Background: The "nutcracker" syndrome is most commonly caused by arterial compression of the left renal vein between the superior mesenteric artery and the aorta. As a consequence venous blood pressure increases within the renal pelvis, ureter and gonadal veins. This compression syndrome may be treated by endovascular stent implantation into the left renal vein. Case report: A 20 year old female patient was referred to us, suffering from pain in her left side, gross proteinuria and the suspicion of "nutcracker" syndrome. Symptoms were present for the last 3 years. Angio MRI was performed and confirmed compression of the left renal vein between the aorta and the superior mesenteric artery. The patient was qualified for endovascular treatment. A self expandable metallic stent, diameter 16 x 40 mm was implanted into the left renal vein. Control venography confirmed good placement of the stent and a good immediate hemodynamic effect of the procedure. The patient remains symptom free in a 14 month follow up period. Conclusions: At present, endovascular stenting seems to be the method of choice for the treatment of the nutcracker syndrome

Januszewicz, Magdalena

Nawrot, Ireneusz

Rowinski, Olgierd

Szmidt, Jacek

Wojtaszek, Mikołaj

Polish Journal of Radiology

English

Jagiellonian Univeristy Repository

82C A S E  R E P O R TEndovascular treatment of nutcracker syndrome – a case report Olgierd Rowinski1, Magdalena Januszewicz1, Mikołaj Wojtaszek1, Ireneusz Nawrot2, Jacek Szmidt21 2nd Department of Clinical Radiology, Medical University of Warsaw, Poland2 Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, PolandAuthor’s address: Mikołaj Wojtaszek, 2nd Department of Clinical Radiology, Medical University of Warsaw, e-mail: nwojtaszek@interia.pl Summary Background:  The „nutcracker" syndrome is most commonly caused by arterial compression of the left renal vein between the superior mesenteric artery and the aorta. As a consequence venous blood pressure increases within the renal pelvis, ureter and gonadal veins.   This compression syndrome may be treated by endovascular stent implantation into the left renal vein.  Case report:  A 20 year old female patient was referred to us, suffering from pain in her left side, gross proteinuria and the suspicion of “nutcracker” syndrome. Symptoms were present for the last 3 years. Angio MRI was performed and confirmed compression of the left renal vein between the aorta and the superior mesenteric artery. The patient was qualified for endovascular treatment. A self expandable metallic stent, diameter 16 x 40 mm was implanted into the left renal vein. Control venography confirmed good placement of the stent and a good immediate hemodynamic effect of the procedure. The patient remains symptom free in a 14 month follow up period.  Conclusions:  At present, endovascular stenting seems to be the method of choice for the treatment of the nutcracker syndrome.  Key words:  nutcracker syndrome • renal vein compression • vein stenting • venous stents PDF fi le: http://www.polradiol.com/fulltxt.php?ICID=510549Otrzymano: 2007.03.20Zaakceptowano: 2007.09.30Sygnatura: © Pol J Radiol, 2007; 72(4): 82-85BackgroundNutcracker syndrome is usually a result of the left renal vein compression between the superior mesenteric artery and the aorta. It may lead to distension of the venous sys-tem in the renal pelvis, calyces and gonads. The syndrome is manifested by pains in the left lumbar region and the abdomen. Hematuria, proteinuria, varicocele in men and dysmenorrhea in women may also occur [1, 2].It is not easy to diagnose nutcracker syndrome. Patients with the aforementioned nonspecific symptoms are usually consulted and diagnosed for a long time. Establishing cor-rect diagnosis is possible on the basis of imaging modalities, such as Doppler sonography and angio-CT [3]. One of the methods of treatment of nutcracker syndrome (apart from more commonly used surgical methods) is endo-vascular stent implantation into the left renal vein. Such a procedure was first performed by Neste in 1996 and ended with success [4]. In the paper we present our experience in endovascu-lar treatment of a 20-year-old female with symptomatic hematuria and proteinuria, diagnosed with nutcracker syn-drome.Case reportA 20-year-old female patient was referred to the Department of General, Vascular and Transplant Surgery 83© Pol J Radiol, 2007; 72(4): 82-85 Endovascular treatment of nutcracker syndrome – a case report of the Medical University of Warsaw because of persistent isolated proteinuria, pain in the left flank and suspicion of nutcracker syndrome. The symptoms of moderate severity had persisted for 3 years. Physical examination revealed no abnormalities. Blood pressure was within normal limits recommended by the WHO. Laboratory tests revealed pro-teinuria of ca. 0.45 g/day. Positive results of orthostatic test (significant difference in proteinuria between day and night – 1.07g/12h vs. 0.07g/12h ) indicated the presence of symp-tomatic nutcracker syndrome.Imaging modalities were applied to confirm the diagnosis. USG visualized a stenosis of the left renal vein to 2.1 mm, located above the aorta (Fig. 1). Angio-MR confirmed unequivocally a significant stenosis of the left renal vein at the site where it passed between the aorta and the  superior mesenteric artery. Contrast enhancement of both kidneys was normal. Renal vein stenosis was also confirmed by angio-CT, which included preliminary measurements of the left renal artery (Fig. 2). The patient was qualified for renal vein angioplasty with an expandable vascular stent. After venography performed with the use of a calibrated cathe-ter, which confirmed left renal vein stenosis over the aorta, from the approach through the right femoral vein, a vascular stent of 16 x 40 mm dimensions (Wallstent, Boston Scientific Corp.) was placed in the left renal vein (Fig. 3 and 4). Control venography demonstrated a good early hemody-namic effect of the procedure. The patient was immobi-lized for 24 hours postoperatively, with Plavix 1 x 75 mg for 30 days and acetylsalicylic acid 1 x 150 mg chronically instituted. Control Doppler sonography performed 3 days after the procedure demonstrated that the stent had not  expanded to its full diameter yet in the peripheral segment Figure 2.  Angio-CT of the renal arteries and veins – 16-row CT. A. The axial layer at the renal venous level – compression of the left renal vein visible. B. Multiplanar reconstruction – cross-section of the left renal vein above the stenosis site. C. Multiplanar reconstruction – cross-section of the left renal vein at the stenosis site (SMA – superior mesenteric artery, A – aorta, RV – renal vein). D. Reconstruction – measurements of the degree of stenosis of the left renal vein.Figure 1.  Diagnostic Doppler sonography. Left renal vein stenosis between the aorta and the mesenteric artery accompanied by increased renal venous flow velocity beyond the obstruction site.ABCD84© Pol J Radiol, 2007; 72(4): 82-85Case Reportof the renal vein, but the venous outflow of blood from the kidney, as well as inferior vena caval flow, was unobstruct-ed. There was no renal vein distension in the vicinity of the renal hilus, which had been observed previously (Fig. 5). The patient was discharged from the hospital 4 days after the procedure without any abnormalities in the basic exam-inations and urinalysis. She has remained asymptomatic in 14-month follow-up. Urinalysis results show no abnormali-ties, without any signs of proteinuria or hematuria.DiscussionNutcracker syndrome can be diagnosed only after exclu-sion of all other known causes of hematuria and proteinuria. Examinations enabling the diagnosis are based on many diag-nostic methods, among which Doppler sonography and angio-MR options are of particular value. However, the diagnosis can be established unequivocally only by elective venography of the left renal vein and the inferior vena cava [3]. Nutcracker syndrome may occur in two variants, anterior nutcracker syndrome and posterior nutcracker syndrome. Anterior nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery and the aorta, whereas the posterior syndrome involves hypertension in the left renal vein situated behind the aorta, due to vein compression by the aorta and the spinal column [5].Various methods of treatment of this syndrome have been proposed to date. In case of disorders manifested only by sporadic left flank pains and microscopic hematuria, the method of choice is long-term observation and close nephrological surveillance [6]. On the other hand, severe and persistent painful symptoms, as well as marked hema-turia, provide indications for surgical or endovascular intervention. The intervention methods include left kidney autotransplantation, new venous anastomosis of the left kidney to the inferior vena cava, and endovascular stenting of the left renal vein [7, 8].According to some authors, autotransplantation of the kid-ney is the method of choice in treatment of anterior nut-cracker syndrome [5, 9]. On the other hand, endovascular treatment gives good results in the management of venous compression syn-dromes such as May-Thurner syndrome (compression of the left iliac vein by the common iliac artery). For this rea-son, Neste performed in 1996 the first procedure of stent Figure 4.  Venography – condition after expandable stent (WALLSTENT) implantation into the left renal vein. Free venous drainage to VCI, without collateral flow.Figure 3.  Venography of the left renal vein using a calibrated catheter – narrowing above the drainage site to inferior vena cava visible, collateral flow in the paraspinal plexuses.85© Pol J Radiol, 2007; 72(4): 82-85 Endovascular treatment of nutcracker syndrome – a case report  placement in the left renal vein because of nutcracker syn-drome [4]. In contrast to other surgical treatment methods, endovascular treatment allows to avoid extensive abdomi-nal surgery and associated complications. The implanted stent has mesh structure and therefore undergoes rapid endothelization after placement, which reduces the risk of thromboembolism.Ensuring free blood outflow without pressure gradient also prevents distant thromboembolic complications. Although the observations concerning distant results of renal vein stenting applied as the treatment of nutcracker syndrome have been scarce in the available literature, the observa-tions of distant stent patency in other venous systems (hepatic veins and the portal system in case of TIPPS anas-tomoses, as well as in venous pathologies of liver grafts) indicate that it is possible to use this method also in hepatic vein obstruction syndrome [10]. In conclusion, endovascu-lar treatment of nutcracker syndrome seems currently to be the method of choice. 1. deSchepper A: „Nutcracker” phenomenon of the renal vein and venous pathology of the left kidney. J Belge Radiol 1972; 55: 507–511.  2. Challenger RJ, Dougherty WS, Flisak ME et al.: Left renal vein hypertension as a cause of persistent gross hematuria. Urology 1996; 48(3): 468–72. 3. Ahmed K, Sampath R, Khan MS: Current trends in the diagnosis and management of renal nutcracker syndrome: a review. Eur J Vasc Endovasc Surg. 2006; 31(4): 410–6. 4. Neste MG, Narasimham DL, Belcher KK: Endovascular stent placement as a treatment for renal venous hypertension. J Vasc Interv Radiol. 1996; 7(6): 859–61. 5. Ali-El-Dein B, Osman Y, Shehab El-Din AB et al.: Anterior and posterior nutcracker syndrome: a report on 11 cases. Transplant Proc. 2003; 35(2): 851–3. 6. Tanaka H, Waga S: Spontaneous remission of persistent severe hematuria in an adolescent with nutcracker syndrome: seven years' observation. Clin Exp Nephrol. 2004; 8(1): 68–70. 7. Hartung O, Grisoli D, Boufi M et al.: Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: lessons learned from the first five cases. J Vasc Surg. 2005; 42(2): 275–80. 8. Segawa N, Azuma H, Iwamoto Y et al.: Expandable metallic stent placement for nutcracker phenomenon. Urology. 1999; 53(3): 631–3. 9. Shokeir AA, el-Diasty TA, Ghoneim MA: The nutcracker syndrome: new methods of diagnosis and treatment. Br J Urol. 1994; 74(2): 139–43. 10. Lorenz JM, Van Ha T, Funaki B et al.: Percutaneous treatment of venous outflow obstruction in pediatric liver transplants. J Vasc Interv Radiol. 2006; 17(11 Pt 1): 1753–61.References:Figure 5.  Control postoperative USG – an expanded stent in the left renal vein. In Doppler sonography water outflow through the left renal vein visible.

Endovascular treatment of nutcracker syndrome : a case report

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Endovascular treatment of nutcracker syndrome : a case report

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