.jpurol.2019.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/02/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Nutcracker syndrome (NS) defines an entity generated by the compression of the left renal vein resulting in venous hypertension, which transmitted in a retrograde direction may cause hematuria, proteinuria, and varicocele. The literature concerning exclusively pediatric patients is very rare. OBJECTIVE To report the authors' experience with pediatric NS in the last 18 years. STUDY DESIGN This is a retrospective review of the patients followed up in the authors' center with diagnosis of NS based on clinical and imaging tests (ultrasound, computed tomography/magnetic resonance imaging, and phlebography). The primary outcome was the success of the conservative approach in the study patients. RESULTS AND DISCUSSION A total of 21 patients were diagnosed with NS and followed up for a mean period of 52.3 months (37.1-67.5). The mean age at diagnosis was 11.7 years (9.9-13.4). The most frequent symptom of presentation was hematuria in 16 patients (76.2%), being macroscopic in 75% patients and related to physical exercise in 42.9% patients. Other symptoms were left varicocele in 7 patients (33%) and proteinuria in 6 patients (28.6%). Mild to moderate cases received conservative treatment (change of physical activity, postural hygiene), which achieved resolution of symptoms in 16 patients (76.2%). Five cases (23.8%) finally needed a more aggressive approach. Two (9.5%) of them required endovascular procedures (intravascular stent in the renal vein in 1 case and embolization of the spermatic vein in 1 case); in one (4.8%) of the patients, transposition of the left renal vein and kidney autotransplantation were performed, and 2 (9.5%) of the patients with mild cases required surgical correction of the varicocele. CONCLUSIONS Hematuria, usually macroscopic and related to physical exercise, is the most frequent symptom in pediatric patients with NS. The authors advocate studying the aortomesenteric junction by abdominal ultrasound in patients with varicocele or with intermittent macroscopic hematuria. Diagnosis is based on non-invasive tests; phlebography should be reserved for severe cases that require an interventionist attitude. A long period of conservative treatment is the first approach for pediatric patients with NS.
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Beita AKV, Whayne TF. The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old. Cardiovasc Hematol Agents Med Chem 2019; 17:74-81. [PMID: 31538906 DOI: 10.2174/1871525717666190920100518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/22/2022]
Abstract
This review is directed at increasing awareness of two diverse rare upper gastrointestinal problems that occur at opposite ends of the age spectrum and are difficult to diagnose and treat. The Superior Mesenteric Artery Syndrome (SMAS) likely involves a young patient, especially female, and is especially associated with rapid weight loss, resulting in relative strangulation of the duodenum by a narrowing of the angle between the Superior Mesenteric Artery (SMA) and the aorta. On the other hand, atherosclerosis of the SMA is associated most likely with postprandial upper intestinal ischemia and abdominal pain occurs in the elderly at high risk for cardiovascular (CV) disease. Medical management of the SMAS in the young involves good alimentation and weight gain to overall increase the intestinal fat pad. Medical management of SMA atherosclerotic ischemia in the elderly is directed at marked lipid lowering with atherosclerotic plaque stabilization or even regression. If needed, surgery for SMAS can be attempted laparoscopically with duodenojejunoscopy which is the most popular procedure but there are also more conservative possibilities that avoid division of the duodenum. In addition, sometimes direct vision is needed to successfully operate on SMAS. If surgery is needed for SMA atherosclerotic ischemia, it is usually attempted endoscopically with angioplasty and stent placement. Most important, in the case of these two rare clinical entities, is that the clinician have a suspicion of their presence when indicated so that the young or old patient can be spared unnecessary suffering and return to good health in a timely fashion.
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Affiliation(s)
| | - Thomas F Whayne
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, United States
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8
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Pillon R, Pennesi M, Rabach I, Barbi E. Adolescent with intermittent haematuria. Arch Dis Child Educ Pract Ed 2019; 104:157-159. [PMID: 29748226 DOI: 10.1136/archdischild-2018-315049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/10/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Roberto Pillon
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Marco Pennesi
- Paediatrics, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Ingrid Rabach
- Paediatrics, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.,Paediatrics, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
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9
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de Macedo GL, Dos Santos MA, Sarris AB, Gomes RZ. Diagnosis and treatment of the Nutcracker syndrome: a review of the last 10 years. J Vasc Bras 2018; 17:220-228. [PMID: 30643508 PMCID: PMC6326141 DOI: 10.1590/1677-5449.012417] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The nutcracker syndrome is characterized by a group of clinical manifestations caused by compression of the Left Renal Vein. The main symptoms are: macro and micro hematuria, proteinuria, and flank pain. Diagnosis is usually made after excluding other causes, because there are no clinical criteria for diagnosis. Confirmation is by Doppler ultrasonography or computed tomography. Treatment can vary, depending on patient characteristics and the severity of the symptoms, while conservative treatment, open surgery, and endovascular surgery may be employed. Currently, open surgery is still the first-line treatment, but some less invasive approaches are gaining acceptance.
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Affiliation(s)
| | | | - Andrey Biff Sarris
- Universidade Estadual de Ponta Grossa - UEPG, Departamento de Medicina Ponta Grossa, PR, Brasil
| | - Ricardo Zanetti Gomes
- Universidade Estadual de Ponta Grossa - UEPG, Departamento de Medicina Ponta Grossa, PR, Brasil
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10
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A systematic review on management of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord 2017; 6:271-278. [PMID: 29292117 DOI: 10.1016/j.jvsv.2017.11.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/20/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE 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. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the LRV. The paucity of data regarding the management of this uncommon disease process poses a challenge for adequate recommendations of the best treatment modality. Herein, we aim to present a systematic review for the management of NS. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards to systematically search the electronic databases of MEDLINE from October 1982 to July 2017 for articles about the management of NS. Included were studies in English, Spanish, and German in all age groups. RESULTS The literature search provided 249 references. After abstract and full review screening for inclusion, 17 references were analyzed. Eight (47%) described the open surgical approach. The LRV transposition was the most commonly reported technique, followed by renal autotransplantation. Seven (41.11%) described the endovascular technique of stent implantation, and two (11.7%) described the minimally invasive laparoscopic extravascular stent implantation. CONCLUSIONS NS is a rare entity. Multiple techniques have been developed for the treatment of this condition. However, the rarity of this syndrome, the paucity of data, and the short-term follow-up of the existing evidence are the disadvantages that prevent recommendations for the best treatment strategy. Up to now, open surgical intervention, specifically LRV transposition, has been considered by some experts the mainstay for treatment of NS. The endovascular approach is gaining strength as more evidence has become available. However, the long-term patency and durability of this approach remain to be elucidated. Therefore, careful selection of patients is necessary in recommending this technique.
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Stawiarski K, Wosnitzer M, Erben Y. A novel hybrid left renal vein transposition and endovascular stenting technique for the treatment of posterior nutcracker syndrome. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2017; 3:142-145. [PMID: 29349403 PMCID: PMC5764855 DOI: 10.1016/j.jvscit.2017.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/23/2017] [Indexed: 11/19/2022]
Abstract
Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. We describe a case of a 28-year-old man who presented with microscopic hematuria, left-sided flank pain, and testicular swelling. Computed tomography findings were consistent with posterior nutcracker syndrome. He underwent a novel hybrid operation that included left renal vein transposition followed by endovascular stenting. Repeated imaging at 3 and 12 months revealed a patent stent with complete resolution of symptoms.
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Affiliation(s)
- Kristin Stawiarski
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, Conn
| | - Matthew Wosnitzer
- Department of Urology, Yale New Haven Health, Northeast Medical Group, Fairfield, Conn
| | - Young Erben
- Section of Vascular and Endovascular Surgery, Yale University, New Haven, Conn
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12
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Ananthan K, Onida S, Davies A. Nutcracker Syndrome: An Update on Current Diagnostic Criteria and Management Guidelines. Eur J Vasc Endovasc Surg 2017; 53:886-894. [DOI: 10.1016/j.ejvs.2017.02.015] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023]
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13
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Síndrome del cascanueces. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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14
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Nutcracker syndrome: A rare cause of left flank pain that can also manifest as unexplained pelvic pain. Joint Bone Spine 2016; 84:557-562. [PMID: 27932281 DOI: 10.1016/j.jbspin.2016.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 02/07/2023]
Abstract
Nutcracker syndrome (NCS) is symptomatic unilateral renal venous hypertension due to compression of the left renal vein between the superior mesenteric artery and aorta (anterior NCS) or between the aorta and spine (posterior NCS). The left ovarian or spermatic vein empties into the left renal vein and is an additional site of venostasis in about half the cases of NCS. The presenting symptom of NCS in about half the cases is atypical left flank pain suggesting a disorder of the lower ribs or thoracolumbar spinal junction, particularly as the pain worsens with standing and increased lumbar lordosis. NCS may be suggested by any combination of the following manifestations: hematuria, which is often only microscopic; orthostatic proteinuria; varicocele and infertility; dyspareunia and other gynecological symptoms; varicose veins in the pelvis, buttocks, or upper thighs; orthostatic hypotension and fatigue; and abdominal pain. Narrowing of the left renal vein on imaging studies is required but far from sufficient to establish the diagnosis. Several converging clinical findings and a marked pressure gradient between the left renal vein and inferior vena cava must be present also. Urological procedures and vascular surgery are being superseded by endovascular stenting with or without simultaneous treatment of the acquired gonadal vein insufficiency by embolization.
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15
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Zucker EJ, Ganguli S, Ghoshhajra BB, Gupta R, Prabhakar AM. Imaging of venous compression syndromes. Cardiovasc Diagn Ther 2016; 6:519-532. [PMID: 28123973 DOI: 10.21037/cdt.2016.11.19] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Venous compression syndromes are a unique group of disorders characterized by anatomical extrinsic venous compression, typically in young and otherwise healthy individuals. While uncommon, they may cause serious complications including pain, swelling, deep venous thrombosis (DVT), pulmonary embolism, and post-thrombotic syndrome. The major disease entities are May-Thurner syndrome (MTS), variant iliac vein compression syndrome (IVCS), venous thoracic outlet syndrome (VTOS)/Paget-Schroetter syndrome, nutcracker syndrome (NCS), and popliteal venous compression (PVC). In this article, we review the key clinical features, multimodality imaging findings, and treatment options of these disorders. Emphasis is placed on the growing role of noninvasive imaging options such as magnetic resonance venography (MRV) in facilitating early and accurate diagnosis and tailored intervention.
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Affiliation(s)
- Evan J Zucker
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;; Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Suvranu Ganguli
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Brian B Ghoshhajra
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Rajiv Gupta
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;; Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Anand M Prabhakar
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Mahmoud O, Vikatmaa P, Aho P, Halmesmäki K, Albäck A, Rahkola-Soisalo P, Lappalainen K, Venermo M. Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord 2016; 4:355-70. [DOI: 10.1016/j.jvsv.2016.01.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 01/10/2016] [Indexed: 11/30/2022]
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17
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Markovic J, Shortell C. Right gonadal vein transposition for the treatment of anterior nutcracker syndrome in a patient with left-sided inferior vena cava. J Vasc Surg Venous Lymphat Disord 2016; 4:340-2. [DOI: 10.1016/j.jvsv.2015.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/15/2015] [Indexed: 01/29/2023]
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18
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Wu Z, Zheng X, He Y, Fang X, Li D, Tian L, Zhang H. Stent migration after endovascular stenting in patients with nutcracker syndrome. J Vasc Surg Venous Lymphat Disord 2016; 4:193-9. [DOI: 10.1016/j.jvsv.2015.10.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/11/2015] [Indexed: 11/30/2022]
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19
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Left ovarian to left external iliac vein transposition for the treatment of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord 2016; 4:114-8. [DOI: 10.1016/j.jvsv.2015.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/11/2015] [Indexed: 11/23/2022]
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