Treatment Of Nutcracker Syndrome Research Articles

Use of tubularized bovine pericardium in left renal vein transposition for nutcracker syndrome

Nutcracker syndrome is an extrinsic compression of the left renal vein by the superior mesenteric artery anteriorly and aorta posteriorly, resulting in hallmark manifestations of hematuria, proteinuria, and flank and/or pelvic pain. This report illustrates the case of a patient with a history of left flank pain and intermittent gross hematuria every 2 weeks. The patient denies any pelvic pain or gastrointestinal or lower extremity symptoms. Urinalysis revealed red blood cells, but no infection was noted. The cystoscopy findings were normal. Computed tomography urography showed left renal vein and duodenal compression between the aorta and superior mesenteric artery with a narrow aortic–superior mesenteric artery angle. The patient underwent left renal vein transposition to the distal inferior vena cava via a transabdominal approach. The left renal vein was transected at the inferior vena cava; however, the length was too short to create a tension-free anastomosis. Thus, a bovine pericardium sheet was tubularized and used as an interposition graft. The patient recovered well and is symptom-free. Left renal vein transposition is a well-described surgical technique in the treatment of nutcracker syndrome. The use of a vein or prosthetic graft has been described. This case demonstrates the use of an alternate conduit for reconstruction.

Endovascular approach for nutcracker syndrome using an arterial stent: The first Latin-American experience

ObjectiveThe exact prevalence of nutcracker syndrome (NCS) is unknown, due to the very low incidence of this disease plus the absence of definitive diagnostic criteria. Some authors have reported a higher prevalence of this condition in women, however published and available information is limited. Due to symptoms and consequences that can cause, it is important to suspect it and diagnose it. The aim of this study was to report the outcomes of the first Latin-American experience in the treatment of NCS using an endovascular approach with a left renal vein (LRV) balloon and arterial stent angioplasty. MethodsThe study design was a retrospective cohort analysis of 11 patients who underwent endovascular approach with LRV balloon and arterial stent angioplasty for the treatment of NCS between January 2019 and April 2022 in Bogota, Colombia. ResultsDuring January 2019 to April 2022, 553 patients were treated for congestive pelvic syndrome. Only 11 patients have clinical criteria (hematuria, varicose pelvic veins, and left flank pain), imaging diagnostic criteria (abdominal veins Doppler ultrasound or abdominal computed tomography with superior mesentery artery – abdominal aorta angle <39°) and an average of LRV – inferior vena cava pressure measurement comparison difference of 6mmHg for NCS. The 100% were female patients. All the patients were under 65 years and underwent endovascular approach (EVA) with LRV balloon and arterial stent angioplasty. The 100% of patients presented resolution of the collateral vein circulation in the final control phlebo-cavography. The average age was 46.5 years old. Ten patients had an anterior type of NCS and only 1 had a posterior type of NCS. None of the patients had NCS due to secondary causes such as pancreatic head tumors. ConclusionsThis study shows that the endovascular approach with LRV balloon and arterial stent angioplasty is a safe and cost-effective treatment for NCS with low incidence of complications and no need of postoperative reintervention in short and middle term follow-up.

Nutcracker Syndrome: Challenges in Diagnosis and Surgical Treatment

Nutcracker syndrome (NCS) is an uncommon syndrome that presents with signs and symptoms caused by compression of the left renal vein (LRV), whereas 'nutcracker phenomenon' is solely used to refer to the anatomical configuration without clinical symptoms. Treatment for NCS may include nonoperative management, open surgical intervention, and in some instances endovascular stenting. We present a single-center retrospective case series of patients who presented with NCS managed with open surgical interventions. A single-center, retrospective review of patients managed from 2010-2021. We diagnosed NCS via a thorough clinical examination and additional cross-sectional imaging studies including magnetic resonance venography and/or computed tomography venography. For further confirmation of the diagnosis, duplex ultrasound was frequently combined with contrast venography. Thirty eight patients were included in our study from 2010-2021. Twenty one (55.3%) patients presented with symptoms including flank pain, abdominal pain, hematuria, and fatigue. The remaining 17 (44.7%) patients had nutcracker phenomenon. Within the group of patients diagnosed with NCS, 11 patients underwent LRV transposition. Symptoms related to NCS improved in 10 patients. Hematuria in 1 patient did not improve. Transposition of the LRV is an effective treatment for NCS. Nonoperative management is an option for those patients experiencing less severe or nonspecific clinical symptoms.

Left Renal Vein Decompression and Left Renal Artery Denervation Is a Novel Treatment for Nutcracker Syndrome and Shows Improvement in Quality of Life and Chronic Pain

Left Renal Vein Decompression and Left Renal Artery Denervation Is a Novel Treatment for Nutcracker Syndrome and Shows Improvement in Quality of Life and Chronic Pain

Spiral saphenous vein graft for left renal vein reconstruction after endovascular failure in the treatment of nutcracker syndrome.

Nutcracker syndrome (NS) is caused by compression of the left renal vein (LRV) between the aorta and superior mesenteric artery. Symptoms include hematuria, flank pain, and chronic fatigue.1 A 15-year-old female was consulted for definitive management of NS. Two years ago, she started experiencing fatigue, headaches, nausea, and flank pain. Workup revealed NS, and she underwent endovascular LRV stenting at another institution, achieving complete symptoms resolution. Three months later, symptoms recurred, and she required two reinterventions, elsewhere, with venography and balloon angioplasty due to stent thrombosis.

Bovine Pericardial Tube as a Conduit for Left Renal Vein Transposition in Treatment of Nutcracker Syndrome

Abstract Nutcracker syndrome (NCS) is caused by compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery. This results in left renal venous hypertension and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein, also called renal vein entrapment syndrome. Its treatment includes open surgical technique as well as minimally invasive technique, namely laparoscopic and endovascular techniques. Here, we report the case of a young male diagnosed with NCS treated with LRV transposition using bovine pericardium as conduit interposing between inferior vena cava and LRV.

Laparoscopic placement of left renal vein extravascular stenting in treatment of nutcracker syndrome: Techniques and long-term outcomes.

We aimed to assess the feasibility and efficacy of laparoscopic extravascular stent in treatment of nutcracker syndrome by transperitoneal or retroperitoneal approach. Seventy-six patients with nutcracker syndrome were retrospectively enrolled from a tertiary referral center, and underwent transperitoneal (63 patients) or retroperitoneal (13 patients) laparoscopic extravascular stent from March 2011 to December 2020. Surgical parameters, complications, imaging and clinical outcomes were collected and analyzed. All procedures were successfully carried out without open conversion. The median operation time, estimated blood loss, and postoperative hospital day were 120 (interquartile range [IQR]: 90-144) min, 20 (IQR: 10-30) ml, and 7 (IQR: 6-9) days. At a median follow-up of 52 (range: 9-127) months, 60 (79%) patients had complete symptom resolution, 14 (18%) patients had significant symptom improvement, and 2 (3%) patients reported no symptom improvement. Ninety-four percent (50/53) of hematuria, 91% (30/33) of proteinuria, and 89% (25/28) of flank/abdominal pain resolved after extravascular LRV stenting. No significant differences were detected in surgery parameters and recovery rates of clinical symptoms between two approaches (each p > 0.05). However, patients with transperitoneal approach need longer to achieve complete recovery compared with retroperitoneal approach (8.7 vs. 1.5 months, p = 0.016). Laparoscopic extravascular stent performed either transperitoneally or retroperitoneally is a feasible and effective option in treatment of nutcracker syndrome. Retroperitoneal laparoscopic extravascular stent required shorter time to achieve complete recovery, which should be considered whenever possible in surgical decision-making.

Hybrid Management for Anterior Nutcracker Syndrome: Left Renal Vein Stenting with Laparoscopic Stent Exofixation

IntroductionLeft renal vein stenting (LRVS) for the treatment of anterior nutcracker syndrome (NCS) has been associated with a significant risk of stent migration into the inferior vena cava or right ventricle.Surgical techniqueA hybrid technique is reported for the treatment of NCS to prevent stent migration. The first part of the procedure consists of LRVS at the level of the aortomesenteric compression. The second part consists of laparoscopic stent exofixation through a transperitoneal direct approach. The left renal vein is exposed in order to visualise the stent meshes through the venous wall. Stent exofixation in performed with a simple transfixing polypropylene stitch, reinforced with a Teflon pledget.DiscussionThe hybrid treatment of anterior NCS combining laparoscopic stent exofixation with left renal vein stenting is a simple and low morbidity technique. Further follow up data are needed to evaluate its potential benefit in reducing the risk of left renal vein stent migration.

V05-02 ROBOTIC ASSISTED LAPAROSCOPIC PLACEMENT OF EXTRAVASCULAR STENT FOR NUTCRACKER SYNDROME

You have accessJournal of UrologyUpper-Tract Reconstruction (V05)1 Apr 2020V05-02 ROBOTIC ASSISTED LAPAROSCOPIC PLACEMENT OF EXTRAVASCULAR STENT FOR NUTCRACKER SYNDROME Buddima Ranasinghe*, Sohrab Arora, Amit Patel, Judith Lin, and Craig Rogers Buddima Ranasinghe*Buddima Ranasinghe* More articles by this author , Sohrab AroraSohrab Arora More articles by this author , Amit PatelAmit Patel More articles by this author , Judith LinJudith Lin More articles by this author , and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000874.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal nutcracker syndrome (NCS) is a venous entrapment caused by compression of the left renal vein (LRV) between the aorta and superior mesenteric artery (SMA). Surgical options for treatment of NCS include LRV transposition, gonadal vein transposition, renocaval bypass, and renal autotransplantation. Endovascular left renal vein stenting may lead to stent migration and fracture. Thus, we present an alternative, unique, minimally invasive treatment option. METHODS: A 20-year-old man presents with intermittent, debilitating left flank pain for 6 months. He developed an episode of gross hematuria without hypertension, oliguria, dysuria, or fever. CT venogram showed compression of the LRV between the aorta and SMA with an acute, aortomesenteric angle of 25 degrees. Venogram with pressure measurement showed a gradient of 3 mmHg across the compression. Intravascular ultrasound showed 94.4% luminal compression of the LRV. After discussion of all surgical and endovascular options, the patient decided to proceed with robotic-assisted laparoscopic resection of fibrous ring and placement of extravascular graft. The patient was positioned with right lateral decubitus. Six ports were used via transperitoneal technique. After the retroperitoneal space was incised along the inner margin of the descending colon, the LRV was mobilized. The pancreas and the left adrenal vein was identified. Tissue surrounding the left gonadal vein was excised. The fibrous bundles were excised around the outflow end between the aorta and SMA to release the renal vein compression. An externally reinforced, expanded PTFE, 16 mm in diameter, was introduced and bound to the surface of the renal vein along the long axis to prevent blood vessel compression. The PTFE cuff was sutured and tacked to the surface of the aorta and retroperitoneal tissues. SMA was lowered and stabilized over the graft. RESULTS: The operative time was 3 hours. Estimated blood loss of 10 ml. Length of stay was 1 day with no complications. At 4-week postop visit, he was doing well with full resolution of the left flank pain. Post-op intravascular ultrasound showed patent left renal vein with no evidence of elevated flow velocities. Renal vein cuff visualized at SMA with PSV of 67 cm/sec. Left gonadal vein patent with retrograde flow noted. CONCLUSIONS: Robotic-assisted laparoscopic resection of a fibrous ring and placement of an extravascular cuff around the left renal vein is an effective, minimally invasive approach for treatment of nutcracker syndrome with no warm ischemic injury and no venous anastomosis. Magnification and stability of the dual-lens robotic camera offer excellent visibility and substantially lower blood loss compared to open surgery. Source of Funding: NONE © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e470-e470 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Buddima Ranasinghe* More articles by this author Sohrab Arora More articles by this author Amit Patel More articles by this author Judith Lin More articles by this author Craig Rogers More articles by this author Expand All Advertisement PDF downloadLoading ...

A minimally invasive alternative for the treatment of nutcracker syndrome using individualized three-dimensional printed extravascular titanium stents.

BackgroundThis study was designed to evaluate the clinical and radiographic outcomes of patients with nutcracker syndrome (NCS) who were treated with three-dimensional printing (3DP) extravascular titanium stents (EVTSs). The 3DP EVTS was expected to release the hypertension of the left renal vein (LRV) produced by its compression between the superior mesenteric artery (SMA) and the aorta without causing any complications.MethodThe pre-operative kidney model of each patient was printed out to enable surgical planning. After that, the EVTS was designed based on the LRV's primitive physiologic structure using computer-aided design software, and each stent was printed out with a precision setting of 20 μm. Seventeen patients who had been suffering from NCS underwent laparoscopic 3DP EVTS placement. The surgical procedure was designed for the placement of EVTS, taking great care in positioning and fixing the stent. Surgical data, which included patient demographic characteristics as well as pre- and post-operative test results, were collected and analyzed.ResultsThe mean duration of surgery was 75 ± 9 min, and the mean blood loss was 20 ± 5 mL. Computed tomography examinations revealed that the pre- and post-operative angle between the SMA and the aorta ranged from 18.7° ± 4.3° to 48.0° ± 8.8° (P < 0.05); in patients with left varicocele, the mean diameter of the left spermatic vein ranged from 3.7 ± 0.5 to 1.3 ± 0.2 mm (P < 0.05). Moreover, Doppler ultrasound examinations showed that the peak velocity of blood flow at the hilar area ranged from 12.4 ± 3.3 to 18.5 ± 3.4 cm/s (P < 0.05). No side effects were observed in the 24 to 42 months following surgery.ConclusionThe findings after 2 years of follow-up suggest that the 3DP EVTS is a safe and effective minimally invasive alternative for the treatment of NCS.

Outcomes of Left Renal Vein Stenting in Patients with Nutcracker Syndrome

Nutcracker syndrome (NCS) is a rare condition that can present with hematuria, flank pain, pelvic varicosities, or chronic pelvic congestion related to left renal vein (LRV) compression. Open surgery, specifically LRV transposition, has been the mainstay of treatment, but during the past few years, LRV stenting has emerged as a valid alternative without sufficient evidence to support it. This study aimed to assess outcomes of renal vein stenting in the treatment of NCS. A retrospective chart review of patients with NCS who underwent LRV stenting between 2010 and 2018 was performed. End points were perioperative adverse outcomes, symptom relief, and stent patency. Symptom resolution was classified as complete, partial, and none on the basis of the interpretation of medical records on clinical follow-up. Standard descriptive statistics and survival analysis were used. Seventeen patients (16 female; mean age, 35.8 ± 14.6 years; mean body mass index, 21.3 ± 4.1 kg/m2) diagnosed with NCS and treated with LRV stenting were identified. Five of these had a prior LRV transposition that had failed within a mean of 7.0 ± 4.9 months. Ten patients had coexisting pelvic congestion syndrome treated with gonadal vein embolization. The most frequent sign and symptom were hematuria (9/17 patients) and flank pain (14/17 patients), respectively. All patients received self-expanding stents (mean diameter, 12.7 ± 1.6 mm), the smaller ones typically placed in the previously transposed LRVs. No perioperative complications occurred. Eight patients were discharged on the same day; the remaining stayed longer for pain control (mean hospital stay, 1.0 ± 1.3 days). At an average follow-up of 33 ± 25 months, 13 (76.5%) patients had symptom relief (9 complete, 4 partial). Three of the four patients whose symptoms persisted had previous LRV transposition surgery. Five of nine patients who presented with hematuria had it resolved. Three patients underwent a reintervention. Two of these had successful balloon venoplasty for restenosis. The third patient had persistent debilitating pain despite a patent stent and eventually underwent renal auto transplantation with no symptom relief. Two-year primary and primary assisted patencies were 81.8% and 90%, respectively. No stent migration occurred. Endovascular treatment with renal vein stenting is safe and effective, providing good midterm patency rates and symptom relief. Minimally invasive approaches may have a potential role in the treatment of NCS. Larger series and longer follow-up are needed to better assess its comparative performance against LRV transposition.

Safety and efficacy of laparoscopic three-dimensional printed extravascular stent placement for nutcracker syndrome

Objective To assess the safety and effectiveness of laparoscopic implantation of three-dimensional (3D)-printed extravascular stent for treatment of nutcracker syndrome (NCS). Methods The clinical data of NCS in our hospital were prospectively collected from August 2015 to August 2016. Doppler ultrasound and CT examination were performed before the operation of all the patients who were in line with the diagnostic criteria of NCS. The 3D model of extravascular stents with especial device to prevent migration was designed and was made by 3D metal printer with titanium alloy. The left renal vein(LRV) was exposed completely up to the inferior vena cava, then the stent was placed around the compressed LRV. Results 10 patients were enrolled in the study, including 9 males and 1 females, age (21.5+ 4.6) years. Among these patients, there were 4 cases with severe hematuria, 1 case with proteinuria, 5 cases with left lumbago, and 5 cases with left severe varicocele. The preoperative doppler ultrasound examination showed the diameter of the the compressed LRV was (1.57±0.25)mm, and flow velocity was (164.40±55.27)cm/s; the diameter of the LRV at the renal hilum was (8.7±1.59)mm, and flow velocity was(10.70±2.21)cm/s. The average operation time was (75±11) min, and the average hospital stay after operation was 7 d. All symptoms were relieved at 3-7 d after operation. All patients were asymptomatic and all stents were stable after follow-up. At 12 months after surgery, the diameter of the LRV at the renal hilum was (8.23±1.90)mm on doppler ultrasound, and there was significant decrease (P<0.01); the flow velocity was (21.20±3.88)cm/s, and there was significant increase (P<0.01). Conclusions Laparoscopic three-dimensional printed extravascular stent placement is a safe, effective and minimally invasive technique for treatment of NCS. Key words: Nutcracker syndrome; 3D printing; Extravascular stent; Minimally invasive; Laparoscopy

A systematic review on management of nutcracker syndrome.

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. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the LRV. The paucity of data regarding the management of this uncommon disease process poses a challenge for adequate recommendations of the best treatment modality. Herein, we aim to present a systematic review for the management of NS. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards to systematically search the electronic databases of MEDLINE from October 1982 to July 2017 for articles about the management of NS. Included were studies in English, Spanish, and German in all age groups. The literature search provided 249 references. After abstract and full review screening for inclusion, 17 references were analyzed. Eight (47%) described the open surgical approach. The LRV transposition was the most commonly reported technique, followed by renal autotransplantation. Seven (41.11%) described the endovascular technique of stent implantation, and two (11.7%) described the minimally invasive laparoscopic extravascular stent implantation. NS is a rare entity. Multiple techniques have been developed for the treatment of this condition. However, the rarity of this syndrome, the paucity of data, and the short-term follow-up of the existing evidence are the disadvantages that prevent recommendations for the best treatment strategy. Up to now, open surgical intervention, specifically LRV transposition, has been considered by some experts the mainstay for treatment of NS. The endovascular approach is gaining strength as more evidence has become available. However, the long-term patency and durability of this approach remain to be elucidated. Therefore, careful selection of patients is necessary in recommending this technique.

Gonadal Vein Transposition in the Treatment of Nutcracker Syndrome

The favored approach in the management of nutcracker syndrome (NCS) has traditionally been renal vein transposition (RVT), with more recent efforts at endovascular therapies as well. Gonadal vein transposition (GVT) has been infrequently used and chiefly in special circumstances. GVT has the potential to reduce operative complexity and to improve safety of the left renal vein. In this study, we compare the safety and efficacy of GVT and RVT as the operative approach of choice in the treatment of NCS. Six patients who underwent open repair for NCS between January 2008 and March 2016 were identified from the medical record. Primary outcomes were symptom resolution and patency of the reconstruction, and secondary outcomes were the need for reintervention and occurrence of major morbidity. During the study period, four patients underwent repair of NCS by GVT; one patient required renal autotransplantation and one underwent RVT. The patients' mean age was 31 years, their mean body mass index was 24.9 kg/m2, and 83% were female. All presented with symptoms of flank pain. In addition, one-third had varicosities, and half had gross or microscopic hematuria. All patients had evidence of renal vein compression (one posterior, five anterior) and significant pelvic venous congestion on cross-sectional imaging. Average operative times and estimated blood loss for the non-GVT and GVT cohorts were 220 minutes and 108.5 minutes, respectively, and 125 mL and 450 mL, respectively. There were no major perioperative complications, including acute kidney injury, renal failure necessitating dialysis, prolonged ventilation, hemorrhage, or wound infection, among others. During an average follow-up of 572 days, all patients had either clinical (three) or radiographically proven (three) patency as well as complete (four) or partial (two) symptomatic relief, and no patient has required reintervention. In this series, GVT is as effective as RVT in reported series and offers the benefit of shorter operative times, lower blood loss, and avoidance of manipulation of the renal vein.

Treatment of nutcracker syndrome with open and endovascular interventions.

Nutcracker syndrome (NS) is a rare cause of hematuria, flank pain, and renal venous hypertension due to compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery. To evaluate outcomes of open surgery and endovascular interventions, we reviewed our experience. A retrospective review of clinical data of all patients treated at our institution with an intervention for NS between January 1, 1994, and February 28, 2014, was performed. Primary outcomes were morbidity and mortality. Secondary outcomes included late complications, patency, freedom from reintervention, and resolution of symptoms. Thirty-seven patients (30 female, seven male) with a mean age of 27 years (range, 14-62 years) were treated. The most frequent symptom was flank pain (97%); the most frequent sign was hematuria (68%). NS was diagnosed with duplex ultrasound scanning with measurement of LRV diameters and flow velocities (87%), with computed tomography or magnetic resonance venography (94%), and with contrast venography with measurement of pressure gradients (93%). Initial treatment was open surgery in 36 patients, endovascular in 1. Distal transposition of the LRV into the inferior vena cava (IVC) was performed in 31 patients. Adjunctive procedures to optimize venous outflow included great saphenous vein cuff in six patients, great saphenous vein patch in four, and both cuff and patch in four. Three patients had patch alone; two had transposition of the left gonadal vein into the IVC. Two patients had anterior reimplantation of retroaortic LRV into the IVC. There were no major early complications, renal failure, or mortality. Three patients underwent early reinterventions within 30 days (stent, two; open revision, one). All LRVs and left gonadal veins were patent at discharge. Follow-up was 36.8 ± 52.6 months (range, 1-216 months). Reinterventions after 30 days were performed in eight patients because of LRV stenosis (n = 7) or LRV occlusion (n = 1). One stent migrated into the IVC and required endovascular removal with repeated stenting. Six patients required stenting. Primary, primary assisted, and secondary patencies at 24 months were 74%, 97%, and 100%, respectively. Freedom from reintervention at 12 and 24 months was 76% and 68%, respectively. Resolution of symptoms occurred in 33 patients (87%). Open surgery, mostly LRV transposition, remains a safe and effective treatment of patients with NS. However, one of three patients after open repair required reintervention, most frequently LRV stenting. Open reconstruction should be tailored to the patient's anatomy, and placement of vein cuff or patch may reduce restenosis. Although renal vein stents improved patency, the safety and durability of currently available stents need to be established.

Retroperitoneal Laparoscopic Extravascular Stent Placement for Renal Nutcracker Syndrome: Initial Experience

Objective: To report our initial experience in treating renal nutcracker syndrome by retroperitoneal laparoscopic extravascular stenting. Patients and Methods: Two male patients, aged 13 and 16 years, were diagnosed with nutcracker syndrome and received retroperitoneal laparoscopic extravascular stent placement. The perioperative data were collected and evaluated. The follow-up was 10 and 18 months. Results: Both procedures were successful without obvious complications. Total operative time was 65 and 50 min, estimated blood loss was 110 and 70 ml, and postoperative hospital stay was 4 and 6 days. The symptom of gross hematuria ceased 3 and 6 days after surgery. Both patients had normal findings during follow-up. Conclusions: Treatment of nutcracker syndrome by retroperitoneal laparoscopic extravascular stent placement is a safe and feasible procedure, especially for youngsters in the period of physical development. Longer follow-up and further experience are needed to evaluate the efficacy of this procedure.

Treatment of Nutcracker Syndrome with Open and Endovascular Interventions.

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.

Treatment of nutcracker syndrome with spermatic vein ligation and iliac vein anastomosis: Case report of three cases

Three patients with nutcracker syndrome (NCS) were enrolled in the study. Their clinical symptoms mainly included proteinuria and serious varicocele. Color Doppler ultrasound and computed tomography showed that the patients had constricted abdominal aortas, reduced superior mesenteric artery angles, and thinned left renal veins. Patients then underwent left spermatic vein ligation and iliac vein anastomosis. They were checked three months after their operation, and results showed that their sperms were improved and their proteinuria disappeared. The color Doppler ultrasound showed new cycle pathways. NCS clinical manifestations are complicated, and need combination diagnosis of symptoms and auxiliary examination to determine surgical indications. Ligation of spermatic vein and vein anastomosis can be used to treat NCS.

Nutcracker syndrome due to left-sided inferior vena cava compression and treated with superior mesenteric artery transposition

Left renal vein hypertension secondary to left renal vein compression has been described as a cause of persistent hematuria in nutcracker syndrome. Malformation of the inferior vena cava (IVC), although rare and frequently asymptomatic, may also result in left renal vein hypertension, with resultant hematuria when it is severely compressed. We report a 20-year-old man with persistent hematuria due to compression of left-sided IVC. The patient was successfully treated by means of superior mesenteric artery (SMA) transposition and division of the fibrous bundle at the origin of the SMA. His postoperative course was uneventful. Compression of the left IVC is a unique form of nutcracker syndrome. SMA transposition, together with division of a fibrous bundle at the origin of the SMA if present, is a safe and effective surgical procedure for this special entity.

The nutcracker syndrome: an underrecognized cause of hematuria

Nutcracker syndrome (NCS) is an uncommon cause of hematuria. It refers to the compression of the left renal vein between the aorta and superior mesenteric artery. It can cause both microscopic and gross hematuria. Hematuria may be associated with left flank pain. The diagnosis of NCS is often delayed. Most patients may have symptoms for many years and non-diagnostic evaluations before accurate diagnosis can be established. It should be included in the differential diagnosis of unexplained hematuria. The diagnosis and treatment of nutcracker syndrome are discussed. NCS is a rare but treatable clinical condition. An inclusion of this entity in the differential diagnosis of patients with unknown cause of hematuria and flank pain can achieve efficient management of this condition.