She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. Endovascular stenting and angioplasty is a new and evolving minimally invasive method to treat circulatory disorders caused by diseased arteries. The endovascular therapy of the nutcracker syndrome ncs. 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. Endovascular stent surgery is a minimally invasive surgical procedure that uses advanced technology and instrumentation to treat disorders of the circulatory system such as blockage or damage to blood vessels caused by the buildup of plaque fatty deposits, calcium deposits, and scar tissue in the. Renal nutcracker syndrome genetic and rare diseases. In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. Pelvic congestion syndrome, which is a cause of chronic pelvic pain in women, may be due to nutcracker syndrome. Results are encouraging at followup periods beyond two.
Vulvovaginal varicosities and pelvic congestion syndrome. 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. 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 recently treated a young woman incapacitated by left flank pain and hematuria with a new external stenting procedure, which relieved the nutcracker syndrome. 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. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup.
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. We report on 3 patients who presented with nutcracker syndrome, including one patient with a circumaortic lrv resulting in posterior nutcracker syndrome, who underwent successful endovascular treatment with renal vein stenting. The patient was diagnosed with nutcracker syndrome and underwent endovascular. Although the nutcracker syndrome represents a form of vascular compression, no previous reports have appeared in the vascular surgical literature. There is a wide variety of stents used for different purposes, from expandable coronary, vascular and biliary stents, to simple plastic stents used to allow the flow of urine between kidney and bladder. There are many modalities of treatment of nutcracker syndrome. It should not be confused with with superior mesenteric artery syndrome aka wilkie syndr. Although often asymptomatic, it may result in varicocele, ovarian vein syndrome, haematuria, flank or abdominal pain, lrv hypertension, and pelviureteral varices. The small intestines hang like baggy sausages off the branched stems of the superior mesenteric artery sma, and in some individuals, the sma. Endovascular management of nutcracker syndrome after. 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 and hypertension radiology case. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures.
Endovascular stenting is an alternative treatment option. Endovascular treatment of posterior nutcracker syndrome. Endovascular interventions have become the treatment of choice for most cases of cbos. Angioplasty, stent stroke prevention froedtert hospital. 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. Surgical placement of an external stent to the lrv is another surgical approach to ncs. It was described for the first time in 1996 by nesteet al. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. Endovascular angioplasty with stenting cas treatment. Endovascular procedures uses a minimally invasive approach to reopening blocked vessels and restoring blood flow to a threatened extremity. My daughter has nutcracker syndrome testicular disorders. 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. Vertebral artery angioplasty and stenting is used to treat patients with stenosis at the origin of the vertebral artery. The lrv transposition was the most commonly reported technique, followed by renal autotransplantation.
It can be preferred to open surgery because of the long period of renal congestion. Expanding metallic stent placement for nutcracker phenomenon. 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. Term of nutcracker syndrome ncs is used for patients with clinical symptoms associated with nutcracker anatomy. This case illustrates the features of nutcracker syndrome, also known as renal vein entrapment syndrome, and an uncommon cause of secondary hypertension. Nutcracker syndrome is one of the many unfortunate consequences of our bipedal lifestyle. 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. We finally went to mayo clinic and she was diagnosed there. Endovascular stent placement as a treatment for renal venous hypertension. If hematuria is not present it is termed nutcracker phenomenon. The mainstay of therapy is stent placement covered or uncovered, selfexpanding or balloon expandable. Endovascular stenting randwick angioplasty sydney nsw. Renal vein stenting for nutcracker syndrome endovascular.
A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. Nutcracker syndrome ns is a welldefined pathologic process in which the therapeutic approach of first choice, although not globally accepted, is currently stenting of the left renal vein lrv with a selfexpanding stent, which may be associated with left gonadal vein lgv embolization. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. The chance is that we have a minimally invasive approach that works.
She underwent successful extravascular stenting with complete symptom resolution. Endovascular stent placement for nutcracker phenomenon. Mesoaortic compression of the left renal vein the so. 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. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. Endovascular treatment of nutcracker syndrome request pdf. Management of renal nutcracker syndrome by retroperitoneal. Surgical and endovascular interventions for nutcracker. It can be preferred to open surgery because of the long period of renal congestion, additional anastomoses and.
Nutcracker syndrome with pelvic congestion treated by. Endovascular treatment of nutcracker syndrome sciencedirect. 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. Endovascular treatments also are a good alternative for patients who have had prior open procedures and have been told that they have are too high a risk for another open procedure.
Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome. Endovascular stenting as the first step in the overall. We retrospectively evaluated the endovascular stenting experience with 61 patients with a. At cleveland clinic, our first option is typically the least invasive, if at all possible. The terms nutcracker phenomenon and nutcracker syndrome ncs are sometimes used as synonym in the literature. 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. These procedures were originally designed for patients who are poor candidates for open surgery. Nutcracker syndrome is an entity resulting from left renal vein compression by.
Based on the advantages of retroperitoneal laparoscopic surgery, this approach should become a standard method for nutcracker syndrome repair. Subjects and methods patients between january 1993 and september 2000, 73 stents were implanted in 52 cancer patients with superior vena cava syndrome. Some people may not have symptoms, while others develop severe and. Extravascular stent management for migration of left renal. Research article endovascular management of aortailiac stenosis and occlusive disease by kissingstent technique mengliu 1,2 andfuxianzhang 1 department of vascular surgery, beijing shijitan hospi tal, capital medical university, beijing, china. Development of an evidencebased approach to managing these patients has been. The etiology of pcs is unclear and the optimum treatment is uncertain. Pelvic congestion syndrome pcs is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. She had surgery, which is left renal vein transposition, where. The clinical syndrome caused by impingement of the left renal vein lrv between the superior mesenteric artery sma and abdominal aorta has been termed nutcracker syndrome. Endovascular techniques have emerged as preferable alternatives to surgical ligation for treatment of cbs. Endovascular therapy is one of the greatest achievements of modern medicine because it has made it possible to treat various complex vascular problems safely and effectively without any surgery.
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. A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months. In addition, embolization of the pseudoaneurysm before or after stenting to. Research article endovascular management of aortailiac. After a successful endovascular stenting and a 6month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. Over the years, results have continued to improve and indications have been expanded to all patients.
With no accepted protocol for nutcracker syndrome repair, retroperitoneal laparoscopic donor nephrectomy and renal autotransplantation should be determined on a casebycase basis. Aneurysms and dissections of the aorta in the chest can be treated by inserting stents to strengthen the artery. 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. Stenting as first option for endovascular treatment of. Although surgical repair has been the standard of care, more recently endovascular stenting of the renal vein has been proposed. Endovascular stenting for treatment of nutcracker syndrome. Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. Baishideng publishing group inc, 7041 koll center parkway, suite 160, pleasanton, ca 94566, usa.
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