End points were perioperative adverse outcomes, symptom relief, and stent patency. The nutcracker syndrome, first reported in 1950, is said to occur when the nutcracker phenomenon is accompanied by clinical symptoms including chronic abdominal pain and haematuria. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. I have nutcracker syndrome also and i am so happy i found this site. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these. She underwent successful extravascular stenting with complete symptom resolution. Several complications of lrv stenting including stent migration, thrombosis, and restenosis have been reported 40, 42, 45, and the theoretical longterm risk of stent erosion has also been discussed in the literature, which is especially relevant as these patients are generally younger. Diagnosis and treatment of the nutcracker syndrome. Late stent migration into the right ventricle in a patient. Surgical treatment of posterior nutcracker syndrome. Nutcracker syndrome, or mesoaortic compression of the left renal vein lrv, with associated symptoms related to venous hypertension in the left kidney, is a rare entity that may. Jul 14, 2017 posts about nutcracker syndrome written by docpark. Common signs and symptoms when the condition shows no symptoms, its usually known. Cgsurg106 venous angioplasty with or without stent.
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. Despite modern imaging modalities, the diagnosis of nutcracker syndrome is difficult. The prevalence of nutcracker syndrome is unknown 1 and while not an inherited condition, cases in siblings have been reported 3. The nutcracker syndrome ncs comprises symptoms and findings such as varicocele, ovarian.
A novel hybrid left renal vein transposition and endovascular. Imaging findings and clinical features of abdominal. Endovascular stenting for nutcracker syndrome sciencedirect. Jun 12, 2016 posted in nutcracker syndrome, techniques, venous, venous intervention tagged gonadal vein transposition, nutcracker phenomena, nutcracker syndrome, stent migration leave a comment post navigation previous post dysphagia lusoria a simplified approach next post complex femoral pseudoaneurysm with arteriovenous fistula and large hematoma treated.
Endovascular management of nutcracker syndrome after migration of a laparoscopically placed extravascular stent. Moreover, 2 cases of early stent migration have been reported 8,16 and 2 cases of late stent slipping. After placing a stent, normal blood flow is reestablished, avoiding pathologic collateral systems. Endovascular management of nutcracker syndrome after. We report a case of migration of a laparoscopically. Most seen symptoms are haematuria, left flank pain, abdominal pain and varicocele. Herein, we present a case of intestinal perforation caused by a biliary stent in. 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. A minimally invasive alternative for the treatment of nutcracker. This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. Nutcracker syndromean unusual case of chronic left upper. Surgical treatment of posterior nutcracker syndrome presented. Robotassisted laparoscopic extravascular stent for.
Nutcracker syndrome ncs is the most common term for compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. Endovascular management of recurrent stenosis following. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. A rational approach to imaging begins with duplex ultrasonography, followed by ct or. Nutcracker syndrome or left renal vein compression is shown in the pelvic phlebography. The clinical symptoms of nutcracker syndrome almost disappeared at 3 months after the treatment. The exact prevalence of nutcracker syndrome is unknown, likely because of the variable presenting features. Postoperatively, 2 cases of stent migration were found at 12 months. Nutcracker syndrome, caused by left renal vein lrv compression as it passes between the superior mesenteric artery and aorta, causes. Current surgical therapy involves placement of an oversized renal vein stent with partial protrusion into the inferior vena cava ivc to relieve stenosis and prevent stent migration. Endoscopic biliary stents have been recently applied with increasing frequency as a palliative and curable method in several benign and malignant diseases. Nutcracker syndrome ncs, also known as left renal vein lrv. Lrv is another option that has shown longterm resolution of symptoms.
I have 2 children, but suffered multiple misscarrages, but thinking they were related to my bloodclotting disorder. The severity of nutcracker syndrome is variable, and affected individuals may be completely asymptomatic or. This technique can be extremely helpful in diagnosing nutcracker syndrome, identifying an abnormality of the sma as the cause of nutcracker syndrome, and assessing response to treatment extravascular stent migration, fig 2d and e. Laparoscopic extravascular stent placement for nutcracker. Size selection for the stent is highly reliant on precise lrv measurements by intravascular ultrasound before placement, and it is usually oversized up to 20% to prevent migration. Outcomes of left renal vein stenting in patients with nutcracker. Extravascular stent management for migration of left renal. Treatment options for pelvic congestion syndrome servier. Following are the common symptoms that have been studied in the nutcracker syndrome. Symptoms vary widely and are often exacerbated by physical activity. Placement of an endovascular stent in the left renal vein lrv for the treatment of nutcracker syndrome has recently increased in popularity, owing to the minimally invasive nature of the procedure. Shanwen chen, hongkun zhang, lu tian, ming li american journal of kidney diseases 2012, 60 2. The nutcracker syndrome is a rare condition, but is certainly underdiagnosed.
Given the paucity of cases in the literature and lack of data regarding longterm. Both sma and lrv anomalies have been pointed out as the primary cause of nutcracker syndrome. Renal vein stenting for nutcracker syndrome endovascular. Results of endovascular treatment for patients with. Nutcracker syndrome encompasses classical symptoms of hematuria and flank pain resulting from the compression of the left renal vein between the aorta and the superior mesenteric artery. I just recently had a major surgery for something called nutcracker syndrome. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications.
She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. Nutcracker syndrome ncs is caused by compression of left renal vein lrv, usually between the aorta and the superior mesenteric artery sma. 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. When symptomatic, such compressions can result in a variety of uncommon syndromes in the abdomen and pelvis, including median arcuate ligament syndrome mals, maythurner syndrome, nutcracker syndrome, superior mesenteric artery sma syndrome, upj obstruction, ovarian vein syndrome ovs, and other forms of ureteral compression. In this case, the pressure increase develops an insufficiency in the left gonadal vein. Imaging findings and clinical features of abdominal vascular. Despite potential serious consequences, diagnosing ncs is often challenging, circuitous and commonly delayed. 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 figure 1. Outcomes of left renal vein stenting in patients with nutcracker syndrome. Complications include stent migration, intrastent restenosis, fractures, and venous occlusion. 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. The authors of this study have concluded that venous stent migration in.
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. Some people may not have symptoms, while others develop severe and persistent symptoms. 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. D baylor university medical center, dallas, tx, usa. Stents in the renal vein can cause fibromuscular hyperplasia. Renal vein stenting for nutcracker syndrome endovascular today. Multidetector ct of vascular compression syndromes in the. Nutcracker syndrome is an entity resulting from left renal vein compression by the superior mesenteric artery and the aorta, leading to symptoms of left flank pain and hematuria.
This study included nutcracker syndrome patients who were treated by laparoscopic extravascular stent placement from june 2009 to august 20. The mild nutcracker syndrome can be witnessed in children during the changes their body undergoes due to growth. Nutcracker syndrome is a clinical entity leading to renal venous hypertension due to extrinsic compression of the left renal vein by the superior mesenteric artery. My daughter has nutcracker syndrome testicular disorders. However, it is estimated to be relatively more common in females and usually presents in the 3rd or 4th decade of life.
To report our techniques and experience of laparoscopic extravascular stent placement for nutcracker syndrome. Nutcracker syndromean unusual case of chronic left upper ab. The nutcracker syndrome is a vascular disorder, but the signs and symptoms are mainly urological or gynecological. Endovascular management of recurrent stenosis following left. She had surgery, which is left renal vein transposition, where her symptoms resolved for about two weeks.
Nutcracker syndrome got its name because the compression of the renal vein is like a nutcracker cracking a nut. Term of nutcracker syndrome ncs is used for patients with clinical symptoms associated with nutcracker anatomy. In some cases, nutcracker syndrome may not need treatment, especially for patients who are. I have found very little information on this syndrome.
Stent migration was observed in two patients without recurrence of the symptoms at 12 months after the operation and no stent reimplantation or surgery was needed fig 4. 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. Nutcracker syndrome ncs, or renal vein entrapment syndrome, is a rare and easily. We describe a case of a 28yearold man who presented with microscopic hematuria, leftsided flank pain, and. Scvs endovascular treatment of nutcracker syndrome. At 1month followup, subjects improved, including 2 who had persistent but less microscopic hematuria than before treatment. 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. N2 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Minimally invasive management includes both endovascular stent placement and laparoscopically placed extravascular stent use. To prevent potential stent migration, either during deployment or afterward, we also chose to use a longer ie, 60 mm stent, with extension from the gonadal vein to 1 cm into the ivc.
Anterior nutcracker syndrome is caused by abnormal branching of the superior mesenteric artery that decreases the aortamesenteric angle to below 90, and posterior nutcracker syndrome is caused by the compression of the left renal vein between the abdominal aorta and the vertebral body. The term nutcracker syndrome is reserved for patients with both clinical and radiological nutcracker features 2. Aug 31, 2017 minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Clinical and surgical data and shortterm outcomes were. Extravascular stent management for migration of left renal vein. My main symptoms are left flank pain and unexplained hematuria. Renal nutcracker syndrome genetic and rare diseases. Conventional treatment has been surgical, commonly through transposition of the left renal vein to a more caudal location on the inferior vena cava. Pain physicians should be aware of the signs and symptoms of nutcracker syndrome and include it in their differential diagnoses when a patient presents with chronic visceral abdominal pain. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. 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. As a reminder, although most of the migrated stents pass through the intestinal tract without symptoms, a small portion can lead to complications. A 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. Posterior nutcracker syndrome is caused by the compression of left renal vein between the abdominal aorta and the vertebral body.
In patients with unexplained leftsided hematuria, flank pain or nonspecific abdominal pain, careful interrogation of diagnostic abdominal imaging should be performed to exclude the. Posted in nutcracker syndrome, techniques, venous, venous intervention tagged gonadal vein transposition, nutcracker phenomena, nutcracker syndrome, stent migration leave a comment post navigation previous post dysphagia lusoria a simplified approach next post complex femoral pseudoaneurysm with arteriovenous fistula and large hematoma treated. 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. The pain is severe around the week before my monthly and the week after. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. Nutcracker syndrome servier phlebolymphologyservier. Nutcracker syndrome can be treated, and treatments depend on your age, anatomy, and symptoms. 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. Stent migration after endovascular stenting in patients with. Symptoms can be triggered or aggravated by physical activity. The nutcracker phenomenon left renal vein lrv entrapment syndrome refers to compression of the lrv most commonly between abdominal aorta and superior mesenteric artery. Stent migration after endovascular stenting in patients with nutcracker. The nutcracker phenomenon refers to the compression of the left renal vein between.
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. As symptoms failed to improve 2 months after medical treatment, the patient. Dus is the initial choice after clinical suspicion based on symptoms. However, there are some rare cause of gross hematuria including nutcracker syndrome ncs with occasionally delayed. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis.
Nutcracker syndrome is diagnosed through imaging such as doppler ultrasound dus, computed tomography ct, magnetic resonance imaging mri, and venography. 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. Nov 22, 2017 the nutcracker syndrome, first reported in 1950, is said to occur when the nutcracker phenomenon is accompanied by clinical symptoms including chronic abdominal pain and haematuria. We finally went to mayo clinic and she was diagnosed there. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. Nutcracker syndrome describes an array of incapacitating symptoms caused by. Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Jul 24, 2015 a 30yearold female was diagnosed with nutcracker syndrome for severe left flank pain. The selection of the imaging modality is a stepwise process. 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. I would like to find anyone that has been diagnosed with the nutcracker syndrome. 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. While an attempt at medical management works for some, others experience ongoing symptoms. Extravascular stent management for migration of left renal vein endovascular stent in nutcracker syndrome.
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