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. Esophageal stent placement memorial sloan kettering cancer. Esophageal stents are a treatment option in patients with esophageal strictures. Review of the current literature, primarily case studies, case series, and retrospective studies indicates that angioplasty has also been used with mixed results. To diagnose nutcracker syndrome, your upmc doctor will. Mesenteric ischemia can come on suddenly or develop over time. The alternative option of endovascular or extravascular stenting is very. Endovascular stenting of benign superior vena cava syndrome. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. Dsyphagia this is characterized by the sensation of food getting stuck under the breast bone. Doctors often diagnose nutcracker syndrome after ruling out other conditions. Esophageal stenting a stent is a metal, tubelike device that can be placed in the esophagus to hold open a narrowed portion so you can eat and drink more easily. Nutcracker syndrome can be challenging to diagnose because its symptoms can be like other urologic or gynecologic disorders. This can lead to renal venous hypertension, resulting in rupture of thinwalled veins into.
Patients of nutcracker syndrome having the only symptom of significant varicocele are recommended for surgery from our experience. Application of extravascular stenting for nutcracker. Find out more about this condition that restricts blood flow to the small intestine. To place the stent in your vein, your surgeon will. Endovascular stenting has shown promising longterm resolution of symptoms but can be complicated by stent migration or thrombosis. The endovascular treatment is appropriate in patients with superior vena cava syndrome of benign etiology with low complications rates and good permeability. Endovascular stenting is an alternative treatment option. Materials and methods we retrospectively evaluated the endovascular stenting experience with 61 patients with a median age of 26 years.
Extravascular stent management for migration of left renal. We present a case of a 54yearold female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. We report the efficacy and safety of endovascular stenting for nutcracker syndrome at longterm followup. Learn more about treatment options for this aneurysm that occurs in the wall of an artery located behind the knee joint. It is caused when the left iliac or other veins are compressed btween the right iliac or other arteries and the spine, which also increases the risk. Scvs endovascular treatment of nutcracker syndrome. Furthermore, the venous return from the left gonadal vein returning to the left renal vein is blocked, thus causing testicular pain. Hybrid intervention for treatment of the nutcracker syndrome. 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. The stent will not be as wide or as flexible as a normal esophagus so you will need to take care with certain foods and in the way you eat to prevent blocking the stent. However, currently, there are few data about the pure endovascular approach in the posterior nutcracker syndrome related to evolution in the midterm. Endovascular stenting for the nutcracker phenomenon. Renal vein stenting for nutcracker syndrome a potentially lessinvasive treatment for a rare but debilitating condition. If hematuria is not present it is termed nutcracker phenomenon.
It was described for the first time in 1996 by neste et al. 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. Despite modern imaging modalities, the diagnosis of nutcracker syndrome is difficult and requires a high index of suspicion. One operation used to treat esophageal cancer is esophagectomy. Thoracic aortic aneurysm doctors and departments mayo clinic.
Thrombosis, stent migration, fracture and restenosis are the complications of the endovascular stenting but they are rare. Endovascular angioplasty with stenting cas treatment. 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. Current trends in the diagnosis and management of renal. The endovascular therapy of the nutcracker syndrome ncs. 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.
This is because both mts and pcs are anatomic variants in the structure of abdominal veins that predispose the patient to all three issues. The stent is typically covered in nature and inserted endoscopically. Renal vein stenting for nutcracker syndrome endovascular. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid. Some people may not have symptoms, while others develop severe and persistent symptoms.
It can be preferred to open surgery because of the long period of renal congestion, additional anastomoses and extensive dissection requirement of the open surgery. Endovascular treatment of posterior nutcracker syndrome. Heartburn this is a burning sensation under the breastbone. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Before the procedure, you will receive anesthesia or medication to help you relax.
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. This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. This information explains your esophageal stent placement, including how to prepare for your procedure and how to care for yourself after your procedure. Endovascular treatment is a safe, effective, and very minimally invasive technique that provides good longterm patency rates for patients with ncs, and under the premise morphologic measurements, 14mmdiameter, 60mmlong selfexpanding stents should be first considered for chinese patients with ncs.
Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed. 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. Endovascular stenting of the renal vein has been reported for nutcracker syndrome with a promising safety and efficacy profile. Although it is in its infancy, endovascular therapy for nutcracker syndrome is a viable option that may circumvent more invasive procedures. Endovascular stent placement for the treatment of nutcracker. Posts about nutcracker syndrome written by docpark. Our case report confirms nutcracker syndrome may be treated through endovascular means, eliminating symptoms and providing a durable alternative to open surgery. Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the. A prospective trial of selfexpanding metal stents in the palliation of malignant esophageal strictures near the upper esophageal sphincter. Endovascular stenting for nutcracker syndrome sciencedirect. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or.
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. 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. 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. Dancer who overcame nutcracker syndrome denied school funding. Esophageal cancer diagnosis and treatment mayo clinic. Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome. 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. Jun 02, 2016 a dancer is fighting for funding to go to a top prestigious musical academy after battling back to health when she was diagnosed with a debilitating condition called nutcracker syndrome. Percutaneous angioplasty and stenting for symptomatic lrv compression and the nutcracker syndrome is an excellent alternative to more invasive approaches. Typically, a selfexpanding nitinol or stainless steel stent is used. Results of endovascular treatment for patients with. Mesenteric ischemia doctors and departments mayo clinic. 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. Eating after esophageal stent placement boston scientific.
Endovascular therapy, specifically catheterdirected thrombolysis followed by stent placement, is the current primary intervention for maythurner syndrome moudgill, 2009. 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. 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. Nutcracker syndrome got its name because the compression of the renal vein is like a nutcracker cracking a nut. 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. Endovascular treatment of nutcracker syndrome request pdf. Endovascular management of nutcracker syndrome after. 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. Minimally invasive treatments for venous compression syndromes. 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. 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. 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 name derives from the fact that, in the sagittal plane andor transverse plane, the sma and aa appear to be a nutcracker crushing a nut.
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 to the pancreas and. It was described for the first time in 1996 by nesteet al. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Methods we report the case of a 26yearold woman with 4 months of intermittent flank pain and hematuria, diagnosed with nutcracker syndrome by both duplex ultrasound and axial based imaging. Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of. 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 chinese patients with ncs. 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. 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 bladd. Learn about this serious condition in which the upper part of the blood vessel that feeds blood to the body is weakened. Stenting for nutcracker syndrome your surgeon may choose to treat your nutcracker syndrome using a stent a small mesh tube to hold your left renal vein open and allow for proper blood flow. Popliteal artery aneurysm doctors and departments mayo. Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Covered stents are used in endovascular surgical procedures such as endovascular aneurysm repair.
Follow up computed tomography with intravenous contrast showed a widely patent stent. Endovascular treatment of nutcracker syndrome sciencedirect. While traditionally treated with open surgery, the last several years have seen increased utilization of an endovascular approach through stenting of the lrv. Robotassisted laparoscopic extravascular stent for. Cgsurg106 venous angioplasty with or without stent. Stent grafts are also used to treat stenoses in vascular grafts and fistulas used for hemodialysis. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures.
Another clinical study has shown that nutcracker syndrome is a frequent finding in varicoceleaffected patients and possibly, nutcracker syndrome should be routinely excluded as a possible cause of varicocele and pelvic congestion. Considering the process neednt to transplant lrv or to insert entovascular stent, extravascular stenting is a feasible, safe option for the nutcracker syndrome. The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement. Endovascular treatment of nutcracker syndrome journal of. The patient was treated with stenting of her left renal vein. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration.
Nutcracker syndrome servier phlebolymphologyservier. A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months. Endovascular stenting for treatment of nutcracker syndrome. 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 nutcracker syndrome genetic and rare diseases.
Intravenous stent placement for the treatment of nutcracker syndrome. The endovascular treatment of nutcracker syndrome is currently considered by some to be the preferred treatment option in this pathologic process despite its risks. Entrapment of the left renal vein lrv between the abdominal aorta and superior mesenteric artery sma causing the classic clinical triad of hematuria, varicocele, and left abdominal or flank pain was first described in 1950. During esophagectomy, your surgeon removes the portion of your esophagus that contains the tumor, along with a portion of the upper part of your stomach, and nearby lymph nodes. Endovascular stenting randwick angioplasty sydney nsw. 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. Venous stents may lead to fibromuscular hyperplasia, embolization and proximal migration which may be fatal. 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 is most commonly used for symptomatic relief in those with dysphagia secondary to malignancy. Management options can range from conservative to surgical, with the endovascular approach becoming an increasingly common one. At the threeweek followup, she reported near resolution of nausea and abdominal pain. In women, the hypertension in the left gonadal vein can also cause increased pain during menses.
Results are encouraging at followup periods beyond 2 years. 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 renal venous hypertension caused by ncs can be severe enough to lead to formation of an aneurysm and development of hydronephrosis. Nutcracker syndrome ncs may present with just leftsided flank pain. Common signs and symptoms when the condition shows no symptoms, its usually known. The nutcracker syndrome results most commonly from the compression of the left renal vein between the abdominal aorta and superior mesenteric artery, although other variants exist. 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. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the lrv. We report a case of migration of a laparoscopically. Esophageal stenting an esophageal stent procedure is a relatively safe and effective method of palliation improvement of symptoms and treatment of esophageal disease.
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. Surgical and endovascular interventions for nutcracker syndrome. More recently, endovascular stenting has been described in several small series but have reported stent fracture, thrombosis, and migration. 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. Chest pain experienced by most patients with nutcracker esophagus, chest pain may feel the same as the pain produced by a heart attack. This is an example of what your stent may look like. Nutcracker syndrome ncs is a rare pathology manifested by pain or hematuria in males and females alike. Management options include endovascular or laparoscopic extravascular stent placement, which is very appealing given the minimally invasive nature of these procedures. Optimal duration of anticoagulation after stenting for svcs due to catheter relatedthrombosis itsnot well defined.
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 result in severe symptoms requiring operative intervention. Nutcracker syndrome is a rare diagnosis and may manifest in unusual ways. As more cases are reported, endovascular repair is becoming an alternative treatment for nutcracker syndrome. Esophageal stents are available in different types and in lengths ranging from 60 to 150 millimeters 2. Nutcracker syndrome results from compression of the left renal vein lrv between the aorta and the superior mesenteric artery sma. Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. A stent graft or covered stent is type of vascular stent with a fabric coating that creates a contained tube but is expandable like a bare metal stent. Maythurner syndrome affects the iliac or femoral veins, vascular structures containing internal and external veins that have several connections in the pelvic and abdominal region. Nutcracker syndrome ncs is caused by compression of left renal vein lrv, usually between the aorta and the superior mesenteric artery sma.