Nutcracker syndrome ncs is the name given to entrapment of the left renal vein lrv between the aorta and superior mesenteric artery sma. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. The first case report of endovascular stent placement for renal vein. Peak velocity in the aortomesenteric portion, and the anteroposterior diameter ratio of the renal hilum and the aortomesenteric portion of the left renal vein on duplex ultrasound after stenting was significantly decreased compared to that on duplex ultrasound before stenting p 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. 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. Endovascular stenting for nutcracker syndrome sciencedirect. Ct imaging findings of abdominopelvic vascular compression. Nutcracker syndromean unusual case of chronic left upper ab. The sma normally originates from the aorta at a 90 angle with a ventral. Several case reports have proved the usefulness of endovascular stent placement in adults with nutcracker syndrome since 1996 2, 3, 4, 6. Jan 01, 20 endovascular stent placement for nutcracker phenomenon endovascular stent placement for nutcracker phenomenon li, heping.
We report a case of migration of a laparoscopically. Renal nutcracker syndrome genetic and rare diseases. Doppler ultrasonography can assess the anteroposterior diameter and peak velocity of the lrv in two places. 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. Although the mechanism of secondary hypertension induced by lrv compression is not obvious, the probable mechanism has been described below. The relationship between the abdominal aorta, sma, lrv v. Endovascular therapy provides an alternative therapy with satisfactory longterm clinical and imaging results for symptomatic patients with nutcracker syndrome. Endovascular angioplasty with stenting cas treatment. Pdf endovascular stenting for nutcracker syndrome researchgate. This highly visible cobalt chromium stent with thin struts is designed to provide outstanding flexibility and conformability. Li h1, sun x, liu g, zhang y, chu j, deng c, zhou b, chen w, yang j. The flexive cobaltchromium endovascular stent system is the new treatment option for tortuous iliac lesions. The diagnosis of the nutcracker syndrome is made when the phenomenon is accompanied by clinical symptoms.
The ct scan identified compression of the lrv between the sma and aorta, with an. We think the stent placement in the sma might be an option for the treatment of mesenteric ischemia caused by aortic dissection. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Endovascular stent placement for nutcracker phenomenon ios. Control tomography showing patent stent 5 months after the procedure.
A minimally invasive alternative for the treatment of nutcra. Excessive fibrous tissue was found at the origin of the sma, and excised for adequate decompression of the lrv fig. Nutcracker syndrome is an entity resulting from left renal vein compression by. Nutcracker phenomenon and nutcracker syndrome undiagnosed. Longterm followup after endovascular stent placement for treatment of nutcracker syndrome. Endovascular stent placement for the treatment of nutcracker phenomenon in three. The nutcracker phenomenon results from the partial occlusion of the distal segment of the left renal vein lrv as a result of compression of the lrv between the abdominal aorta aa and the superior mesenteric artery sma. It may coincide with sma syndromecompression of the third portion of the. Stent placement for acute superior mesenteric artery. His fatigue markedly improved after insertion of a left renal vein stent. The stent is fully open and the renal vein free from stenosis figure 9. The first clinical report of this phenomenon was by elsadr and mina 6 in 1950. Mdct findings in patients with nutcracker and pelvic congestion syndrome.
Multidetector ct of vascular compression syndromes in the. 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 phenomenon and nutcracker syndrome mayo clinic proceedings, vol. Normally, the angle between the sma and aa is approximately 450. It may coincide with sma syndromecompression of the third portion of the duodenum by the abdominal aorta and the sma. Endovascular stent placement for the treatment of nutcracker. Endovascular stent placement should be an alternative nonsurgical treatment in select cases of nutcracker syndrome because of its less invasive approach and simple performance. Nutcracker phenomenon is an uncommon condition that may lead to a syndrome of chronic abdominal pain. Endovascular stent placement forthe treatment of nutcracker phenomenon in three pediatricpatients. A minimally invasive alternative for the treatment of nutcracker. Nutcracker syndrome servier phlebolymphologyservier. A case of secondary hypertension associated with the. Left renal vein transposition for nutcracker syndrome.
It is characterized by compression of the left renal vein lrv between the superior mesenteric artery sma and the abdominal aorta. 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 ncpnutcracker syndrome ncs in figure 1. Endovascular management of nutcracker syndrome after. Expanding metallic stent placement for nutcracker phenomenon. After a failed second attempt of laparoscopically placed extravascular stent placement, the patient underwent successful endovascular stent placement with. 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.
Because there is a risk of stroke from bits of plaque breaking off during the procedure, an apparatus, called an embolic protection device, may be used. Endovascular stent placement as a treatment for renal venous hypertension. Renal vein stenting for nutcracker syndrome endovascular today. Nutcracker syndrome ncs is defined by the compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma, known as anterior nutcracker syndrome fig. The term nutcracker phenomenon refers to the anatomic compression of the lrv that can occur between the sma and the aorta anterior nutcracker or, if the lrv has a retroaortic or circumaortic course, between the aorta and an underlying vertebral body posterior nutcracker. Endovascular management of recurrent stenosis following left renal vein transposition for the treatment of nutcracker syndrome donald t. Excessive fibrous tissue was found at the origin of the sma, and excised.
It may coincide with sma syndromedcompression of the third portion of the duodenum by the abdominal aorta and the sma. Placement of external or intravascular stents has been described with good results. Here, we present a case of a 24yearold male with a sevenyear history of chronic fatigue syndrome, which was subsequently found to have imaging characteristics consistent with nutcracker phenomenon. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. After that, the evts was designed based on the lrvs primitive physiologic structure using computeraided design software, and each stent was printed out with a. Endovascular stent placement for nutcracker phenomenon endovascular stent placement for nutcracker phenomenon li, heping. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration. Extravascular stent management for migration of left renal vein.
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. Current trends in the diagnosis and management of renal. Expandable metallic stent placement for nutcracker phenomenon. After a successful endovascular stenting and a 6month period of antiplatelet and. 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. The first reported case of endovenous stent placement for the lrv compression syndrome.
The purpose of this study was to evaluate late results of lrv transposition and identify risk factors affecting outcomes. An incidental detection of nutcracker phenomenon in an. A stent is a cylinderlike tube made of thin metalmesh framework used to hold the artery open. Nov 22, 2017 the phenomenon is so named because of fact that in the sagittal view, the sma and aa appear to be a nutcracker crushing a nut. The varicose gonadal vein was seen arising from the lrv. Nutcracker phenomenon presenting as left varicocele. Endovascular stenting for treatment of nutcracker syndrome. The traditional clinical manifestations of nutcracker syndrome is usually accompanied with abdominal pain, hematuria, orthostatic proteinuria, and varicocele formation, however, hypertension is rarely reported as main clinical feature. Images c and d show stent placement ct images in the axial and coronal plane, respectively. The endovascular stent was found migrated to the left of sma and adhered to the vessel wall tightly, and the stent could not be moved.
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. The first description of placement of an intravascular stent for lrv. Method the preoperative kidney model of each patient was printed out to enable surgical planning. Minimally invasive management includes both endovascular stent placement and laparoscopically placed extravascular stent use. Nutcracker syndrome, endovascular stent, hematuria. Several treatment options have been described to relieve associated symptoms. Various reports describe cases of the nutcracker syndrome coexisting with the superior mesenteric artery sma syndrome, a close cousin and more wellknown syndrome involving compression of the duodenum by the sma. Nutcracker syndrome symptoms, treatment, causes, surgery. Discussion the nutcracker phenomenon ncp consists of. Pdf nutcracker syndrome ncs is a rare pathology manifested by pain or. 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.
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. The phenomenon is so named because of fact that in the sagittal view, the sma and aa appear to be a nutcracker crushing a nut. If you are on blood thinners your doctor will instruct you if you need to stop these medications prior to the procedure. 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. Chen w, chu j, yang jy, li hp, zhuang wq, huang yh. A 50yearold man had a mesenteric ischemia related to superior mesenteric artery sma occlusion associated with a type b aortic dissection. Baltazar u, dunn j, floresguerra c, schmidt l, browder w.
We will seek authorization from your insurance company prior to your procedure. Surgical and endovascular interventions for nutcracker. Endovascular stent placement for nutcracker phenomenon. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. The patient was diagnosed with nutcracker syndrome and underwent endovascular. 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. The normal angle between the sma and the aorta is 90, but the lrv is. Endovascular stent and stentgraft placement with adjunctive. At the end of the procedure, the sma was securely fixed on the. Endovascular treatment of a teenager with nutcracker syndrome. 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. The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement. Jul 29, 2016 chen w, chu j, yang jy, li hp, zhuang wq, huang yh. Endovascular stent placement for the treatment of nutcracker syndrome article in international urology and nephrology 444.
The ncs or left venous hypertension is a rare clinical manifestation often caused by the compression of left renal vein lrv between abdominal aorta and superior mesenteric artery sma, an anatomical variation known as the nutcracker phenomenon 3. 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. 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. 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. Herein, the authors report three pediatric cases with successful followup for 2 or 3 years after intravenous stent placement with nutcracker syndrome. Some people may not have symptoms, while others develop severe and. Arterial stent placement is covered by most private insurance providers as well as medicare.
We decided to perform stent placement for the sma and could avoid mesenteric ischemia. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or. Extravascular stent management for migration of left renal. Flexive balloon expandable stent for iliac arteries boston. Endovascular stent placement for the treatment of nutcracker phenomenon in three pediatric patients. 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. If you are on blood thinners your doctor will instruct you if you. Nutcracker syndrome ncs, also known as left renal vein lrv hypertension. Current management approach for left renal vein entrapment.
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