scholarly journals TREATMENT OF AORTA MESENTERIC COMPRESSION: CURRENT PROBLEMS AND PROSPECTS

2021 ◽  
pp. 36-42
Author(s):  
I. R. Nesterenko
Keyword(s):  
Ct Angiography ◽  
Doppler Ultrasound ◽  
Renal Vein ◽  
Color Doppler ◽  
Left Renal Vein ◽  
Clinical Manifestations ◽  
Color Doppler Ultrasound ◽  
Nutcracker Syndrome ◽  
Pelvic Organs ◽  
Vein Stenosis

Left renal vein compression between the aorta and the superior mesenteric artery at an acute angle of the origin of the latter (“the nutcracker syndrome”) often leads to phlebohypertension in the left renal vein causing a combination of structural and functional changes in the kidneys and pelvic organs, different clinical manifestations such as left-sided varicocele, hematuria, pelvic venous congestion syndrome, the development of renal failure. The objective of the research: to determine indications for surgical and conservative treatment of aorta mesenteric compression. Materials and methods. The study included 210 patients (142 men and 68 women) with suspected “nutcracker syndrome” who were referred to vascular surgeons for a consultation by urologists and gynecologists during the period from 1999 to 2020, mainly from the western regions of Ukraine (about 11 million population). The age of the patients ranged from 12 to 52. All patients were interviewed for specific complaints: pain in the left lumbar region and left half of abdomen, inability to eat large amounts of food, hematuria, proteinuria, hemospermia, erectile dysfunction, left sided varicocele in men, and left sided pudendal varicosity and dysmenorrhea in women. All referred patients with suspected “nutcracker syndrome” underwent color Doppler ultrasound to determine the presence of pathological reflux in the left renal and gonadal veins by measuring peak systolic velocities in order to confirm or exclude that pathology. The patients with confirmed left renal vein stenosis underwent CT angiography. Results. According to color Doppler ultrasound, different degree of aorta mesenteric compression was confirmed in 138 (65.7%) patients (83 men and 55 women), critical left renal vein stenosis was observed in 35 of them. Two patients were diagnosed with the retroaortic left renal vein (“posterior nutcracker”). According to observations, clinical manifestations of AMC syndrome severe forms occurred in case of an increase in the diameter of the distal part of the LRV compared to its proximal segment by 3-6 times as well as in case of an increase in peak systolic velocity in the stenosed proximal segment by 6-14 times (by 8.7 times on average) compared to the left renal vein distal segment. Conclusions. Color Doppler ultrasound with determination of peak systolic velocities and diameters of the left renal and gonadal veins, pathological reflux in them must be the obligatory diagnostic stage in the patients with suspected AMC. The choice of treatment approach should be made taking into account clinical and laboratory indices, as well as the assessment of AMC severity according to instrumental data (ultrasound, CT angiography, MRA, etc.). The severity of pathomorphological changes in the pelvic organs and their consequences proves the need to eliminate phlebohypertension in the left renal and gonadal veins. LRV transposition proves its effectiveness in the remote postoperative period.

scholarly journals Polymorphism of Clinical Manifestations in Patients with “the Nutcracker Syndrome”

2021 ◽  
Vol 11 (8) ◽  
pp. 381-391
Author(s):  
Iryna Romanivna Nesterenko
Keyword(s):  
Doppler Ultrasound ◽  
Renal Vein ◽  
Color Doppler ◽  
Left Renal Vein ◽  
Clinical Manifestations ◽  
Diagnostic Algorithm ◽  
Color Doppler Ultrasound ◽  
Lumbar Region ◽  
Nutcracker Syndrome ◽  
Left Lumbar Region

Introduction. “The nutcracker syndrome”  occurs due to abnormal compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta. Clinical manifestations range from hematuria, proteinuria, pain in the left lumbar region, left sided varicocele in men, and left sided pudendal varicosity in women to the development of severe anemia and renal failure in some cases due to progressive phlebohypertension.Materials and methods. The study included 210 patientswith suspected “nutcracker syndrome” . The age of the patients ranged from 12 to 52. All patients were interviewed for specific complaints. All referred patients  underwent color Doppler ultrasound. The patients with confirmed left renal vein stenosis underwent CT angiography.Results of the researchAccording to color Doppler ultrasound, different degree of aorta mesenteric clamp (AMC) was confirmed in 138 (65.7%) patients, critical LRV stenosis was observed in 35 of them. The predominant complaints of the patients with AMC included pain in the left half of the abdomen and left lumbar region, left sided varicocele and left sided pudendal varicosity, hematuria.. More than half of the patients with AMC complained of dysmenorrhea, and one in four patients with AMC complained of erectile dysfunction.Conclusions. There is no consensus on the diagnostic algorithm for this pathology detection. There is a lack of evidence base (multicenter clinical randomized trials) regarding the clinical selectivity of treatment approaches. The pathology is rarely diagnosed due to a number of objective and subjective reasons, nonspecific symptoms, and therefore it deserves special attention in the study of pathogenesis, diagnosis and choice of treatment approach.

scholarly journals Nutcracker syndrome accompanied by hypertension: a case report and literature review

2021 ◽  
Vol 49 (1) ◽  
pp. 030006052098573
Author(s):  
Rui-feng Wang ◽  
Chun-ze Zhou ◽  
Yu-qin Fu ◽  
Wei-fu Lv
Keyword(s):  
Renal Vein ◽  
Clinical Symptoms ◽  
Color Doppler ◽  
Left Renal Vein ◽  
Plasma Renin ◽  
Color Doppler Ultrasound ◽  
Secondary Hypertension ◽  
Flank Pain ◽  
Nutcracker Syndrome ◽  
History Of

Nutcracker syndrome (NCS) refers to characteristic clinical symptoms that develop secondary to the nutcracker phenomenon (NCP), defined as compression of the left renal vein between the superior mesenteric artery and the aorta. A 22-year-old Chinese man presented with a 2-year history of hypertension and left flank pain after activity; his blood pressure fluctuated within 130–150/90–100 mmHg without treatment. He had microscopic hematuria (2+) and increased plasma renin activity. The findings of both color Doppler ultrasound and computed tomography angiography were consistent with a diagnosis of NCS. The patient had no history of familial hypertension or special medications. Secondary hypertension-related examinations showed no significant abnormalities. After placement of an endovascular stent in the left renal vein, normal blood flow resumed and the collateral circulation was reduced. Both the hypertension and flank pain were alleviated within 3 days after the intervention and did not reappear during the following 11 months. NCP/NCS accompanied by hypertension is very rare. The possibility of NCP/NCS should be considered when secondary hypertension cannot be explained by other factors. The mechanism by which hypertension is caused by NCP/NCS is rather complex and deserves further investigation.

scholarly journals Left Renal Vein Thrombus and Pulmonary Thromboembolism Caused by Nutcracker Syndrome: a Case Report

2021 ◽  
Author(s):  
Kanta Hori ◽  
Shota Yamamoto ◽  
Maki Kosukegawa ◽  
Noboru Yamashita ◽  
Yuichiro Shinno
Keyword(s):  
Case Report ◽  
Renal Vein ◽  
Pulmonary Thromboembolism ◽  
Case Reports ◽  
Left Renal Vein ◽  
Clinical Manifestations ◽  
Venous Hypertension ◽  
Nutcracker Syndrome ◽  
Case Presentation ◽  
Renal Venous Hypertension

Abstract Background: Nutcracker syndrome (NCS) refers to compression of the left renal vein (LRV) between the aorta and superior mesenteric artery (SMA), which results in renal venous hypertension and its resultant clinical manifestations. Left renal vein thrombus (LRVT) complicating NCS is relatively rare. To the best of our knowledge, there are only four case reports of LRVT complicating NCS. Furthermore, there are no reports of pulmonary thromboembolism (PTE) caused by NCS. Herein, we describe a rare case of NCS causing LRVT and PTE and its clinical management. Case Presentation: A 40-year-old man was admitted to our hospital with acute left flank pain. Computed tomography angiography (CTA) revealed compression of the LRV between the aorta and the SMA with an LRVT. Furthermore, CTA revealed bilateral PTE. Rivaroxaban was administered as an anticoagulant. Twenty days after initiation, CTA revealed complete resolution of PTE and LRVT, and repeat CTA at 3 and 6 months showed no recurrence. Conclusions: This case report demonstrates that NSC may be a possible cause of LRVT and PTE. We review the reported cases of NCS complicated by LRVT and discuss the imaging modalities for NCS.

scholarly journals Ultrasound Characteristics of the Nutcracker Syndrome

2018 ◽  
Vol 24 (2) ◽  
Author(s):  
Ihor Kobza ◽  
Irena Nesterenko ◽  
Volodymyr Nesterenko
Keyword(s):  
Blood Flow ◽  
Renal Vein ◽  
Doppler Ultrasonography ◽  
Color Doppler ◽  
Left Renal Vein ◽  
Peak Systolic Velocity ◽  
Gonadal Vein ◽  
Critical Stenosis ◽  
Vein Stenosis

The article presents the results of color Doppler ultrasonography of the left renal vein and gonadal vein with the determination of the peak systolic velocity of blood flow and abnormal blood reflux in patients with left-sided varicocele. The objective of the research was to compare preoperative ultrasound characteristics of the left renal vein, left gonadal vein, peak systolic velocity of blood flow and the presence of abnormal blood reflux, the formation of ultrasound criteria for the selection of patients for surgical correction of phlebohypertension. Results. Ultrasound signs of aorta mesenteric compression were absent in 24 (24.5%) patients; the signs of aorta mesenteric compression without critical left renal vein stenosis were observed in 64 (65.3%) patients; critical stenosis of the left renal vein was diagnosed in 10 (10.2 %) patients. The patients with critical stenosis of the left renal vein underwent left renal vein transposition. Conclusions. Ivanissevich surgery with prognostically low risk of relapse is recommended for the patients with left-sided varicocele without any signs of aorta mesenteric compression. Patients with the signs of aorta mesenteric compression require clear determination of the degree of left renal vein stenosis. We consider the transposition of the left renal vein to be indicated in case of critical stenosis when the correlation of the diameters of the distal and proximal segments of the left renal vein is ≥ 3 and the ratio of peak systolic velocities in the proximal and distal segments is ≥ 6. Thus, the diagnosis of phleborenohypertension in the patients with varicocele by means of color Doppler ultrasonography with the determination of blood flow velocity indicators in the left renal vein circulation and the determination of the critical stenosis of the left renal vein is decisive in choosing the surgical method of treatment. This provides an opportunity to evaluate the cause of varicocele occurrence and choose the optimal method of surgical treatment.  

scholarly journals Left renal vein entrapment syndrome: nutcracker syndrome!

2019 ◽  
Vol 12 (9) ◽  
pp. e230877 ◽  
Author(s):  
Louise Dunphy ◽  
Marta Penna ◽  
Emily Tam ◽  
Jihene EL-Kafsi
Keyword(s):  
Renal Vein ◽  
Left Renal Vein ◽  
Clinical Manifestations ◽  
Flank Pain ◽  
Vascular Compression ◽  
Nutcracker Syndrome ◽  
Venous Circulation ◽  
Lumbar Vein ◽  
Normal Gallbladder ◽  
Specific Symptoms

Nutcracker syndrome (NCS) is a rare vascular compression disorder that involves compression of the left renal vein most commonly between the aorta and the superior mesenteric artery (SMA), although variations exist. It is associated with the formation of the left renal vein from the aortic collar during the 6th–8th week of gestation and abnormal angulation of the SMA from the aorta. Collateralisation of venous circulation including mainly the left gonadal vein and the communicating lumbar vein are the most significant effects. It has a female predilection occurring in the third to fourth decade and it tends to be diagnosed earlier in men. Affected individuals may present with a myriad of symptoms such as haematuria, left flank pain and proteinuria. As patients often present with these non-specific symptoms to primary care, knowledge of NCS is essential. The diagnosis can be rendered with Doppler ultrasonography, retrograde venography, CT angiography, intravascular ultrasound and magnetic resonance angiography. The authors describe the case of a 39-year-old woman with a low body mass index (BMI) presenting with generalised abdominal and flank pain as well as chronic microcytic anaemia. Physical examination findings were suggestive of biliary or renal colic. Laboratory investigations confirmed her anaemia (haemoglobin 88 g/L, mean corpuscular volume (MCV) 72 fL), but were otherwise unremarkable. Urinalysis showed proteinuria and haematuria. However, ultrasonography was unremarkable with a normal gallbladder and no evidence of calculi. Her CT scan showed marked compression of the left renal vein between the aorta and the SMA (nutcracker phenomenon), with upstream left renal, left gonadal and left lumbar vein dilatation. She was managed conservatively. This paper provides an overview of the aetiology, embryology, clinical manifestations, imaging modalities and management of NCS.

scholarly journals Posterior nutcracker syndrome: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Cecilia Gozzo ◽  
Renato Farina ◽  
Pietro Valerio Foti ◽  
Francesco Aldo Iannace ◽  
Andrea Conti ◽  
...  
Keyword(s):  
Renal Failure ◽  
Doppler Ultrasound ◽  
Renal Vein ◽  
Left Renal Vein ◽  
Nutcracker Syndrome ◽  
First Line ◽  
Scrotal Pain ◽  
Chronic Hepatitis B Virus ◽  
Line Imaging ◽  
Posterior Nutcracker Syndrome

Abstract Background Posterior nutcracker syndrome is defined by the compression of the left renal vein between the abdominal aorta and a lumbar vertebral body. It can be clinically manifest with intermittent hematuria, gonadal or spermatic reflux resulting in varicocele. Ultrasound is the first-line imaging which require  more accurate study  with contrast-enhanced computed tomography. Management can be conservative in younger patients with mild hematuria due to the high spontaneous remission rate and invasive with open surgical and endovascular interventions. We describe a very rare case with compression of the left renal vein due to an osteophyte of the spine. Case presentation A 62-year-old Caucasic male came to our radiology department for chronic hepatitis B virus (HBV)-related liver disease follow-up and mild scrotal pain. The ultrasound examination revealed a compression of the left retro-aortic renal vein in the aorto-vertebral space caused by an osteophyte. Duplex Doppler ultrasound revealed flow congestion in the left renal vein and renal failure; power Doppler ultrasound showed left varicocele. Conclusions Doppler ultrasound is the first-line imaging and allows the detection of all the typical signs of posterior nutcracker: left renal vein stenosis, flow congestion and renal failure. Nutcracker syndrome should be suspected in older patients with left varicocele associated with hematuria. Failure to diagnose and treat these patients could have serious consequences for their health.

V484: Laparoscopic Spleno-Renal Venous Bypass for Left Renal Vein Nutcracker Syndrome

2007 ◽  
Vol 177 (4S) ◽  
pp. 161-162
Author(s):  
Benjamin I. Chung ◽  
Monish Aron ◽  
Nicholas J. Hegarty ◽  
Inderbir S. Gill
Keyword(s):  
Renal Vein ◽  
Left Renal Vein ◽  
Nutcracker Syndrome ◽  
Venous Bypass
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