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Rezaei-Kalantari K, Fahrni G, Rotzinger DC, Qanadli SD. Insights into pelvic venous disorders. Front Cardiovasc Med 2023; 10:1102063. [PMID: 36742076 PMCID: PMC9892065 DOI: 10.3389/fcvm.2023.1102063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/06/2023] [Indexed: 01/20/2023] Open
Abstract
Pelvic venous disorders (PeVD), sometimes referred to as pelvic congestion syndrome (PCS), widely impact affected patients-mainly young women's quality of life, causing puzzling, uncomfortable symptoms sometimes requiring months or years to get an explanation, while simply remaining undiagnosed in other cases. Because pelvic pain is a non-specific symptom, an appropriate diagnosis requires a careful patient workup, including a correlation between history and non-invasive imaging. Invasive imaging is frequently required to confirm the diagnosis and plan treatment. Current therapeutic approaches principally rely on minimally invasive techniques delivered through endovascular access. However, while comprehensive descriptive classifications such as the symptoms-varices-pathophysiology (SVP) classification exist, universally accepted guidelines regarding therapy to apply for each SVP category are still lacking. This review strongly focuses on PeVD imaging and discusses available therapeutic approaches with regard to pathophysiological mechanisms. It proposes a new classification scheme assisting clinical decision-making about endovascular management to help standardize the link between imaging findings and treatment.
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Affiliation(s)
- Kiara Rezaei-Kalantari
- Department of Radiology, Rajaie Cardiovascular, Medical and Research Center, Cardio-Oncology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Guillaume Fahrni
- Department of Diagnostic and Interventional Radiology, Cardiothoracic and Vascular Division, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland,*Correspondence: Guillaume Fahrni,
| | - David C. Rotzinger
- Department of Diagnostic and Interventional Radiology, Cardiothoracic and Vascular Division, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Salah D. Qanadli
- Department of Diagnostic and Interventional Radiology, Cardiothoracic and Vascular Division, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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2
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Nastasi DR, Fraser AR, Williams AB, Bhamidi V. A systematic review on nutcracker syndrome and proposed diagnostic algorithm. J Vasc Surg Venous Lymphat Disord 2022; 10:1410-1416. [PMID: 36007798 DOI: 10.1016/j.jvsv.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Nutcracker syndrome (NCS) is an increasingly recognized venous compressive disease. Although people with NCS can experience debilitating symptoms, making an accurate diagnosis can often be challenging owing to the broad spectrum of clinical presentations and radiologic findings. In the present systematic review, we assessed the most frequent clinical and radiologic criteria used in establishing a diagnosis of NCS and have proposed a comprehensive framework for clinical decision-making. METHODS We performed a systematic review to identify all observational studies or case series conducted within the previous 10 years that had studied patients with a clinical and radiologic diagnosis of NCS. The extracted data included details related to the study design, participant demographics, presenting clinical features, and radiologic criteria. These details were compared between studies and synthesized to establish a comprehensive diagnostic framework that would be applicable to clinical practice. RESULTS In the present review, we included 14 studies with a total of 384 patients with NCS. The most common clinical features of NCS were hematuria (69.5%), left flank or abdominal pain (48.4%), pelvic pain (23.1%), and varicocele (15.8%). Computed tomography and ultrasound were the most commonly used imaging modalities, with a threshold for left renal vein stenosis of >80% the most frequently used diagnostic parameter. Eight studies had used venography, with the renocaval pressure gradient the most commonly measured parameter. Two studies had reported using intravascular ultrasound. The findings from our review have shown that a thorough clinical workup of NCS should include critical evaluation of the presenting clinical features and exclusion of alternative diagnoses. All patients should undergo duplex ultrasound with or without the addition of computed tomography or magnetic resonance imaging. Any patient considered for therapeutic intervention should also undergo diagnostic venography with measurement of the renocaval pressure gradient and, if available, intravascular ultrasound with measurement of the left renal vein diameters. CONCLUSIONS NCS is a challenging condition in terms of the diagnosis and management both. We have proposed a comprehensive diagnostic framework based on the currently available literature to aid in clinical decision-making.
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Affiliation(s)
- Domenico R Nastasi
- Department of Vascular and Endovascular Surgery, Gold Coast University Hospital, Southport, QLD, Australia.
| | - Annabel R Fraser
- Department of Vascular and Endovascular Surgery, Gold Coast University Hospital, Southport, QLD, Australia
| | - Aman B Williams
- Department of Vascular and Endovascular Surgery, Gold Coast University Hospital, Southport, QLD, Australia
| | - Venu Bhamidi
- Department of Vascular and Endovascular Surgery, Gold Coast University Hospital, Southport, QLD, Australia
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3
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John MM, Oo TZ, Aftab S. An Unusual Cause of Abdominal Pain in a Middle-Aged Female: The Nutcracker Syndrome. Cureus 2022; 14:e30696. [DOI: 10.7759/cureus.30696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/05/2022] Open
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4
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Muheilan M, Walsh A, O’Brien F, Tuite D. Nutcracker syndrome, conservative approach: a case report. J Surg Case Rep 2022; 2022:rjac423. [PMID: 36299914 PMCID: PMC9592149 DOI: 10.1093/jscr/rjac423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 08/25/2022] [Indexed: 11/14/2022] Open
Abstract
The nutcracker phenomenon (NCP) refers to the compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery (SMA). Nutcracker syndrome (NCS) should be limited to patients who present with the characteristic clinical signs and symptoms alongside diagnostic imaging of the anatomy associated with the syndrome. We report a case of NCS presenting with painless visible hematuria and left flank pain. Imaging showed a left renal vein stenosis at the origin of the SMA with collateralization. Diagnosis of NCP is made by a variety of imaging techniques; approaches to the treatment of NCS include conservative methods, open surgical, laparoscopic or endovascular techniques. Correlation with symptoms, laboratory results and excluding other causes continues to be important in the workup of NCS. Collaboration with the establishment of an International Consortium database will aid in the understanding of this rare disease.
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Affiliation(s)
- Muheilan Muheilan
- Correspondence address. Department of Urology, Cork University Hospital, Cork, Ireland. E-mail:
| | - Anna Walsh
- Department of Urology, Cork University Hospital, Cork, Ireland
| | - Frank O’Brien
- Department of Urology, Cork University Hospital, Cork, Ireland
| | - David Tuite
- Department of Radiology, Cork University Hospital, Cork, Ireland
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5
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A Teenage Girl With Left Flank Pain. J Emerg Med 2022; 63:e80-e81. [DOI: 10.1016/j.jemermed.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/20/2022] [Accepted: 07/09/2022] [Indexed: 11/07/2022]
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6
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Arslan S, Sarıkaya Y. Aneurysm of the left ascending lumbar communicating vein: Its prevalence and possible association with nutcracker phenomenon. Clin Imaging 2022; 85:22-28. [DOI: 10.1016/j.clinimag.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/13/2022] [Accepted: 02/22/2022] [Indexed: 11/03/2022]
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7
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Khan H, Al-Jabbari E, Shroff N, Barghash M, Shestopalov A, Bhargava P. Coexistence of superior mesenteric artery syndrome and nutcracker phenomenon. Radiol Case Rep 2022; 17:1927-1930. [PMID: 35401899 PMCID: PMC8987811 DOI: 10.1016/j.radcr.2022.03.063] [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: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022] Open
Abstract
Superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal obstruction. Nutcracker syndrome occurs as the result of external compression of the left renal vein. Although they share a similar pathophysiology, SMA and nutcracker syndrome occurring simultaneously is rare. In this case report, we discuss the pathophysiology and unique computed tomography findings in a 25-year-old female patient diagnosed with SMA syndrome who was also incidentally found to have a coexisting nutcracker phenomenon. Due to similar pathogenesis, radiologists should consider the possibility of coexistence of these rare syndromes in appropriate patients.
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Affiliation(s)
- Hasan Khan
- Department of Radiology, University of Texas Medical Branch, 301 University Blvd., UTMB, Galveston, TX 77555, USA
| | - Esraa Al-Jabbari
- Department of Radiology, University of Texas Medical Branch, 301 University Blvd., UTMB, Galveston, TX 77555, USA
| | - Neel Shroff
- Department of Radiology, University of Texas Medical Branch, 301 University Blvd., UTMB, Galveston, TX 77555, USA
| | - Maggie Barghash
- Department of Radiology, University of Texas Medical Branch, 301 University Blvd., UTMB, Galveston, TX 77555, USA
| | - Alexander Shestopalov
- Department of Radiology, University of Texas Medical Branch, 301 University Blvd., UTMB, Galveston, TX 77555, USA
| | - Peeyush Bhargava
- Department of Radiology, University of Texas Medical Branch, 301 University Blvd., UTMB, Galveston, TX 77555, USA
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8
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The Superior Mesenteric Artery Angle and Abdominal Main Vessel Diameters in Normovolemic Children: For Practical Sonographic Evaluation. Ultrasound Q 2021; 37:343-348. [PMID: 34855710 DOI: 10.1097/ruq.0000000000000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Knowledge of the normal size of important abdominal vessels is important for determination of hydration status and intravascular volume. Knowing the normal value of superior mesenteric artery (SMA) exit angle from the aorta (SMA angle) is necessary for the diagnosis of clinical pathologies caused by SMA compression. OBJECTIVES The aim of this study was to determine the normal SMA angles and normal diameters of the main abdominal vascular structures of pediatric participants on ultrasonography (USG). METHODS Between January 2019 and July March 2019, the USG examinations obtained from 210 participants (age range, 1-214 years; mean age, 83.5 [SD, 5.5] months; females 51%, males 49%) with normal abdominal examinations were prospectively evaluated. The participants were divided into 5 groups according to age. Body mass index values of the participants were kept equal. RESULTS The diameters of the abdominal vascular structures increased with age, and the statistical differences among the age groups were significant. In all groups, no statistically significant difference was observed between sexes (P > 0.05). The SMA angle was between 17° and 58° (mean, 37.8° [SD, 8.5°]). A statistically significant difference was observed between the age groups in terms of SMA angle (P < 0.05). No statistically difference was found between sexes (P > 0.58-0.912). CONCLUSIONS In our study, we think that the measurements obtained by USG provide normal values of the diameters of the abdominal main vessels and SMA angle. These values can be used as a reference for interpreting hydration status, vascular diameter assessment, and SMA compression syndromes.
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9
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Kolber MK, Cui Z, Chen CK, Habibollahi P, Kalva SP. Nutcracker syndrome: diagnosis and therapy. Cardiovasc Diagn Ther 2021; 11:1140-1149. [PMID: 34815965 DOI: 10.21037/cdt-20-160] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022]
Abstract
Nutcracker syndrome (NCS) is an extrinsic compression of the left renal vein (LRV) by the superior mesenteric artery (SMA) anteriorly and aorta posteriorly resulting in renal vascular congestion manifesting as hematuria, proteinuria, orthostatic hypotension, pain, or even renal dysfunction. Long-standing venous compression can encourage collateral drainage pathways through gonadal and pelvic veins, which may explain reported symptom and syndrome overlap with pelvic congestion syndrome. Diagnosis can be challenging and variable, frequently involving a combination of ultrasound Doppler, cross-sectional, and invasive imaging. Often, intravascular pressure measurements are required to prove a renocaval pressure gradient to aid in a definitive diagnosis. Conservative management is appropriate, especially in children, who tend to outgrow the disorder. In the interim, medical management with angiotensin converting enzyme inhibitors (ACEIs) is a useful therapy to manage orthostatic hypotension in the pediatric population. In adults, invasive therapies are more frequently pursued. These are aimed at relieving the extrinsic compression on the LRV. The standard of care is renal vein transposition, with renal autotransplantation reserved for recalcitrant cases. Endovascular stenting is a less invasive option. Laparoscopic placement of an exovascular stent is a newer therapy intended to minimize trauma to the LRV. In this review, we will discuss the clinical manifestations, diagnostic criterion, imaging features, and conservative and surgical therapies for this condition.
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Affiliation(s)
- Marcin K Kolber
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zhonghao Cui
- University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Christine K Chen
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peiman Habibollahi
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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10
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Boui M, Nabil H, Badr S, Salah B, Zakaria Z, Salah B, Mehdi A, Abdelilah M, Rachid A, Abderrahim R. Left renal vein compression complicating intragastric balloon insertion. Radiol Case Rep 2021; 16:3589-3592. [PMID: 34603566 PMCID: PMC8463737 DOI: 10.1016/j.radcr.2021.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 01/03/2023] Open
Abstract
Obesity is a real public health problem and is of growing concern. People are resorting to surgical or endoscopic means to fight against overweight and obesity. In recent years, there has been a marked increase in the use of these means and in particular the insertion of a gastric balloon which seems to present less risk than surgical methods. Renal complications from intragastric balloon placement are extremely rare. We report here the case of compression of the left renal vein revealed by lumbar pain and hematuria in an overweight 39-year-old woman who benefited from the balloon gastric placement one month before symptoms. The scanner made the diagnosis and showed a good evolution after the withdrawal of the balloon.
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Affiliation(s)
- Meriem Boui
- Department of Radiology, Avicenne Military Hospital, Marrakech, Morocco,Corresponding author.
| | - Hammoune Nabil
- Department of Radiology, Avicenne Military Hospital, Marrakech, Morocco
| | - Slioui Badr
- Department of Radiology, Avicenne Military Hospital, Marrakech, Morocco
| | - BenElhend Salah
- Department of Radiology, Avicenne Military Hospital, Marrakech, Morocco
| | - Zouaki Zakaria
- Department of Radiology, Avicenne Military Hospital, Marrakech, Morocco
| | - Bellasri Salah
- Department of Radiology, Avicenne Military Hospital, Marrakech, Morocco
| | - Atmane Mehdi
- Department of Radiology, Avicenne Military Hospital, Marrakech, Morocco
| | | | - Akka Rachid
- Department of Hematology, Avicenne Military Hospital, Marrakech, Morocco
| | - Raissi Abderrahim
- Department of Gatroenterology, Avicenne Military Hospital, Marrakech, Morocco
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11
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Doppler ultrasound in standing position is superior to demonstrate nutcracker phenomenon in children with varicocele. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.954130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Wang R, Wang M, Xia Z, Gao C, Kuang Q, Fang X, Yu M, Peng Y, Li X, Wei Y, Ju T. Value of magnetic resonance imaging indices of left renal vein entrapment in the diagnosis of nutcracker syndrome in children. Transl Pediatr 2021; 10:1285-1293. [PMID: 34189086 PMCID: PMC8192989 DOI: 10.21037/tp-20-466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Nutcracker syndrome (NCS) is also known as left renal vein (LRV) compression syndrome. Magnetic resonance imaging (MRI) can better depict the anatomical structure of soft tissues in the area of compression. Diagnosis of NCS using MRI in adults is not uncommon. However, there are few studies on the diagnosis of NCS using MRI in children. Therefore, we conducted this study to evaluate the clinical value of the MRI indices of the LRV in the diagnosis of NCS in children. METHODS This study was a single-center retrospective analysis. One hundred seventy-four patients with suspected NCS were enrolled from January 2017 to July 2020. The inclusion criteria for suspected NCS were mainly based on clinical symptoms or signs, laboratory examinations and imaging reports. Other diseases that may cause hematuria and/or proteinuria were excluded. We grouped the patients based on the diagnostic criteria for NCS into a nutcracker group and a control group. The receiver operating characteristic (ROC) curve was constructed for evaluating the value of MRI indices in the diagnosis of NCS. RESULTS The majority of NCS patients presented with orthostatic proteinuria (OP) (67.2%), followed by hematuria (55.2%), abdominal pain (19.0%), and left flank pain (15.5%). The areas under the curve (AUCs) for the superior mesenteric artery (SMA) angle, beak sign, and compression ratio (CR) in the diagnosis of NCS were 0.870, 0.895, and 0.878, respectively, and the best cutoff values of the SMA angle and CR were 36.8 and 3.99, respectively. The specificities of SMA angle <36.8°, beak sign, CR >3.99, SMA angle <36.8° and beak sign, SMA angle <36.8° and CR >3.99, and beak sign and CR >3.99 were 82.5%, 93.8%, 93.8%, 97.9%, 95.9% and 97.9%, respectively. CONCLUSIONS Children with SMA angles less than 36.8°, beak signs and CR greater than 3.99 should be highly suspected of having NCS. Among these parameters, "beak sign" showed the highest diagnostic accuracy by MRI, and the combination of any two of the above parameters achieved a higher specificity than the single parameters.
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Affiliation(s)
- Ren Wang
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Meiqiu Wang
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Zhengkun Xia
- Department of Pediatrics, Jinling Hospital, Nanjing University, School Medical, Nanjing, China
| | - Chunlin Gao
- Department of Pediatrics, Jinling Hospital, Nanjing University, School Medical, Nanjing, China
| | - Qianhuining Kuang
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Xiang Fang
- Department of Pediatrics, Jinling Hospital, Nanjing University, School Medical, Nanjing, China
| | - Min Yu
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yinchao Peng
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Xiaojie Li
- Department of Pediatrics, Affiliated Jinling Hospital, Medical School of Nanjing University, China
| | - Yaqin Wei
- Department of Pediatrics, Jinling Hospital, Nanjing University, School Medical, Nanjing, China
| | - Tao Ju
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
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Meissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M, Learman LA, Atashroo D, Lurie F, Passman MA, Basile A, Lazarshvilli Z, Lohr J, Kim MD, Nicolini PH, Pabon-Ramos WM, Rosenblatt M. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. Phlebology 2021; 36:342-360. [PMID: 33849310 PMCID: PMC8371031 DOI: 10.1177/0268355521999559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This Practice Guidelines document has been co-published in
Phlebology [DOI: 10.1177/0268355521999559] and Journal of
Vascular Surgery: Venous and Lymphatic Disorders [DOI:
10.1016/j.jvsv.2020.12.084]. The publications are
identical except for minor stylistic and spelling differences in keeping
with each journal’s style. The contribution has been published under a
Attribution-Non Commercial 4.0 International (CC BY-NC 4.0), (https://creativecommons.org/licenses/by-nc/4.0/)
With the support of the American College of Obstetricians and
Gynecologists, the American Vein & Lymphatic Society, the American
Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and
Interventional Radiology Society of Europe, the European Venous Forum, the
International Pelvic Pain Society, the International Union of Phlebology,
the Korean Society of Interventional Radiology, the Society of
Interventional Radiology, and the Society for Vascular Surgery
As the importance of pelvic venous disorders (PeVD) has been increasingly
recognized, progress in the field has been limited by the lack of a valid and
reliable classification instrument. Misleading historical nomenclature, such as
the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to
recognize the interrelationship of many pelvic symptoms and their underlying
pathophysiology. Based on a perceived need, the American Vein and Lymphatic
Society convened an international, multidisciplinary panel charged with the
development of a discriminative classification instrument for PeVD. This
instrument, the Symptoms-Varices-Pathophysiology (“SVP”) classification for
PeVD, includes three domains—Symptoms (S), Varices (V), and Pathophysiology (P),
with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H),
and Etiologic (E) features of the patient’s disease. An individual patient’s
classification is designated as SVPA,H,E. For patients with pelvic
origin lower extremity signs or symptoms, the SVP instrument is complementary to
and should be used in conjunction with the
Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP
instrument accurately defines the diverse patient populations with PeVD, an
important step in improving clinical decision making, developing
disease-specific outcome measures and identifying homogenous patient populations
for clinical trials.
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Affiliation(s)
- Mark H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Neil M Khilnani
- Department of Radiology (Interventional Radiology) Weill Cornell Medicine-New York Presbyterian Hospital, New York, USA
| | - Nicos Labropoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, USA
| | - Antonios P Gasparis
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, USA
| | | | - Milka Greiner
- Interventional Radiology, Hopital Americain de Paris, Paris, France
| | - Lee A Learman
- Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Roanoke, USA
| | - Diana Atashroo
- Department of Obstetrics and Gynecology, Stanford Medicine, Palo Alto, USA
| | - Fedor Lurie
- Department of Surgery, Jobst Vascular Institute, Promedica, Toledo, USA
| | - Marc A Passman
- Department of Surgery, University of Alabama School of Medicine, Birmingham, USA
| | - Antonio Basile
- Department of Interventional Radiology, University of Catania, Catania, Italy
| | | | - Joann Lohr
- Department of Surgery, University of South Carolina School of Medicine, Columbia, USA
| | - Man-Deuk Kim
- Department of Radiology, Yonsei University School of Medicine, Seoul, South Korea
| | | | - Waleska M Pabon-Ramos
- Department of Radiology (Interventional Radiology), Duke University School of Medicine, Durham, USA
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14
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St Hilaire C, Paisley M, Greene J, Casey KM. Left renal vein transposition for posterior Nutcracker syndrome. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:243-246. [PMID: 33997563 PMCID: PMC8095107 DOI: 10.1016/j.jvscit.2021.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/27/2021] [Indexed: 12/02/2022]
Abstract
Nutcracker syndrome (NCS) is a rare cause of pelvic venous congestion syndrome and is secondary to either compression of the left renal vein in its normal anatomic position by the superior mesenteric artery and aorta or less commonly when the left renal vein is in a retroaortic position, compressed between the aorta and the spine. We herein present a unique case of NCS in a female patient with a history of chronic pelvic pain and venous congestion. We also review the literature and discuss the diagnostic modalities, differential diagnosis, and various open surgical and endovascular options for NCS.
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Affiliation(s)
- Cameron St Hilaire
- Department of General Surgery, Santa Barbara Cottage Hospital, Santa Barbara, Calif
| | - Michael Paisley
- Department of General Surgery, Santa Barbara Cottage Hospital, Santa Barbara, Calif
| | - Justin Greene
- Department of Interventional Radiology, Santa Barbara Cottage Hospital, Santa Barbara, Calif
| | - Kevin M Casey
- Department of General Surgery, Santa Barbara Cottage Hospital, Santa Barbara, Calif
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15
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Pardinhas C, do Carmo C, Gomes C, Escada L, Alves R. Nutcracker Syndrome: A Single-Center Experience. Case Rep Nephrol Dial 2021; 11:48-54. [PMID: 33708799 PMCID: PMC7923731 DOI: 10.1159/000512589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/25/2020] [Indexed: 12/14/2022] Open
Abstract
Nutcracker syndrome, whose prevalence and natural history are still poorly known, is a clinical syndrome caused by left renal vein compression between the superior mesenteric artery and the aorta. Long-term results and treatment outcomes are not well known. Our group aimed to characterize 7 patients diagnosed with nutcracker syndrome in childhood and to describe their clinical manifestations, diagnostic approaches, and mostly their clinical evolution, rate of complications, and treatment outcomes.
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Affiliation(s)
- Clara Pardinhas
- Nephrology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Carmén do Carmo
- Pediatrics Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Clara Gomes
- Pediatrics Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Luís Escada
- Nephrology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Coimbra University Hospital Center, Coimbra, Portugal
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16
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Falsetti L, Martino GP, Mattioli M, Menetti S, Serra C. Chronic abdominal pain and haematuria in internal medicine: do not forget about the Nutcracker syndrome. Intern Emerg Med 2021; 16:443-445. [PMID: 32951161 DOI: 10.1007/s11739-020-02426-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Lorenzo Falsetti
- Internal and Sub-Intensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti"di Ancona, Via Conca 10, Ancona, Italy.
| | | | - Massimo Mattioli
- UOC Emergency Department, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Saverio Menetti
- Internal Medicine, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Carla Serra
- Department of Organ Failure and Transplantation, Ultrasound Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
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17
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Kim SH. Doppler US and CT Diagnosis of Nutcracker Syndrome. Korean J Radiol 2020; 20:1627-1637. [PMID: 31854150 PMCID: PMC6923211 DOI: 10.3348/kjr.2019.0084] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/17/2019] [Indexed: 12/23/2022] Open
Abstract
Nutcracker syndrome (NCS) is a syndrome caused by compression of the left renal vein (LRV), between the abdominal aorta and the superior mesenteric artery, resulting in hypertension of the LRV and hematuria. Doppler ultrasonography (US) has been commonly used for the diagnosis of NCS. However, several technical issues, such as Doppler angle and sample volume, need to be considered to obtain satisfactory results. In addition, morphologic changes of the LRV and a jetting phenomenon across the aortomesenteric portion of the LRV on contrast-enhanced computed tomography (CECT) are diagnostic clues of NCS. With proper Doppler US and CECT, NCS can be diagnosed noninvasively.
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Affiliation(s)
- Seung Hyup Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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18
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Tonolini M, Foti PV, Costanzo V, Mammino L, Palmucci S, Cianci A, Ettorre GC, Basile A. Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion. Insights Imaging 2019; 10:119. [PMID: 31853900 PMCID: PMC6920287 DOI: 10.1186/s13244-019-0808-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/18/2019] [Indexed: 01/06/2023] Open
Abstract
Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation. The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Pietro Valerio Foti
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Valeria Costanzo
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Luca Mammino
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Stefano Palmucci
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical-Surgical Specialties, Institute of Obstetrics and Ginecology, University of Catania, Catania, Italy
| | - Giovanni Carlo Ettorre
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Basile
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
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19
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Nalcacioglu H, Ceyhan Bilgici M, Tekcan D, Genc G, Bostanci Y, Yakupoglu YK, Sarikaya S, Ozkaya O. Nutcracker Syndrome in Children: Role of Doppler Ultrasonographic Indices in Detecting the Pattern of Symptoms. J Clin Med 2018; 7:jcm7080214. [PMID: 30104539 PMCID: PMC6111325 DOI: 10.3390/jcm7080214] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 07/29/2018] [Accepted: 08/08/2018] [Indexed: 12/20/2022] Open
Abstract
The purpose of this study was to evaluate the clinical characteristics of 44 pediatric patients who were diagnosed as having nutcracker syndrome (NCS). 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. The clinical data from 44 pediatric patients who were diagnosed as having NCS from January 2008 to December 2015 were retrospectively reviewed. We grouped the patients according to the presenting symptoms as symptomatic (loin pain; macroscopic hematuria or both) and non-symptomatic (microscopic hematuria and proteinuria were detected incidentally) and evaluated the left renal vein DUS indices in these two groups separately. Asymptomatic NCS was found in 27 (61.4%) patients; 21 (47.7%) of whom were admitted for the evaluation of proteinuria. The most frequent presenting symptoms were left flank pain (20.5%) and macroscopic hematuria (13.6%); and 2 (4.5%) patients presented with a combination of left flank pain and macroscopic hematuria. The mean ratio of the diameter of the hilar portion of the left renal vein (LRV) to that of the aortomesenteric portion was 4.36 ± 1.55. The mean ratio of the peak velocity (PV) between the two sites of the LRV was 7.32 ± 2.68 (3.1–15.6). The differences in the ratio of the diameters were statistically significant between the two groups and significantly higher in children with asymptomatic NCS (p = 0.025). The PV ratios of the LRV (p = 0.035) were significantly higher in asymptomatic children with NCS than in the symptomatic group. Our study identifies that increased compression ratio of the LRV entrapment is most observed in orthostatic proteinuria and microscopic hematuria.
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Affiliation(s)
- Hulya Nalcacioglu
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Meltem Ceyhan Bilgici
- Pediatric Radiology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Demet Tekcan
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Gurkan Genc
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Yakup Bostanci
- Urology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | | | - Saban Sarikaya
- Pediatric Urology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Ozan Ozkaya
- Pediatric Nephrology Department, Istinye University Faculty of Medicine, 34010 Istanbul, Turkey.
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