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Ozsvath K, Raffetto JD, Lindner E, Murphy EH. Venous compression syndromes in females: A descriptive review. Semin Vasc Surg 2023; 36:550-559. [PMID: 38030329 DOI: 10.1053/j.semvascsurg.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023]
Abstract
Venous compression syndromes have been described, yet the role of sex is poorly understood. Although iliac vein compression has been discussed more often with the advent of newer technologies, research has fallen short on defining epidemiology, best practices for evaluation and treatment, and differences in responses to treatment between men and females. The authors report on iliac vein compression, nonthrombotic renal vein compression, and other venous compression syndromes in females. Literature searches of PubMed were performed using the following keywords: females/females and May Thurner, venous stenting, venous outcomes, deep venous disease, deep venous compression, venous stenting, renal vein compression, renal vein surgery/stent, popliteal vein entrapment, venous thoracic vein entrapment, and popliteal vein entrapment. The articles prompted the authors to research further as the referenced articles were reviewed. Sex representation has not been addressed adequately in the research of venous compression syndromes, making the discussion of best treatment options and long-term outcomes difficult. More specific understanding of epidemiology and response to interventions will only come from research that addresses these issues directly, understanding that some of these syndromes occur rarely.
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Affiliation(s)
- Kathleen Ozsvath
- St Peters Health Partners, Vascular Associates, Albany, NY; Samaritan Hospital, 2 New Hampshire, Troy, NY, 12211.
| | - Joseph D Raffetto
- Harvard Medical School, Boston, MA; Uniformed Services University of the Health Sciences, Bethesda, MD; Veterans Affairs Boston Healthcare System, Boston, MA; Brigham and Females's Hospital, Boston, MA
| | | | - Erin H Murphy
- Venous and Lymphatic Center, Sanger Heart and Vascular, Atrium Health, Charlotte, NC
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Agarwal A, Litra F, Barr LL. A Rare Cause of Abdominal and Flank Pain in Children: Nutcracker Syndrome. Cureus 2021; 13:e16422. [PMID: 34414047 PMCID: PMC8364742 DOI: 10.7759/cureus.16422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 11/05/2022] Open
Abstract
The nutcracker phenomenon is characterized by compression of the left renal vein typically between the abdominal aorta and superior mesenteric artery. It is an uncommon and often undiagnosed condition that has the potential to cause a range of symptoms including hematuria and abdominal or flank pain. The term nutcracker syndrome refers to the clinical manifestations of the nutcracker phenomenon. Diagnosis can be made with Doppler ultrasound, computed tomography angiography, magnetic resonance angiography, or venography. Management can range from conservative treatment in the pediatric population due to high spontaneous remission rate to surgical and endovascular interventions. We discuss the case of a previously healthy young female who presented with abdominal pain. Diagnosis of nutcracker syndrome was made based on imaging. The patient was managed conservatively. This case highlights the importance of considering nutcracker syndrome in the differential diagnosis when evaluating patients with abdominal and flank pain.
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Affiliation(s)
- Ankit Agarwal
- Pediatrics, Ascension Sacred Heart, University of Florida, Pensacola, USA
| | - Florentina Litra
- Pediatrics, Ascension Sacred Heart, University of Florida, Pensacola, USA
| | - Lori L Barr
- Pediatric Radiology, Radiology Associates of Florida, Radiology Partners, Pensacola, USA
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Granata A, Distefano G, Sturiale A, Figuera M, Foti PV, Palmucci S, Basile A. From Nutcracker Phenomenon to Nutcracker Syndrome: A Pictorial Review. Diagnostics (Basel) 2021; 11:diagnostics11010101. [PMID: 33440614 PMCID: PMC7826835 DOI: 10.3390/diagnostics11010101] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Left renal vein (LRV) entrapment, also known as nutcracker phenomenon if it is asymptomatic, is characterized by abnormality of outflow from the LRV into the inferior vena cava (IVC) due to extrinsic LRV compression, often accompanied by demonstrable lateral (hilar) dilatation and medial (mesoaortic) stenosis. Nutcracker syndrome, on the other hand, includes a well-defined set of symptoms, and the severity of these clinical manifestations is related to the severity of anatomic and hemodynamic findings. With the aim of providing practical guidance for nephrologists and radiologists, we performed a review of the literature through the PubMed database, and we commented on the definition, the main clinical features, and imaging pattern of this syndrome; we also researched the main therapeutic approaches validated in the literature. Finally, from the electronic database of our institute, we have selected some characteristic cases and we have commented on the imaging pattern of this disease.
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Affiliation(s)
- Antonio Granata
- Nephrology and Dialysis Unit, “Cannizzaro” Hospital, 95026 Catania, Italy; (A.G.); (A.S.)
| | - Giulio Distefano
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital “Policlinico—San Marco”, University of Catania, 95123 Catania, Italy; (P.V.F.); (S.P.); (A.B.)
- Correspondence: ; Tel.: +39-3385020778
| | - Alessio Sturiale
- Nephrology and Dialysis Unit, “Cannizzaro” Hospital, 95026 Catania, Italy; (A.G.); (A.S.)
| | - Michele Figuera
- Radiology Unit II, University Hospital “Policlinico—San Marco”, 95123 Catania, Italy;
| | - Pietro Valerio Foti
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital “Policlinico—San Marco”, University of Catania, 95123 Catania, Italy; (P.V.F.); (S.P.); (A.B.)
| | - Stefano Palmucci
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital “Policlinico—San Marco”, University of Catania, 95123 Catania, Italy; (P.V.F.); (S.P.); (A.B.)
| | - Antonio Basile
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital “Policlinico—San Marco”, University of Catania, 95123 Catania, Italy; (P.V.F.); (S.P.); (A.B.)
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Nakashima T, Sahashi Y, Kanamori H, Ohno Y, Okura H. Localized solitary left renal vein thrombus complicating nutcracker syndrome: a case report and review of the literature. CEN Case Rep 2020; 9:252-256. [PMID: 32246272 DOI: 10.1007/s13730-020-00467-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022] Open
Abstract
Nutcracker syndrome (NCS) refers to compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery (SMA). The clinical presentation of NCS includes hematuria, abdominal and left flank pain, gonadal varices, and varicocele formation. Theoretically, thrombosis can occur in the LRV in patients with NCS. However, an isolated solitary left renal vein thrombus (LRVT) complicating NCS is rare. In addition, the clinical features of an LRVT complicating NCS remain unclear. We describe a 43-year-old woman presenting with an asymptomatic LRVT complicating NCS. She was referred to our hospital for investigation of dysfunctional uterine bleeding, and detailed examination revealed endometrial cancer. Computed tomography angiography (CTA) and Doppler ultrasonography revealed compression of the LRV between the aorta and the SMA, as well as an LRVT. CTA performed 4 months after the administration of an anticoagulant showed complete disappearance of the LRVT. We have also included a review of published reports describing LRVT complicating NCS and discussed the clinical features of such a presentation.
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Affiliation(s)
- Takashi Nakashima
- Department of Cardiology, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Yuki Sahashi
- Department of Cardiology, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hiromitsu Kanamori
- Department of Cardiology, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yasushi Ohno
- Department of Respirology, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hiroyuki Okura
- Department of Cardiology, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
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What Each Clinical Anatomist Has to Know about Left Renal Vein Entrapment Syndrome (Nutcracker Syndrome): A Review of the Most Important Findings. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1746570. [PMID: 29376066 PMCID: PMC5742442 DOI: 10.1155/2017/1746570] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 10/12/2017] [Indexed: 12/21/2022]
Abstract
Nutcracker syndrome (NCS) is the most common term for compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. The development of NCS is associated with the formation of the left renal vein (LRV) from the aortic collar during the sixth to eighth week of gestation and abnormal angulation of the superior mesenteric artery from the aorta. Collateralization of venous circulation is the most significant effect of NCS. It includes mainly the left gonadal vein and the communicating lumbar vein. Undiagnosed NCS may affect retroperitoneal surgery and other radiological and vascular procedures. The clinical symptoms of NCS may generally be described as renal presentation when symptoms like haematuria, left flank pain, and proteinuria occur, but urologic presentation is also possible. Radiological methods of confirming NCS include Doppler ultrasonography as a primary test, retrograde venography, which can measure the renocaval pressure gradient, computed tomography angiography, which is faster and less traumatic, intravascular ultrasound, and magnetic resonance angiography. Treatment can be conservative or surgical, depending on the severity of symptoms and degree of LRV occlusion. Nutcracker syndrome is worth considering especially in differential diagnosis of haematuria of unknown origin.
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Park JH, Lee GH, Lee SM, Eisenhut M, Kronbichler A, Lee KH, Shin JI. Posterior nutcracker syndrome - a systematic review. VASA 2017; 47:23-29. [PMID: 29165061 DOI: 10.1024/0301-1526/a000670] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Posterior nutcracker syndrome (PNCS) is the entrapment of the left renal vein between the aorta and the vertebral column. Although uncommon, it is still an important diagnosis due to the high morbidity associated with the risk of secondary anaemia from haematuria, from long-term left renal vein hypertension, vascular thrombosis, and even blood clots in the urinary system. A literature search of PubMed and EMBASE databases was performed and 27 publications containing 27 cases were included for the final analysis. The following frequency of clinical signs and symptoms was noted: twenty-five patients had haematuria, 13 patients had flank pain, and two had hypertension. Overall, male-female distribution was balanced and there were more adult than paediatric (age < 18 years) patients. All symptoms of patients with conservative treatment were either well-controlled or under spontaneous resolution. Conservative management instead of surgical treatment should be preferred in most cases. Taken together, despite the low incidence of PNCS, its recognition and management are highly important. This systematic study explores the evidence base for conservative and medical options.
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Affiliation(s)
- Jae Hyon Park
- 1 Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea.,a These authors contributed equally to this paper
| | - Gi Hoon Lee
- 2 Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.,a These authors contributed equally to this paper
| | - Seul Mi Lee
- 3 Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea.,4 Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Republic of Korea
| | - Michael Eisenhut
- 5 Luton & Dunstable University Hospital NHS Foundation Trust, Lewsey Road, Luton, United Kingdom
| | - Andreas Kronbichler
- 6 Department of Internal Medicine IV, Medical University Innsbruck, Innsbruck, Austria
| | - Keum Hwa Lee
- 3 Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea.,4 Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Republic of Korea
| | - Jae Il Shin
- 3 Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea.,4 Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Republic of Korea.,7 Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
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Micro- and macroscopic hematuria caused by renal vein entrapment: systematic review of the literature. Pediatr Nephrol 2016; 31:175-84. [PMID: 25627663 DOI: 10.1007/s00467-015-3045-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/05/2015] [Accepted: 01/05/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Hematuria secondary to renal vein entrapment is mentioned only passing in textbooks and reviews. METHODS We performed a search of the National Library of Medicine database for peer-reviewed publications using the terms "renal vein" or "nutcracker" and "hematuria". RESULTS We identified 187 published reports/studies that covered 736 patients, of whom 288 had microscopic hematuria and 448 had macroscopic hematuria. The patient cohort comprised 159 patients aged ≤17 years. Abdominal pain was absent in approximately 65% of all patients, and a clinically relevant left-sided varicocele was observed in 29% of the male patients. A normal pre-aortic left renal vein and an anomalous anatomy were noted in 680 and 56 patients, respectively. The body mass index (BMI) was lower in patients with renal vein entrapment than in the controls, with a regression of hematuria correlating with an increase in BMI. A surgical procedure was attempted in 34% of the patients, of which the most common were endovascular stenting and transposition of the renal vein distally into the vena cava. CONCLUSIONS In cases of unexplained hematuria with or without abdominal pain, clinicians should consider the diagnosis of renal vein congestion, especially in males with varicocele. Ultrasonic Doppler flow scanning is the recommended initial diagnostic modality in these patients. Expectation management is advised in the great majority of cases.
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Gulleroglu K, Gulleroglu B, Baskin E. Nutcracker syndrome. World J Nephrol 2014; 3:277-281. [PMID: 25374822 PMCID: PMC4220361 DOI: 10.5527/wjn.v3.i4.277] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/16/2014] [Accepted: 09/17/2014] [Indexed: 02/06/2023] Open
Abstract
The nutcracker phenomenon [left renal vein (LRV) entrapment syndrome] refers to compression of the LRV most commonly between abdominal aorta and superior mesenteric artery. Term of nutcracker syndrome (NCS) is used for patients with clinical symptoms associated with nutcracker anatomy. LRV entrapment divided into 2 types: anterior and posterior. Posterior and right-sided NCSs are rare conditions. The symptoms vary from asymptomatic hematuria to severe pelvic congestion. Symptoms include hematuria, orthostatic proteinuria, flank pain, abdominal pain, varicocele, dyspareunia, dysmenorrhea, fatigue and orthostatic intolerance. Existence of the clinical features constitutes a basis for the diagnosis. Several imaging methods such as Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography and retrograde venography are used to diagnose NCS. The management of NCS depends upon the clinical presentation and the severity of the LRV hypertension. The treatment options are ranged from surveillance to nephrectomy. Treatment decision should be based on the severity of symptoms and their expected reversibility with regard to patient’s age and the stage of the syndrome.
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A Patient With Loin Hematuria Syndrome and Chronic Flank Pain Treated With Pulsed Radiofrequency of the Splanchnic Nerves. Clin J Pain 2013; 29:e26-9. [DOI: 10.1097/ajp.0b013e31828c8922] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mahmood SK, Oliveira GR, Rosovsky RP. An easily missed diagnosis: flank pain and nutcracker syndrome. BMJ Case Rep 2013; 2013:bcr-2013-009447. [PMID: 23709545 DOI: 10.1136/bcr-2013-009447] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
A 27-year-old woman presented to her primary care doctor's office with left flank pain. CT of the abdomen showed an isolated left renal vein thrombus. The clot was initially attributed to her oral contraceptive use; however, closer inspection of CT images revealed nutcracker phenomenon (compression of the renal vein between the superior mesenteric artery and abdominal aorta). Intravascular ultrasound imaging confirmed the diagnosis. Nutcracker syndrome is a rare condition, which if left untreated may cause damage to the left kidney. Although under diagnosed, there are several treatment options available ranging from simple surveillance to surgical resolution.
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Affiliation(s)
- Syed Kashif Mahmood
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Chen S, Zhang H, Tian L, Li M. Endovascular Management of Nutcracker Syndrome After Migration of a Laparoscopically Placed Extravascular Stent. Am J Kidney Dis 2012; 60:322-6. [DOI: 10.1053/j.ajkd.2012.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 04/05/2012] [Indexed: 02/07/2023]
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Newly-identified symptoms of left renal vein entrapment syndrome mimicking orthostatic disturbance. World J Pediatr 2012; 8:116-22. [PMID: 22573421 DOI: 10.1007/s12519-012-0349-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Accepted: 07/04/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND In addition to the urinary abnormalities, symptoms of left renal vein entrapment between the aorta and superior mesenteric artery (left renal vein entrapment syndrome, LRVES) may include abdominal and flank pain as well as chronic fatigue. We investigated various LRVES symptoms in this study. METHODS In 53 pediatric LRVES patients treated at our department, 22 had a score of 5 points or higher on orthostasis. Initial evaluation of LRVES by abdominal ultrasonography showed a stenotic-to-prestenotic vein diameter ratio of 0.2 or less. Definitive diagnosis was made by computed tomography and magnetic resonance angiography. Cortisol, catecholamine (CA), and brain natriuretic peptide (BNP) were also measured. RESULTS The frequency of LRVES was 2.5 times higher in girls than in boys. Low or very low body mass indexes were seen in both sexes. The most common initial finding was urine abnormalities, followed by dizziness and malaise. In 6 patients, orthostasis precluded school attendance. Ten patients had orthostasis scores above 12. Patients unable to attend school had either low levels of plasma or urinary cortisol. Midodrine significantly decreased orthostasis scores. Some patients required treatment with fludrocortisone. Plasma CA, renin, and BNP levels were all normal. CONCLUSIONS Locally excessive venous pressure may cause reversible adrenal dysfunction with transitory Addisonian symptoms. Children with cryptogenic malaise or severe orthostasis should be evaluated for LRVES.
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