Minimally invasive treatments for venous compression syndromes

Surgical treatment of nutcracker syndrome results in improved pain and quality of life

BACKGROUND

Left renal vein (LRV) compression, or nutcracker phenomenon, describes the compression of the LRV, most commonly between the aorta and the superior mesenteric artery. The outflow obstruction that occurs from the compression causes venous hypertension leading to the development of pelvic collaterals, lumbar vein engorgement and gonadal vein reflux. The symptoms associated with LRV compression include abdominal pain, left flank pain, back pain, headache, pelvic pain/pressure, and hematuria. Symptomatic LRV compression can cause chronic pain and disability that impedes activities of daily living. Left renal auto transplantation (LR-AT) is one mode of treatment, leading to decreased pain with no significant vascular or urological complications. Herein we present a five patient case series with symptomatic LRV compression who underwent LR-AT with improved pain and quality of life after surgery.

METHODS

Five patients underwent LR-AT between June 2020-December 2020 to resolve their symptomatic LRV compression. These patients were given three validated surveys pre- and post- intervention, then again at their three month follow up visit to assess their pain and health-related quality of life.

RESULTS

The five patients were all female with the average age of 36.8 years old (36-41) and underwent LR-AT to treat their symptomatic LRV compression. The average Numeric Rating Scale (NRS) pain score pre intervention was 8.3 (range 6.7 to 10) which improved to pain rating 5.22 (range 2.7 to 6) post intervention, p-value = 0.013. The average pain NRS score at 3 month follow up was 3.86 (range 1.3-6), p-value = 0.006 when compared to pre-intervention pain scores. The average pain intensity pre intervention was 4.5 (4 to 5) and 2.7 (1 to 4.3) post intervention, p-value = 0.024. The average pain intensity score at 3 month follow up was 2.24 (range 1.3-3.3), p-value = 0.002 when compared to pre-intervention. The VascuQoL-6 survey score pre intervention averaged score of 9.6 (range 7-12) which improved to an average score of 20.6 (range 18-24), p-value = 0.001. The average VascuQoL score at 3 month follow up was 22.6 (range 22-24), p-value = < 0.001 when compared to pre intervention QoL scores all showing a statistically significant improvement of health-related quality of life.

CONCLUSION

The diagnosis of LRV compression can be challenging due to the non-descript symptoms and overall lack of awareness. Understanding venous tributary pathways and drainage can help clarify why patients present with unusual symptoms. Surgical treatment of LRV compression through LR-AT can improve patients' pain and improve vascular quality of life.

Anterior Nutcracker syndrome in a young male patient: a case report and review of literature

Introduction and importance

The left renal vein (LRV) is affected by a venous compression syndrome called Nutcracker syndrome (NCS). This syndrome is characterized by extrinsic compression of the LRV, which usually occurs between aorta and superior mesenteric artery. It is a rare and under-diagnosed condition, more prevalent in females and that, if left untreated, can lead to severe problems. There are no clear guidelines regarding management. Therefore, the authors report this rare case and its symptoms in male patient and they display current management options.

Case presentation

NCS was observed during computer tomography in a male patient presented with persistent left flank pain and associated haematuria. Ultrasound for left scrotum demonstrated left moderate-sized varicocele. The left varicocele testis unit was 1.6 mm and during the Valsalva manoeuvre in the supine position the testis unit was 2 mm. LRV compression between abdominal aorta and superior mesenteric artery was identified by computer tomography imaging and therefore, diagnosis of NCS was confirmed.

Clinical discussion

The actual prevalence is unclear, and incidence rates have been observed to fluctuate among age group and more prevalent in women. Main symptoms include haematuria, left flank discomfort, varicocele in men, proteinuria and anaemia. Depending on severity of symptoms, management might range from conservative care to surgery.

Conclusion

This treatment strategy was effective in reducing the symptoms of the patients. In young patients, conservative treatment is advised for a fair amount of time. However, more studies on how much the authors should wait before considering surgery is important.

A rare case of left inferior vena cava presenting with May-Thurner syndrome

Background

May–Thurner anomaly is characterized as external venous compression by the arterial framework against hard bony structures. This chronic anatomical lesion infrequently leads to deep vein thrombosis in the lower extremity, and it may lead to leg swelling as a long-term post-thrombotic complication. Left iliac vein compression may not be as uncommon as was previously thought, and it typically occurs in women more than men. Congenital anomalies of venous tree are not rare; they exist in 8.7% of the general population.

Case-presentation

We herein present the first case of right-sided May Thurner Syndrome in a patient with IVC anomalies. In our patient, both common iliac veins formed the left-sided IVC, which extended to the hemiazygos vein and the superior vena cava. Additionally, there was a right-sided suprarenal IVC, which extended to the right atrium.

Conclusion

Understanding the proper anatomy in May-Thurner syndrome helps in better decision making for management of disease pathophysiology.

Aortosternal Venous Compression: A Review of Two Cases

Aortosternal venous compression (AVC) is a rare venous compression syndrome that involves brachiocephalic venous compression due to its positioning between the sternum and the aorta. One of the features of AVC involves compression of the left innominate vein with variability in luminal caliber on inspiration and expiration. Imaging modalities such as computed tomography (CT) examination can aid in initial diagnosis; however, venography can be utilized for confirmatory diagnosis due to its higher specificity during the inspiratory and expiratory phases. Through findings demonstrated during venography, we herein present two cases of confirmed AVC secondary to an aberrant right subclavian artery. Characteristic imaging features in the diagnosis of AVC and its etiology are discussed.

Current Status and Prospect of Stent Placement for May-Thurner Syndrome

Stent implantation has been proven to be safe and has become the first-line intervention for May-Thurner syndrome (MTS), with satisfactory mid-term patency rates and clinical outcomes. Recent research has demonstrated that catheter-directed thrombolysis is the preferred strategy when MTS is combined with deep vein thrombosis after self-expanding stent placement. However, the stent used for the venous system was developed based on the experience obtained in the treatment of arterial disease. Consequently, relatively common corresponding complications may come along later, which include stent displacement, deformation, and obstruction. Different measures such as adopting a stent with a larger diameter, improving stent flexibility, and increasing stent strength have been employed in order to prevent these complications. The ideal venous stent is presently being evaluated and will be introduced in detail in this review.

Endovascular management of nutcracker syndrome in an adolescent patient population

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.

Endovascular and medical therapy of May-Thurner syndrome: Case series and scoping literature review

INTRODUCTION

May-Thurner syndrome has been recognized as a cause of chronic venous insufficiency and a trigger for venous thromboembolism. There is no consensus about the definition, diagnosis, and therapeutic approach. We are aiming to describe its characteristics and a scoping literature review.

METHODS

A retrospective review of patients with May-Thurner syndrome from March 2010 to May 2018 and scoping literature review were made.

RESULTS

Seven patients were identified. All patients were female with a median age of 36 (20-60) years. The median time from the first symptom to diagnosis was 3.41 (0.01-9) years. The primary clinical presentation was post-thrombotic syndrome (4 patients). Six patients had at least one risk factor for deep venous thrombosis. All patients underwent angioplasty with stent; patients with acute deep venous thrombosis, furthermore mechanic thrombectomy with or without catheter-directed thrombolysis were done. There were three complications (one patient, lymphedema, and two venous stent thrombosis). Scoping review results were descriptively summarized.

CONCLUSION

May-Thurner syndrome has a varied spectrum of clinical presentation, and clinical awareness is paramount for diagnosis. Its principal complication is the post-thrombotic syndrome, which is associated with high morbidity. There is no consensus on the antithrombotic treatment approach.

Finite Element Simulations of the ID Venous System to Treat Venous Compression Disorders: From Model Validation to Realistic Implant Prediction

The ID Venous System is an innovative device proposed by ID NEST MEDICAL to treat venous compression disorders that involve bifurcations, such as the May-Thurner syndrome. The system consists of two components, ID Cav and ID Branch, combined through a specific connection that prevents the migration acting locally on the pathological region, thereby preserving the surrounding healthy tissues. Preliminary trials are required to ensure the safety and efficacy of the device, including numerical simulations. In-silico models are intended to corroborate experimental data, providing additional local information not acquirable by other means. The present work outlines the finite element model implementation and illustrates a sequential validation process, involving seven tests of increasing complexity to assess the impact of each numerical uncertainty separately. Following the standard ASME V&V40, the computational results were compared with experimental data in terms of force-displacement curves and deformed configurations, testing the model reliability for the intended context of use (differences < 10%). The deployment in a realistic geometry confirmed the feasibility of the implant procedure, without risk of rupture or plasticity of the components, highlighting the potential of the present technology.

Early clinical outcomes for treatment of post-thrombotic syndrome and common iliac vein compression with a hybrid Oblique self-expanding nitinol stent – the TOPOS study

Summary: Background: Physical attributes of conventional stents used in the ilio-caval territory are often unfavorable in the presence of external compression close to the bifurcation. A hybrid oblique stent was developed for the treatment of common iliac vein compression without compromising the contralateral iliac vein inflow. Patients and methods: The ongoing international monitored TOPOS study enrolled 60 patients with post-thrombotic syndrome (PTS) treated with the sinus-Obliquus stent (optimed) and provisional distal stent extension. At 3-month follow-up, patency rates were obtained from duplex ultrasound, and clinical outcomes were assessed by the Villalta score, revised venous severity score (rVCSS), pain intensity score and chronic venous disease quality of life questionnaire (CIVIQ-20). Results: Mean age was 46.6 ± 14.9 years (68.3 % women). Mean number of implanted stents was 1.9 ± 0.6; 12 (20 %) patients received the hybrid oblique stent only. Forty-eight (80 %) patients had distal stent extension, and 42 (70 %) had stents below the inguinal ligament. Four (7 %) patients (all with stent extension) developed stent thrombosis. Primary and secondary patency rates at 3 months were 93.1 % (95 %CI 83.3–98.1 %), and 100 % (95 %CI 93.8–100 %), respectively. Improvement in Villalta, rVCSS, CIVIQ-20, and pain intensity score from baseline to 3-month follow-up was 6.9 ± 1.4 points (95 %CI 4.1–9.8; p < 0.0001), 3.4 ± 1.0 points (95 %CI 1.3–5.4 points; p < 0.01), 13.6 ± 2.7 points (95 %CI 8.2–19.0 points; p < 0.0001), and 2.4 ± 0.5 (95 %CI 1.4–3.3; p < 0.0001), respectively. At follow-up, 38 (63 %) patients were free from the PTS and none developed contralateral deep vein thrombosis. Conclusions: In patients with PTS and common iliac vein compression, treatment with the hybrid oblique stent with provisional stent extension resulted in high patency rates and improvement in PTS severity and quality of life at 3-month. Two-year results of TOPOS will assess the durability of this treatment.

Compression of left renal vein and left common iliac vein on CT scans: how often are they detected?

Background

The nutcracker and May-Thurner syndromes are rare and, although often underdiagnosed, they can cause limiting symptoms. They are frequently considered only after exclusion of other diagnoses and there is no consensus in the literature on prevalence, incidence, or diagnostic criteria.

Objectives

To estimate the frequency of compression of the left common iliac vein and left renal vein in CT scans of the abdomen and pelvis.

Methods

Descriptive, quantitative, cross-sectional study. The criteria used to define compression of the left renal vein were a hilar/aortomesenteric diameter ratio > 4 and aortomesenteric angle < 39° and the criterion for compression of the left common iliac vein was a diameter < 4mm.

Results

CT scans of 95 patients were analyzed; 61% were women and 39% were men. Left renal vein compression was observed in 24.2% of the sample, with a mean age of 48.8 years, occurring in 27.6% of the women and 18.9% of the men (p = 0.3366). Compression of the left common iliac vein was detected in 15.7% of the sample, with a mean age of 45.9 years, occurring in 24.1% of the women and 2.7% of the men (p = 0.0024). Both veins were compressed in 7.4% of the patients.

Conclusions

Left renal vein compression was detected in women and men at similar frequencies, whereas left common iliac vein compression was more frequent in women. Both venous compressions were most frequently found in patients aged 41 to 50 years.

Venous revascularization to treat posterior nutcracker syndrome by transposition of the left gonadal vein: case report

The Nutcracker Syndrome is manifest in the presence of a symptomatic entrapment of the left renal vein between the abdominal aorta and the superior mesenteric artery. In a more ephemeral variation of this disorder, called the Posterior Nutcracker Syndrome, the renal vein is not compressed anterior to the aorta, but posteriorly, between the artery and the spine. Although there are multiple treatment options, current techniques aim to relieve the symptoms and reduce venous pressure on the left renal vein. 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.

Endovascular Repair of an Abdominal Aortic Aneurysm with Iliac Vein Compression Syndrome

An 84-year-old man with chronic obstructive pulmonary disease (COPD) was referred to our institution for further treatment of severe swelling of the left lower extremity. The left iliac vein was compressed by the abdominal aortic aneurysm and a right common iliac arterial aneurysm measuring 62 mm and 45 mm in diameter and was partially thrombosed. Multiple pulmonary artery embolisms were also noted. Endovascular repair of the abdominal aortic aneurysm and the right common iliac arterial aneurysm was performed because of his respiratory dysfunction. The left leg edema gradually resolved after endovascular treatment. Six months after the treatment, computed tomography (CT) demonstrated resolution of the venous thrombus of the left lower extremity. Although open surgery is reliable treatment for iliac compression syndrome, endovascular treatment might be a feasible and an adequate therapeutic option for patients who have severe comorbidities, complications, or high frailties.

Diagnosis and treatment of the Nutcracker syndrome: a review of the last 10 years

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.

Co-occurring superior mesenteric artery syndrome and nutcracker syndrome requiring Roux-en-Y duodenojejunostomy and left renal vein transposition: a case report and review of the literature

BACKGROUND

The duodenum and the left renal vein occupy the vascular angle made by the superior mesenteric artery and the aorta. When the angle becomes too acute, compression of either structure can occur. Each type of compression is associated with specific clinical symptoms that constitute a rare disorder. If clinical symptoms are mild, conservative treatment is implemented. However, surgery is often the only solution that can improve quality of life and/or avoid life-threatening complications. This report describes a case of a patient with both types of aortomesenteric compression that required two separate surgeries to alleviate all symptoms.

CASE PRESENTATION

A 20-year-old white woman presented to the Emergency Room complaining of sudden onset severe left flank and lower left quadrant abdominal pain, nausea, and vomiting. A clinical work-up revealed elevated white blood cells and hematuria. She was discharged with a diagnosis of urinary tract infection. Symptoms continued to worsen over the subsequent 2 months. Repeated and extensive clinical work-ups failed to suggest evidence of serious pathology. Ultimately, an endoscopy revealed obstruction of her duodenum, and barium swallow identified compression by the superior mesenteric artery, leading to the diagnosis of superior mesenteric artery syndrome. She underwent a Roux-en-Y duodenojejunostomy. Six weeks later she continued to have severe left-sided pain and intermittent hematuria. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. A diagnosis of nutcracker syndrome was made and a left renal vein transposition was performed. Significant improvement was seen after 8 weeks.

CONCLUSIONS

The disorders associated with aortomesenteric compression can lead to serious symptoms and sometimes death. Diagnosis is challenging not only because of the lack of awareness of these rare disorders, but also because they are associated with symptoms that are similar to those seen in less serious diseases. Guidance for health care professionals with respect to relevant radiological and clinical markers needs to be reconsidered in order to clarify the etiology of the diseases and create better diagnostic protocols.

Application of computed tomography venography in the diagnosis and severity assessment of iliac vein compression syndrome: A retrospective study

The objectives are to evaluate the application of computed tomography venography (CTV) in the diagnosis of iliac vein compression syndrome (IVCS), and to assess the factors related to the incidence and development of IVCS and the recurrence of varicose veins.Imaging data of 120 patients with chronic venous disease (CVD) of the lower extremity and 68 subjects without CVD (control) were retrospectively reviewed by radiologists blinded to the groups. CTV, conventional venography, and Doppler ultrasound were compared in the diagnosis and contributing factors for IVCS were also analyzed.CTV required less procedure time than venography or color ultrasonography (P < .001). The rate of iliac venous compression diagnosed by CTV was higher in the CVD group (53.3%) than in the control group (22.1%) (χ = 17.425, P < .001). Risk factors for IVCS included gender, hyperlipidemia, and course of disease (P < .05). Development of femoral vein collateral was more common in patients with IVCS (P < .05). The duration of disease was positively associated with the severity of iliac vein compression (r = 0.321, P < .001). IVCS was an important contributing factor for varicose vein recurrence (51.2%). In patients with IVCS and venous ulcer (C5-C6), the healing time of the ulcer treated with stent was significantly shorter compared with those without stent treatment (P < .001).CTV is accurate for the diagnosis and severity evaluation of IVCS. IVCS might be a contributing factor for varicose vein recurrence. Iliac vein stent implantation as a safe and effective interventional therapy promotes the healing of venous ulcer caused by IVCS.

Surgically Treated Pelvic Pain Caused by Nutcracker Syndrome and Worsened by Cockett Syndrome in a Child

Nutcracker syndrome is rarely seen in the young. Most of the symptoms regress during follow-up. Rarely surgical intervention is necessary. This case presentation is unique for being the first case of nutcracker syndrome and coexistent Cockett syndrome that is treated with surgical intervention.