The left iliac vein is the main vein in your left leg. After a successful endovascular stenting and a 6month period of antiplatelet and. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma. Treatment options for lrv entrapment syndrome consist of expectant. Endovascular stenting in the treatment of pelvic vein congestion. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. My daughter has nutcracker syndrome testicular disorders. Diagnostic and treatment criteria are not well established, and the natural history of ncs. It was described for the first time in 1996 by nesteet al. Variants superior mesenteric artery syndrome wilkie syndrome third portion of the duodenum courses in front of the lrv between the aorta and the sma posterior nutcracker the retroaortic or circumaortic renal vein compressed between the aorta and the vertebral body, 4. Chen and colleagues 2011 retrospectively evaluated the endovascular stenting of 61 individuals with nutcracker syndrome and a median age of 26 years. Endovascular treatment of nutcracker syndrome is a new tool for treating the syndrome offering the advantages of being less invasive and causing less morbidity and mortality. Intravascular stenting approaches in ncs were extrapolated from the stenting. Some people may not have symptoms, while others develop severe and persistent symptoms.
Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. This is because both mts and pcs are anatomic variants in the structure of abdominal veins that predispose the patient to all three issues. Endovascular stent placement for the treatment of nutcracker. Nutcracker phenomenon and nutcracker syndrome are sometimes used interchangeably in literatures. Renal vein entrapment the nutcracker syndrome brandon t. We recently treated a young woman incapacitated by left flank pain and hematuria with a new external stenting procedure, which relieved the nutcracker syndrome.
Mesoaortic compression of the left renal vein the socalled. A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. We finally went to mayo clinic and she was diagnosed there. This case illustrates the features of nutcracker syndrome, also known as renal vein entrapment syndrome, and an uncommon cause of secondary hypertension. Endovascular stenting for nutcracker syndrome sciencedirect. Nutcracker syndrome refers to the complex of clinical symptoms caused by the compression of the left renal vein lrv between the abdominal aorta and the superior mesenteric artery, leading to stenosis of the aortomesenteric portion of the lrv and dilatation of the distal portion. Although these terms have been used quite often interchangeably in the literature, it should be emphasized that ncs must be used when there is evidence of nutcracker anatomy accompanied with clinical symptoms. Although both terms are clinically equivalent, the latter is used for patients who are manifesting the characteristic clinical symptoms of the disorder 2. Jan 07, 2020 maythurner syndrome is a condition that causes the left iliac vein in your pelvis to narrow because of pressure from the right iliac artery. Aug 04, 2011 i also was told, wo blood in urine not a problem, although my nephro at home disagrees. The role of renal autotransplantation in treatment of.
Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. 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. The small intestines hang like baggy sausages off the branched stems of the superior mesenteric artery sma, and in some individuals, the sma compresses the. Nutcracker syndrome should not be confused with superior mesenteric artery syndrome wilkie syndrome also a superior mesenteric artery compression disorder, where the sma compresses the third part of the duodenum the two conditions, however, may be associated. The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting. Renal nutcracker syndrome genetic and rare diseases. Chronic pelvic pain affects approximately 15% of premenopausal women in the united states. This syndrome results most commonly from the compression of the left renal vein between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. Nowadays, with the development of imaging techniques, color doppler sonogram and 3d cta are replacing venography for the diagnosis of nutcracker. Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. Nutcracker syndrome ncs describes left renal vein compression between the superior mesenteric artery and the aorta. Current management approach for left renal vein entrapment. Application of extravascular stenting for nutcracker. These anatomical findings were first described by schepper in 1972 1.
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. Nutcracker syndrome and hypertension radiology case. A 21yearold chinese woman was admitted with a sevenmonth history of. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months. The term nutcracker syndrome dates back to the anatomical description by grant who stated that the left renal vein as it lies between the aorta and the superior mesenteric artery resembles a nut between the jaws of a nutcracker. She underwent successful extravascular stenting with complete symptom resolution. Nutcracker syndrome ncs describes left renal vein compression between the. The lack of diagnosis seems to be related to limited awareness of this disease process by both physicians and. Read surgical and endovascular interventions for nutcracker syndrome, seminars in vascular surgery on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. Compartment syndrome definition of compartment syndrome by. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. Cgsurg106 venous angioplasty with or without stent.
Mesoaortic compression of the left renal vein the so. Followup was completed by clinical exams and duplex ultrasound at 3, 6 and 12 months. Results are encouraging at followup periods beyond two. Intravascular stenting is the implantation of metallic stents performed with the guidance of digital subtraction angiography under a local anesthesia. Nutcracker syndrome describes an array of incapacitating symptoms caused by. Vascular and endovascular surgery overview mayo clinic. Sep 20, 2016 nutcracker syndrome refers to the complex of clinical symptoms caused by the compression of the left renal vein lrv between the abdominal aorta and the superior mesenteric artery, leading to stenosis of the aortomesenteric portion of the lrv and dilatation of the distal portion. This is obtained due to anatomical abnormality causes the right common iliac artery lies on the upper surface and constricting the left common iliac vein against the lumbar spine.
We satisfactorily treated a middleaged man with nutcracker syndrome accompanied by renal enlargement, persistent haematuria, proteinuria and hypertension with a new intravascular stent. Nutcracker syndrome is a very common condition that is present in almost 50% of women with other forms of pelvic vein disease, such as may thurner syndrome mts and pelvic congestion. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches. Stents in the renal vein can cause fibromuscular hyperplasia. Ultimately it may be associated with substantial morbidity and even lifethreatening events. May thurner syndrome symptoms, treatment, causes, complications. I have had pain since i was a child, i am now 29 and after years of searching, going from doc to doc, i finally found out that i had something called nutcracker syndrome which is a clinically manifest variant of nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of. Nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle. We reported a case of successful endovascular stenting of the left renal vein for nutcracker syndrome. Nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily. Nutcracker syndrome symptoms, treatment, causes, surgery. Endovascular stenting for nutcracker syndrome kuokang feng, chunyang huang, chenyuan hsiao, tsunghsing lee, tzuting kuo.
A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. Nutcracker syndrome ncs is the most common term for compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. 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. 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. Left renal vein transposition for nutcracker syndrome. Nutcracker syndrome ncs, also known as left renal vein lrv entrapment syndrome, was first defined anatomically by grant in 1937 as follows.
Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. 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. We report a case of nutcracker syndrome diagnosed with 3dimensional computed tomography angiography 3d cta. Park yb1, lim sh, ahn jh, kang e, myung sc, shim hj, yu sh. Management of renal nutcracker syndrome by retroperitoneal. Nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily overlooked condition. Renal vein stenting for nutcracker syndrome endovascular. Posterior nutcracker syndrome with left renal vein. Left renal vein entrapment syndrome, characterized by the compression of the left renal vein lrv between the superior mesenteric artery sma and the abdominal aorta was first described in 1950. Followup was completed by clinical exams and duplex ultrasound at. Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome. Extravascular stent management for migration of left renal. We report a rare cause if a 12yearold boy who presented with a history of frequent intermittent episodes of painless.
A 52yearold woman who had a history of hematuria two years previously was admitted to another hospital for treatment of recurrent hematuria. Nutcracker syndrome occurs more frequently in women by the 3rd or 4th decades, although cases have been reported in children. Current trends in the diagnosis and management of renal. Symptoms can be due to venous hypertension within the left kidney. Nutcracker syndrome servier phlebolymphologyservier. The nutcracker syndrome ncs is a rare cause of haematuria. Compartment syndrome definition of compartment syndrome. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. We report a case of migration of a laparoscopically. The left kidney vein has to cross over the left sided aorta to get to the right sided vena cava. Maythurner syndrome is a condition that causes the left iliac vein in your pelvis to narrow because of pressure from the right iliac artery. Nutcracker syndrome had been confirmed by conventional venography until recent years. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. Nutcracker syndrome, caused by compression of the left renal vein lrv between the superior mesenteric artery and the aorta, results in left renal and gonadal venous hypertension.
It embraces an extended nonpathognomonic spectrum of symptoms that imply a difficult diagnosis. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement. Several treatment options have been described to relieve associated symptoms. Maythurner syndrome is a condition in which iliofemoral deep venous thrombosis dvt are developed. Nutcracker syndrome european journal of vascular and.
Aug 25, 2016 renal vein entrapment the nutcracker syndrome brandon t. The stent is introduced in the femoral artery going to the lrv. Although it is in its infancy, endovascular therapy for nutcracker syndrome is a viable option that may circumvent more invasive procedures. The patient was diagnosed with nutcracker syndrome and underwent. The underlying anatomic anomaly, first described by gant in 1937, can lead to left renal venous. The development of ncs is associated with the formation of the left renal vein lrv from the aortic collar during the sixth to eighth week of gestation and abnormal angulation of the superior mesenteric artery from the. I just want to let everyone know that i have vericose veins in my uterus. On rare occasions the kidney vein will go behind the aorta. Although the nutcracker syndrome represents a form of vascular compression, no previous reports have appeared in the vascular surgical literature. Surgical approaches for nutcracker syndrome include nephrectomy, nephropexy, renocaval reimplantation, or autotransplantation. Oct 27, 2009 nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Maythurner syndrome mts is an anatomically and pathologically variable condition leading to venous outflow obstruction as a result of extrinsic venous compression in the iliocaval venous territory. Although uncommon, it is an important diagnosis due to the important morbidity associated with it, including the risk of chronic kidney disease from longterm left renal vein lrv hypertension and the risk of lrv thrombosis. Provisional stenting should be performed in bifurcation lesions with intermediatesize side branch 22.
We describe five patients who were treated for nutcracker syndrome by using stenting and analyze the nine cases previously reported. Nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. When the kidney vein goes in front of the aorta, it may be pinched by the intestinal artery sma superior mesenteric artery anterior nutcracker syndrome. Nutcracker phenomenon and nutcracker syndrome ncbi. External stenting of the lrv with this shield technique is. Meissner the nutcracker syndrome is characterized by entrapment and compression of the left renal vein between the abdominal aorta and the superior mesenteric artery sma figure 1.
The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. It is characterized by external compression of the outflow from the left renal vein lrv into the inferior vena cava ivc. I just recently had a major surgery for something called nutcracker syndrome. It should not be confused with with superior mesenteric artery syndrome aka wilkie syndr. She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. The nutcracker syndrome ncs is the clinical equivalent of nutcracker.
Elective stenting of unprotected left main coronary artery stenosis. 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. Pelvic congestion syndrome pcs is a disease that is often undiagnosed in women with pelvic pain. Hybrid intervention for treatment of the nutcracker syndrome. The present case had suffered from left varicocele, but the underlying cause was not sought. The metallic stent is placed in the narrowed portion of the vein 1. Symptoms were hematuria, proteinuria or flank pain. We report a rare cause if a 12yearold boy who presented with a history of frequent intermittent episodes of painless constant haematuria. Your surgeons discuss with you all suitable treatment options, which may include traditional open surgery and minimally invasive techniques. Surgical and endovascular interventions for nutcracker. Placement of left renal venous stent for nutcracker syndrome.
She had surgery, which is left renal vein transposition, where her symptoms resolved for about two weeks. With partial venous obstruction, the condition can be asymptomatic, but progression with symptoms related to chronic venous hypertension or. Renal vein stenting for nutcracker syndrome endovascular today. Entrapment of the left renal vein lrv between the abdominal aorta and superior mesenteric artery sma plus the resulting clinical manifestations. Jun 22, 2017 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. Superior mesenteric artery sma syndrome is a gastrovascular disorder in which the third and final portion of the duodenum is compressed between the abdominal aorta aa and the overlying superior mesenteric artery. Endovascular management of nutcracker syndrome after. The development of ncs is associated with the formation of the left renal vein lrv from the aortic collar during the sixth to eighth week of gestation and abnormal angulation of the superior mesenteric artery from the aorta. The terms nutcracker syndrome ncs or phenomenon ncp refer to the compression of the left renal vein, as it passes through the angle between the aorta and the superior mesenteric artery.
Endovascular treatment of nutcracker syndrome request pdf. Patients of nutcracker syndrome having the only symptom of significant varicocele are. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. Extravascular stent management for migration of left renal vein endovascular stent in nutcracker syndrome lu tian1, shanwen chen2, gaoyue zhang3, hongkun zhang1, wei jin1 and ming li1 abstract background.