Endovascular stenting is an alternative treatment option. A simplified approach with gonadal vein transposition posted on june 12, 2016 june 12, 2016 by docpark the patient is a young woman in her twenties who developed severe right sided abdominal and back pain about 4 months prior to presentation associated with bouts of bloody urine. Vascular and endovascular program partner with a recognized leader in offering care ranging from straightforward vascular disease to the most complex vascular disorders. It can be preferred to open surgery because of the long period of renal congestion, additional anastomoses and extensive dissection requirement of the open surgery. Posts about nutcracker syndrome written by docpark.
This allows time for the body to accept the stent and for new tissue to surround it. Renal vein stenting for nutcracker syndrome endovascular. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months. Nutcracker syndrome is an easily missed cause of hematuria in children. Results are encouraging at followup periods up to 2 years. N2 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome.
Unusual confluence of two rare syndromes results in. Although surgical repair has been the standard of care, more recently endovascular stenting. Endovascular treatment of posterior nutcracker syndrome with a new. We retrospectively evaluated the endovascular stenting experience with 61 patients with a. Extravascular stent management for migration of left renal vein. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. The computed tomographic imaging was closely correla ted to therapeutic interventions and stent migration. Each of these interventions has strengths and weaknesses. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. In one of the largest series of endovascular stents, 75 young patients received venous stents for. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the lrv. Robotassisted laparoscopic extravascular stent for. This only slightly invasive treatment can eliminate the symptoms of the condition.
Introduction nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily overlooked condition. The selection of the imaging modality is a stepwise process. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Endovascular stent placement for the treatment of nutcracker. Nutcracker syndrome european journal of vascular and. Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome. Mayo clinic vascular and endovascular surgeons develop and use advanced diagnostic techniques and surgical treatments, such as balloon angioplasty and stenting, bypass surgery, and carotid endarterectomy. Jun 21, 2012 nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery and the aorta, leading to symptoms of hematuria and left flank pain. Endovascular stenting for nutcracker syndrome sciencedirect. Stents in the renal vein can cause fibromuscular hyperplasia.
Nutcracker syndrome is a rare anomaly resulting from compression of the left renal vein between the aorta and the superior mesenteric artery. Recovery time for nutcracker syndrome stenting can last 23 months. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. Pdf endovascular stenting for nutcracker syndrome researchgate.
The extravascular stenting is an alternative option after migration of left renal vein endovascular stenting. Jul 24, 2015 nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the superior mesenteric artery, which leads to symptoms of hematuria or left flank pain. Some people may not have symptoms, while others develop severe and persistent symptoms. Results are encouraging at followup periods beyond two. Nutcracker syndrome is caused by stenosis of the left renal vein lrv as it passes anteriorly to the aorta through the fork formed by both abdominal aorta aa and superior mesenteric artery sma. Nutcracker syndrome servier phlebolymphologyservier. Though lrv transposition and now lrv stenting are commonly employed methods for treatment of nutcracker syndrome, judicious management of ncs should take into consideration patients age, severity, and chronicity of symptoms along with current lack of data regarding longterm outcomes of stent placement. Patient is a 43 year old woman who had been having bouts of severe left sided abdominal pain for several years with worsening episodes of nausea and vomiting resulting in. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma. Endovascular stenting for treatment of nutcracker syndrome. The first case report of endovascular stent placement for renal vein hypertension was in 1996 by neste et al who described a 58yearold man successfully treated with a wallstent boston scientific corporation, natick, ma. Mesenteric ischemia doctors and departments mayo clinic. Pdf a novel hybrid left renal vein transposition and.
Nutcracker phenomenon ncp, also known as left renal vein entrapment, is characterized by impeded outflow from the left renal vein lrv into the inferior vena cava ivc due to extrinsic lrv compression, often accompanied by demonstrable lateral hilar dilatation and medial mesoaortic narrowing schematic representation of ncp nutcracker syndrome ncs in. Clinicians place an endovascular stent in the left renal vein. Results of endovascular treatment for patients with. Renal nutcracker syndrome ncs is a condition that occurs when the left renal vein the vein that carries blood purified by the left kidney becomes compressed. Endovascular stenting in the treatment of pelvic vein. She underwent successful extravascular stenting with complete symptom resolution. Symptoms were hematuria, proteinuria or flank pain. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike.
Its diagnostic criteria are not well defined, often causing delayed or misdiagnosis. This case report describes a patient diagnosed with nutcracker syndrome who was treated successfully by embolization of the ovarian vein and insertion of a stent. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. Nutcracker syndrome is a variation of nutcracker phenomenon or renal vein entrapment syndrome, in which the arteries near the kidney compress the left renal kidney vein. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. Thrombosis, stent migration, fracture and restenosis are the complications of the endovascular stenting but they are rare.
Endovascular stenting in the treatment of pelvic vein congestion. The name derives from the fact that, in the sagittal plane andor transverse plane, the sma and aa with some imagination appear to be a nutcracker crushing a nut the renal vein. Findings confirm compression of the duodenum wilkie syndrome and compression of the left renal vein nutcracker syndrome. Your surgeons discuss with you all suitable treatment options, which may include traditional open surgery and minimally invasive techniques. Carotid artery angioplasty with stenting cas is a minimally invasive procedure in which a very small hollow tube, or catheter, is advanced from a blood vessel in the groin to the carotid arteries. Nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery and the aorta, leading to symptoms of hematuria and left flank pain. The patient was diagnosed with nutcracker syndrome and underwent. Nutcracker syndrome is diagnosed through imaging such as doppler ultrasound dus, computed tomography ct, magnetic resonance imaging mri, and venography. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Renal nutcracker syndrome genetic and rare diseases. It is characterized by left renal vein entrapment between the abdominal aorta and the superior mesenteric artery causing renal venous hypertension.
Developed by renowned radiologists in each specialty, statdx provides comprehensive decision support you can rely on nutcracker syndrome. It is characterized by external compression of the out. Additionally, this method can be successfully used in the treatment of. Normally, the angle between the sma and aa is approximately 450. Cgsurg106 venous angioplasty with or without stent. Although endovascular stenting is an attractive option, it is not without complications. The nutcracker syndrome ncs results most commonly from the compression of the left renal vein lrv between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. Medstar heart and vascular institute stenting medstar. Hybrid intervention for treatment of the nutcracker syndrome. Jul 14, 2017 posts about nutcracker syndrome written by docpark. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup. This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension.
Extravascular stent management for migration of left renal. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and. Nutcracker syndrome surgery recovery time can last 3 months while the vein andor artery heals. At the threeweek followup, she reported near resolution of nausea and abdominal pain. Nov 22, 2017 although endovascular stenting is an attractive option, it is not without complications. Patient is a 43 year old woman who had been having bouts of severe left sided abdominal pain for several years with worsening episodes of nausea and vomiting resulting in several visits to the emergency room. Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Endovascular stent placement for nutcracker phenomenon. A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months. Mayo clinic has one of the largest and most experienced practices in the united states, with campuses in arizona, florida and minnesota. Renal vein stenting for nutcracker syndrome a potentially lessinvasive treatment for a rare but debilitating condition. We report two patients in whom a hybrid approach was adopted in the process.
Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal 20. Endovascular treatment of nutcracker syndrome journal of. Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Endovascular treatment of posterior nutcracker syndrome with a new autoexpandable stent. Open and endovascular interventions have both been performed to relieve the compression.
Additionally, this method can be successfully used in the treatment of posterior nutcracker syndrome. Nutcracker syndrome symptoms, treatment, causes, surgery. Vascular and endovascular surgery overview mayo clinic. Nutcracker syndrome is a vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric artery sma and aorta, although other variations can exist 1 this can lead to renal venous hypertension, resulting in rupture of thinwalled veins into the collecting system with resultant hematuria. Followup was completed by clinical exams and duplex ultrasound at. Nutcracker syndrome ncs describes left renal vein compression. The nutcracker syndrome is a rare clinic condition associated with severe hematuria and left flank pain due to the entrapment of the left renal vein between the superior mesenteric artery and the aorta.
Stent migration is relatively common after endovascular stenting. In most cases, compression of the left renal vein is between the abdominal aorta the main artery in the abdomen and the superior mesenteric artery, which brings blood. Endovascular angioplasty with stenting cas treatment. The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement. Endovascular treatment of nutcracker syndrome request pdf. Venous stenting, which supports blood flow through vessels affected by deep vein thrombosis or chronic venous insufficiency. Stenting can be used, provided that the same techniques as those in the maythurner syndrome are used, that is, the stent should protrude into the inferior vena cava. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and testicular swelling. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Nutcracker syndrome ncs is caused by compression of left renal vein lrv, usually between the aorta and the superior mesenteric artery sma.
We present a case of a 54yearold female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Renal vein stenting for nutcracker syndrome endovascular today. Conclusion nutcracker syndrome is a rare diagnosis and may manifest in unusual ways. 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. Endovascular treatment by stenting was proposed and is not very invasive, but followup is too short to establish the role of this technique in the management of the nutcracker syndrome. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the superior mesenteric artery, which leads to symptoms of hematuria or left flank pain. We retrospectively evaluated the endovascular stenting experience with 61 patients with a median age of 26 years. A novel hybrid left renal vein transposition and endovascular. The nutcracker syndrome is an emerging indication for venous endovascular stenting.
A case report of a young girl with recurrent hematuria. To retrospectively assess the therapeutic value of endovascular stenting for treatment of the nutcracker syndrome ncs in longterm followup and to explore the selection of the size of stents in chinese patients with ncs. Jun 22, 2017 endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. We retrospectively evaluated the endovascular stenting. Endovascular treatment of nutcracker syndrome scielo. As more cases are reported, endovascular repair is becoming an alternative treatment for nutcracker syndrome. Nutcracker syndrome is a rare diagnosis and may manifest in unusual ways.
We report a case of migration of a laparoscopically. Despite potential serious consequences, diagnosing ncs is often challenging, circuitous and commonly delayed. Longterm followup after endovascular stent placement for. The alternative option of endovascular or extravascular stenting is very. Intermittent hematuria and orthostatic proteinuria with or without abdominal or flank pain are the common clinical manifestations. Nutcracker syndrome is an entity resulting from left renal vein. The patient was treated with stenting of her left renal vein. We describe a case of a 28yearold man who presented with microscopic hematuria, left. Endovascular management of nutcracker syndrome after.
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