Endovascular Treatment of Nutcracker Syndrome

Abstract

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. Both open and endovascular approaches to the treatment of this condition have been described in the literature; however, data on patient outcomes is sparse. Herein we report three patients who presented with nutcracker syndrome, including one patient with posterior nutcracker syndrome due to a retroaortic LRV who underwent successful endovascular treatment with renal vein stenting. Three women (aged 28 to 43 years) presented with symptoms and imaging studies consistent with nutcracker syndrome. Symptoms included pelvic and flank pain in all three patients and episodes of hematuria in one. Imaging studies demonstrated compression of the LRV between the superior mesenteric artery and aorta in two of the patients. The third patient was noted to have a retroaortic LRV with findings of posterior nutcracker syndrome. All three patients underwent venography and LRV stenting (stents included a 12- × 14-mm self-expanding nitinol stent, a 14- × 60-mm Wallstent, and a 16- × 40-mm Wallstent). Intravascular ultrasound was used in two of the three cases. All patients were prescribed on clopidogrel postoperatively. The derotation of follow-up ranged from 1 month to 2 years. At follow-up, all three patients reported significant symptomatic improvement or resolution of symptoms, and duplex ultrasonography demonstrated stent patency in all. Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Results are encouraging at follow-up periods up to 2 years. Additionally, this method can be successfully used in the treatment of posterior nutcracker syndrome.