Treatment of Nutcracker Syndrome with Open and Endovascular Interventions.

Abstract

Nutcracker syndrome (NS) is rare cause of hematuria, left flank pain, and renal venous hypertension due to external compression of the left renal vein (LRV). We reviewed our experience to better define the role of open surgery (OS) and endovascular interventions (ENDO). Retrospective review of all patients treated for NS with OS and ENDO at our institution between January 1994 and September 2013. Primary outcomes were operative morbidity and mortality. Secondary outcomes included primary and secondary patency, freedom from reintervention, and resolution of symptoms. Thirty-four patients (27 females) with a mean age of 27.5 years (range, 14-62 years) were treated. The most frequent symptoms were flank pain (94%) and hematuria (71%). NS was confirmed with duplex ultrasound with measurement of LRV diameters and flow velocities (80%), computerized tomography or magnetic resonance venography (88%), and contrast venography with measurement of pressure gradients (68%). Initial treatment was OS in 33 patients and ENDO in one. Distal transposition of the LRV was performed in 24 patients. Adjuncts to optimize renal venous outflow included saphenous vein (SV) cuff in six patients, SV patch in four, and both SV cuff and patch in one patient. Five patients had SV patch alone and two had transposition of the left gonadal vein (LGV) into the inferior vena cava (IVC). Two patients had anterior reimplantation of retroaortic LRV. There were no major early complications, renal failure, or mortality. Three patients underwent early reinterventions including stenting (2) and open revision (1). All LRVs were patent at discharge. Follow-up was 36.3 ± 50.3 months. Late reinterventions were performed in nine patients due to LRV stenosis (7), LRV occlusion (1), and recurrence of varicocele (1). Three had LRV angioplasty alone, three LRV angioplasty with stenting, two had open revision, and one had coiling of LGV. Six patients underwent additional endovascular reinterventions; three due to LRV stenosis, two due to LRV in-stent restenosis, and one due to LGV stenosis. All had angioplasty with stenting. One patient had stent migration into the inferior vena cava that required emergent endovascular stent removal. Primary and secondary patencies at 24 months were 97% and 100%, respectively. Freedom from reintervention at 12 and 24 months were 73% and 60% respectively. Resolution of symptoms occurred in 26 patients (77%). OS, mostly LRV transposition, remains a safe and effective treatment for patients with NS, and ENDO may be useful to treat restenosis or recurrent symptoms. However, the safety and durability of currently available stents need to be established. Further improvement in patient selection and treatment options in this challenging, young patient population are warranted.