Several treatment options have been described to relieve associated symptoms. Safety and efficiency of endovascular treatment of carotid. 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 angioplasty with stenting cas treatment. The no touch technique used in the renal artery was modified for this situation. Lrv transposition is the most commonly described surgical approach successfully utilized to alleviate pelvic congestion symptoms and hematuria. We report a rare cause if a 12yearold boy who presented with a history of frequent intermittent episodes of painless constant haematuria.
The nutcracker syndrome ncs is a described as a mesoaortic compression of the left renal vein between the abdominal aorta and the superior mesenteric artery together with hematuria. The endovascular therapy of the nutcracker syndrome ncs. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. 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. Ricotta ii, md, aand peter gloviczki, md, rochester, minn objective.
We report a case of migration of a laparoscopically. Endovascular stent placement for nutcracker phenomenon. Figure 5 placement of the stent in the left renal vein. Anticoagulation was started and three weeks later, cta showed complete disappearance. 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.
Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. Renal vein stenting for nutcracker syndrome endovascular. Vascular thoracic outlet syndrome vascular surgery. Endovascular treatment of posterior nutcracker syndrome. 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. Jul 14, 2017 nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle.
Culotte stenting favored for coronary bifurcation lesions. My daughter has nutcracker syndrome testicular disorders. Chen et al have shown, in a longer followup of 61 patients, that endovascular stenting is a primary option for ncs. A 52yearold woman who had a history of hematuria two years previously was admitted to another hospital for treatment of recurrent hematuria. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis.
A randomised comparison of transradial and transfemoral approach for carotid artery stenting. Management of renal nutcracker syndrome by retroperitoneal. Results are encouraging at followup periods beyond two. Left renal vein transposition for nutcracker syndrome. 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 left renal vein against the aorta. Endovascular stenting for nutcracker syndrome sciencedirect. 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. Varicoceles, in the setting of nutcracker syndrome, may need independent repair. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome. In addition, embolization of the pseudoaneurysm before or after stenting to. 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.
Is a complex of clinical symptoms that results from nutcracker phenomenon ncp ncs can be found any time from childhood to old age, with a relatively high prevalence in young and middleaged adults no difference between the sexes. She underwent successful extravascular stenting with complete symptom resolution. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. Similar to stents in the heart to treat a heart attack, stents and balloons are used by endovascular surgeons to treat blocked arteries throughout the body. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. 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. From the peripheral vascular surgery society left renal vein transposition for nutcracker syndrome nanette r. We present a patient whose complaint of flank pain led to the diagnosis of a renal vein thrombosis. 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. Nutcracker syndrome, caused by compression of the left renal vein lrv between the superior mesenteric.
It embraces an extended nonpathognomonic spectrum of symptoms that imply a difficult diagnosis. Compression of the left renal vein lrv between the superior mesenteric artery sma and the aorta was. The brachial artery approach offers a better chance of crossing a complex lesion, but is associated with more access site complications. We reported a case of successful endovascular stenting of the left renal vein for nutcracker syndrome. Methods fifteen selective lcca stenosis patients were treated by the modified no touch technique in the antegrade endovascular. Nutcracker syndrome, endovascular stent, hematuria.
Background open surgery and the retrograde endovascular approach via the distal left common carotid artery lcca have some limitations in lcca ostial stenosis treatment. Nutcracker syndrome is the term used to describe the patient with clinical symptoms of entrapment of the left renal vein between the aorta and the superior mesenteric artery. 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. Renal vein stenting for nutcracker syndrome endovascular today. Surgical and endovascular interventions for nutcracker. Vascular thoracic outlet syndrome vtos is categorized as disorders of the upper extremity, which are caused by compression of the brachial plexus and subclavian artery or vein by bony, soft tissue or muscular anomalies as they emerge from the thoracic outlet. Application of extravascular stenting for nutcracker. Five stents were used in four carotid arteries in four consecutive patients with carotid stenosis of at least 70%. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. The procedures were performed in the operating room with a portable c arm. Flow chart showing how ncs is diagnosed following a pathway from initial. Nutcracker syndrome ncs describes left renal vein compression. Postoperative complications included stent migration to the right atrium after a failed attempt at percutaneous endovascular stent removal. Nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma.
It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. She had surgery, which is left renal vein transposition, where her symptoms resolved for about two weeks. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. Pelvic congestion syndrome, which is a cause of chronic pelvic pain in women, may be due to nutcracker syndrome. Endovascular stenting for nutcracker syndrome kuokang feng, chunyang huang, chenyuan hsiao, tsunghsing lee, tzuting kuo. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Results of endovascular treatment for patients with nutcracker. Looking at it from a transverse plane both sma and aorta. She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. 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. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Jul 24, 2015 a 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. Endovascular treatment of nutcracker syndrome request pdf. Nutcracker syndrome, first reported in 1972, is characterized by hematuria and back pain caused by increased pressure in the lrv as a result of compression between the aorta and the sma.
Endovascular stenting and angioplasty is a new and evolving minimally invasive method to treat circulatory disorders caused by diseased arteries. Extravascular stent management for migration of left renal. Aug 31, 2017 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Thirteen underwent the transfemoral approach and the other two had the transbrachial approach due to a bovine aortic arch. Although endovascular stenting is well accepted for iliocaval occlusive disease. Current management approach for left renal vein entrapment. Robotassisted laparoscopic extravascular stent for. Pdf nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in. A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain.
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. Vascular tos usually occurs in young patients and athletes who are involved in repetitive overhead motion, such as swimming or baseball. Pdf endovascular stenting for nutcracker syndrome researchgate. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications. Surgical and endovascular interventions for nutcracker syndrome. Ruzsa z aimradial 2014 endovascular carotid artery.
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. Nutcracker syndrome and hypertension radiology case. However, currently, there are few data about the pure endovascular approach in the posterior nutcracker syndrome related to evolution in the midterm. Endovascular repair of the ascending aorta can be an effective lifesaving therapy in the properly selected patient and may serve as a bridging therapy to open repair in others. Adjunctive procedures to optimize venous outflow included great saphenous vein cuff. 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. Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Renal nutcracker syndrome genetic and rare diseases. Radcar study radial access for carotid artery stenting. She had surgery, which is left renal vein transposition, where.
Nutcracker syndrome describes an array of incapacitating symptoms caused by lrv. The axillary artery, and the brachial artery were used less frequently 4,8,14,28. Dec 01, 20 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. Further studies should report if this approach has adverse effects and if such a. Nutcracker syndrome ncs is caused by compression of the left renal vein lrv. After attempted percutaneous endovascular removal of the stent failed the protruding stent in the collateral was removed and the remaining stent was pushed into the lrv trunk via a venotomy. Followup included a neurological examination, carotid duplex scan, and of. There are many modalities of treatment of nutcracker syndrome. 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. Endovascular stent placement for nutcracker phenomenon ios. Carotid blowout syndrome emergent endovascular management by.
Posterior nutcracker syndrome with left renal vein. Endovascular stenting for treatment of nutcracker syndrome. This case illustrates the features of nutcracker syndrome, also known as renal vein entrapment syndrome, and an uncommon cause of secondary hypertension. Feb 24, 2015 a look at ascending aorta repair by endovascular stent grafting. In addition, embolization of the pseudoaneurysm before or after stenting to cover the neck of the pseudoaneurysm may be needed. Nutcracker syndrome is an entity resulting from left renal vein. Endovascular stenting for nutcracker syndrome kuokang feng, chunyang huang, chenyuan hsiao, tsunghsing lee, tzuting kuo, chunche shih, chiaopo hsu division of cardiovascular surgery, department of surgery, taipei veterans general hospital and national yangming university school of medicine, taipei, taiwan, roc. If hematuria is not present it is termed nutcracker phenomenon. Ruzsa z aimradial 2014 endovascular carotid artery stenting 1.
It should not be confused with with superior mesenteric artery syndrome aka wilkie syndrome which although also a superior mesenteric artery compression disorder, the sma compresses the. In certain situations, the syndrome can result from a retroaortic or circumaortic left renal vein 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. Endovascular stenting in the treatment of pelvic vein congestion. The mainstay of therapy is stent placement covered or uncovered, selfexpanding or balloon expandable. In this case, abdominal computed tomography angiography was helpful in diagnosing the nutcracker syndrome complicated by the renal vein thrombosis. Placement of left renal venous stent for nutcracker syndrome. Endovascular therapy provides an alternative therapy with satisfactory longterm clinical and imaging results for symptomatic patients with nutcracker syndrome. Pdf a minimally invasive alternative for the treatment. A look at ascending aorta repair by endovascular stent grafting. The small intestines hang like baggy sausages off the branched stems of the superior mesenteric artery sma, and in some individuals, the sma.
Nutcracker syndrome with pelvic congestion treated by balloon. Ultimately it may be associated with substantial morbidity and even lifethreatening events. All these procedures were performed by one experienced interventional. 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. Distal embolic protection devices were used in all cases. The nutcracker syndrome ncs is a rare cause of haematuria. After failed conservative approach, she underwent endovascular stenting and. Results are encouraging at followup periods beyond 2 years. We describe our initial clinical experience using the newly available selfexpanding, nitinol, shapememory, alloyrecoverabletechnology smart stent in treating carotid artery occlusive disease. While these procedures have largely been abandoned due to attendant. This study was designed to evaluate the clinical and radiographic outcomes of patients with nutcracker syndrome ncs who were.
Nutcracker syndrome is an entity resulting from left renal vein compression by. I reached out on instagram and found many others with this disease. Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome. It was described for the first time in 1996 by nesteet al. We report a rare cause if a 12yearold boy who presented with a history of frequent intermittent episodes of painless constant. Endovascular treatment of carotid angioplasty stenting compared with carotid endarterectomy 52 p j m h s vol. Nutcracker syndrome european journal of vascular and.
The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. Nutcracker syndrome, or mesoaortic compression of the left. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Extravascular stent management for migration of left renal vein. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. Endovascular treatment of nutcracker syndrome scielo.
We present a case of a 54yearold female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Endovascular stenting randwick angioplasty sydney nsw. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. Nutcracker syndrome with pelvic congestion treated by. Endovascular interventions have become the treatment of choice for most cases of cbos. Nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle. Some people may not have symptoms, while others develop severe and. Endovascular management of nutcracker syndrome after.
More recently, endovascular stenting of the left renal vein has been reported. We finally went to mayo clinic and she was diagnosed there. Nutcracker syndrome servier phlebolymphologyservier. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches. In cases of nutcracker syndrome, the left renal vein was stenosed between the. Endovascular treatment of nutcracker syndrome sciencedirect. Conventional surgery involves procedures that are associated with increased. Nutcracker syndrome complicated by left renal vein thrombosis. However, further followup and investigation will be required to determine if the durability of this approach compares favorably to current open options for this rare condition. Technical success nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. 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.
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