Clinical Physiology of Circulation

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery


Results of surgical treatment for patients with Nutcracker syndrome

Authors: Arakelyan V.S., Papitashvili V.G., Gamzaev N.R., Nikogosyan M.M., Shumilina M.V., Chernykh N.A., Shilkin D.N.

Company:
Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russian Federation

E-mail: Сведения доступны для зарегистрированных пользователей.

DOI: https://doi.org/10.24022/1814-6910-2024-21-4-332-343

UDC: 616.146.2-007.271-089

Link: Clinical Physiology of Blood Circulaiton. 2024; 21 (4): 332-343

Quote as: Arakelyan V.S., Papitashvili V.G., Gamzaev N.R., Nikogosyan M.M., Shumilina M.V., Chernykh N.A., Shilkin D.N. Results of surgical treatment for patients with Nutcracker syndrome. Clinical Physiology of Circulation. 2024; 21 (4): 332–343 (in Russ.). DOI: 10.24022/1814-6910-2024-21-4-332-343

Received / Accepted:  13.10.2024 / 27.10.2024

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Abstract

Objective. To evaluate the results of surgical treatment of patients with “Nutcracker syndrome”.

Material and methods. A single-center prospective controlled study included 42 operated patients. The median age of the patients was 18 years, with an interquartile range from 16 to 31 years, comprising 24 men (57%) and 18 women (43%). The most common reasons for seeking medical attention included the following symptoms:

renovascular hypertension in 30 (71%) patients,

hematuria and orthostatic proteinuria in 21 (50%) and 15 (36%) cases, respectively,

girdle pain in 16 (38%) patients, abdominal pain in 10 (24%), and varicocele/ovarian varicosities in 17 (40.5%).

All operated patients underwent a standard set of laboratory and instrumental investigations, including a complete blood count and urinalysis, biochemical blood analysis, ultrasound of renal vessels, contrast-enhanced multi-slice computed tomography (MSCT), aortography with venous phase imaging, and phlebography with pressure measurement in the inferior vena cava and left renal vein. In 100% of cases, planned surgical treatment was performed—translocation of the left renal vein to the infrarenal segment of the inferior vena cava.

Results. An immediate positive treatment outcome is observed in 100% of the initially operated patients with nutcracker syndrome, as evidenced by the restoration of normal lumen in the left renal vein according to follow-up MSCT and ultrasound results. In the early postoperative period, there were no fatalities or complications that affected hospitalization duration. The follow-up period ranged from 6 to 24 months (with an average follow-up duration of 14.4 ± 3.6 months). In 7 patients (16.7%), restenosis at the anastomosis site was detected at various times after surgery, associated with persistent clinical symptoms. Reoperation was required for two out of the seven patients.

Conclusion. Translocation of the left renal vein to the infrarenal segment of the inferior vena cava is a safe and effective method for treating symptomatic patients with nutcracker syndrome. The identified cases of symptom recurrence in the late postoperative period indicate the need for an individualized approach to planning the surgical technique for renal vein translocation, as well as the consideration of alternative surgical treatment methods.

References

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  1. Ananthan K., Onida S., Davies A.H. Nutcracker syndrome: an update on current diagnostic criteria and management guidelines. Eur. J. Vasc. Endovasc. Surg. 2017; 53 (6): 886–894. DOI: 10.1016/j.ejvs.2017.02.015
  2. Yih N.D., Chyen L.H., Cunli Y., Jaywantraj P.S., Isip A.B., Anil S.A. Renosplenic shunting in the nutcracker phenomenon: a discussion and paradigm shift in options? A novel approach to treating nutcracker syndrome. Int. J. Angiol. 2014; 23 (1): 71–76. DOI: 10.1055/s-0033-1348883
  3. Dunphy L., Penna M., Tam E., El-Kafsi J. Left renal vein entrapment syndrome: nutcracker syndrome! BMJ Case Rep. 2019; 12 (9): e230877. DOI: 10.1136/bcr-2019-230877
  4. Shin J.I., Lee J.S. Nutcracker phenomenon or nutcracker syndrome? Nephrol. Dial. Transplant. 2005; 20 (9): 2015. DOI: 10.1093/ndt/gfi078
  5. Maloni K.C., Calligaro K.D., Lipshutz W., Vani K., Troutman D.A., Dougherty M.J. Nutcracker syndrome as an unusual cause of postprandial pain. Vasc. Endovascular. Surg. 2020; 54 (3): 283–285. DOI: 10.1177/1538574419896721
  6. Haouimi A. Superior mesenteric artery syndrome with associated Nutcracker syndrome. Radiopaedia.org. 2021; 4: 21. DOI: 10.53347/rid- 88932
  7. Narkhede N.A., Deokar A.B., Mehta K.P., Kamat N.N. Nutcracker syndrome with hypertension as an unusual initial presentation. Indian J. Nephrol. 2017; 27 (6): 472–474. DOI: 10.4103/ijn.IJN_184_16
  8. Azhar A.B., Zeb N.T., Shah S., Khalid A. Nutcracker syndrome with hypertension: a case report. Cureus. 2019; 11 (5): e4781. DOI: 10.7759/ cureus.4781
  9. Dieleman F., Hamming J.F., Erben Y., van der Vorst J.R. Nutcracker syndrome: challenges in diagnosis and surgical treatment. Ann. Vasc. Surg. 2023; 94: 178–185. DOI: 10.1016/j.avsg.2023.03.030
  10. Sarikaya S., Altas O., Ozgur M.M., Hancer H., Yilmaz F., Karagoz A. et al. Treatment of nutcracker syndrome with left renal vein transposition and endovascular stenting. Ann. Vasc. Surg. 2024; 102: 110–120. DOI: 10.1016/j.avsg.2023.11.036
  11. Velasquez C.A., Saeyeldin A., Zafar M.A., Brownstein A.J., Erben Y. A systematic review on management of nutcracker syndrome. J. Vasc. Surg. Venous Lymphat. Disord. 2018; 6 (2): 271–278. DOI: 10.1016/j.jvsv.2017.11.005
  12. Wang R.F., Zhou C.Z., Fu Y.Q., Lv W.F. Nutcracker syndrome accompanied by hypertension: a case report and literature review. J. Int. Med. Res. 2021; 49 (1): 300060520985733. DOI: 10.1177/0300060520985733
  13. Orczyk K., Wysiadecki G., Majos A., Stefańczyk L., Topol M., Polguj M. What each clinical anatomist has to know about left renal vein entrapment syndrome (Nutcracker Syndrome): a review of the most important findings. Biomed. Res. Int. 2017; 2017: 1746570. DOI: 10.1155/2017/1746570
  14. de Macedo G.L., dos Santos M.A., Sarris A.B., Gomes R.Z. Diagnóstico e tratamento da síndrome de quebranozes (nutcracker): revisão dos últimos 10 anos. J. Vasc. Brasil. 2018; 17 (3). DOI: 10.1590/1677-5449.012417
  15. Narkhede N.A., Deokar A.B., Mehta K.P., Kamat N.N. Nutcracker syndrome with hypertension as an unusual initial presentation. Indian J. Nephrol. 2017; 27 (6): 472–474. DOI: 10.4103/ijn.IJN_184_16
  16. Arakelyan V.S., Papitashvili V.G., Gamzaev N.R., Nikoghosyan M.M., Khon V.L. On the issue of repeats. operations for phlebohypertension of the left kidney in Nutcracker syndrome. Children’s Heart and Vascular Diseases. 2023; 20 (3): 220–229 (in Russ.). DOI: 10.24022/1810-0686-2023-20-3-220-229
  17. Arakelyan V.S., Gamzaev N.R., Chshieva I.V., Nikogosyan M.M. Successful surgical treatment of left renal vein compression syndrome in a patient with vasorenal arterial hypertension. Grudnaya i Serdechno-Sosudistaya Khirurgiya. 2022; 64 (5): 547–553 (in Russ.). DOI: 10.24022/0236-2791-2022-64-5-547-553
  18. Arakelyan V.S., Nikoghosyan M.M., Gamzaev N.R. Aortomesetherial compression of the left renal vein. General questions. Modern view on etiology, epidemiology, pathogenesis and diagnosis. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2024; 25 (1): 22–30 (in Russ.). DOI: 10.24022/1810-0694-2024-25-1-22-30
  19. Duncan A.A. How I treat nutcracker syndrome. J. Vasc. Surg. Cases Innov. Tech. 2023; 9 (4): 101344. DOI: 10.1016/j.jvscit.2023.101344
  20. Multon S., Jayet J., Coscas R., Javerliat I., Coggia M. Hybrid management for anterior nutcracker syndrome: left renal vein stenting with laparoscopic stent exofixation. EJVES Vasc. Forum. 2021; 54: 44–48. DOI: 10.1016/j.ejvsvf.2021.11.001
  21. Harrison R., Corse T., Stifelman M. V05-07 Robotic-assistend laprascopic left renal vein transposition for treatment of nutcrscer syndrome. J. Urology [Internet]. 2022; 207 (Suppl. 5): e518. DOI: 10.1097/JU.0000000000002579.07
  22. Wang P., Jing T., Qin J., Xia D., Wang S. Robotic-assisted laparoscopic transposition of the left renal vein for treatment of the Nutcracker syndrome. Urology. 2015; 86 (6): e27–8. DOI: 10.1016/j.urology.2015.09.002

About Authors

  • Valeriy S. Arakelyan, Dr. Med. Sci., Professor, Head of the Department of Surgery of Arterial Pathology, Cardiovascular Surgeon; ORCID
  • Vasil G. Papitashvili, Dr. Med. Sci., Cardiovascular Surgeon, Head of the Department of Surgery of the Main and Peripheral Arteries; ORCID
  • Nazim R. Gamzaev, Cand. Med. Sci., Cardiovascular Surgeon; ORCID
  • Marta M. Nikogosyan, Applicant, Cardiovascular Surgeon; ORCID
  • Margarita V. Shumilina, Dr. Med. Sci., Professor, Head of the Ultrasound Diagnostics Group of Cardiovascular and Organ Pathology; ORCID
  • Nikolay A. Chernykh, Researcher, Cardiovascular Surgeon; ORCID
  • Dmitriy N. Shilkin, Cardiovascular Surgeon; ORCID

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