Tratamento endovascular da síndrome de quebra-nozes: relato de caso / Endovascular treatment of Nutcracker syndrome: case report

A dor pélvica crônica é uma doença debilitante, com impacto na qualidade de vida e custos para os serviços de saúde. A síndrome de quebra-nozes é uma importante causa dessa dor, e se refere a um conjunto de sinais secundários à compressão da veia renal esquerda, mais comumente entre a artéria mesentérica superior e a aorta. Seu tratamento ainda permanece controverso e varia de acordo com a gravidade clínica do paciente. Contudo, a técnica endovascular com implante de stent em veia renal tem obtido excelentes resultados. Relatamos um caso de uma paciente de 59 anos submetida a correção endovascular com stent autoexpansível de nitinol. São apresentados dados clínicos, detalhes do procedimento e resultados do acompanhamento dessa paciente. O sucesso técnico foi obtido e não houve relato de complicações pós-operatórias. Pôde-se observar alívio dos sintomas e melhora nos exames de imagem realizados no acompanhamento de curto prazo

Chronic pelvic pain is a debilitating disease that directly impacts on quality of life and generates costs for health services. Nutcracker Syndrome is an important cause of pelvic pain and consists of a set of signs secondary to compression of the left renal vein, most commonly between the superior mesenteric artery and the aorta. Treatment remains controversial and varies depending on the patient's clinical severity. However, endovascular treatment with renal vein stenting has achieved excellent results. We report the case of a 59 year-old female treated by endovascular repair with a self-expanding nitinol stent. Clinical data, details of the procedure, and follow-up results are presented. Technical success was achieved and there patient reported no postoperative complications. Short-term, there was relief from symptoms and follow-up imaging tests showed improvement

Tratamento endovascular da Sindrome de Quebra-nozes (Nutcracker) / Endovascular treatment of Nutcracker syndrome

A Síndrome do Quebra-nozes se refere a um conjunto de sinais secundários à compressão da veia renal esquerda, mais comumente entre a artéria mesentérica superior e a aorta, levando ao comprometimento do fluxo para a veia cava. O diagnóstico desta síndrome frequentemente é difícil e, por esta razão, o diagnóstico é demorado, em muitos casos. É relatado, nesta publicação, o caso de uma mulher de 51 anos, tratada com sucesso pela embolização da veia ovariana associada ao implante de stent autoexpansível na veia renal esquerda. São discutidos os aspectos técnicos e as dificuldades do procedimento.

Nutcracker syndrome refers to signs and symptoms secondary to compression of the left renal vein, most commonly between the superior mesenteric artery and the aorta, leading to impaired outflow to the vena cava. Diagnosis of this syndrome is often difficult and as result is late in most cases. We report on the case of a 51-year-old woman successfully treated with embolization of the ovarian vein and insertion of a self expandable stent in the left renal vein. Technical details and pitfalls are discussed.

Laparoscopic left renal vein extravascular stenting for treatment of left renal vein entrapment syndrome / 中华泌尿外科杂志

ObjectiveTo investigate the surgical management of left renal vein entrapment syndrome.MethodsEight cases with left renal vein entrapment syndrome (5 males and 3 female ; mean age 26 years) with history of gross hematuria for 3 to 46 months were reviewed.Doppler ultrasound reports suggested compression of the left renal vein at mesenteric angle in all cases.And the dilated segment of the left vein was three-fold than the stricture segment in diameter.CT scan showed the abnormal angle between aorta and superior mesentery artery in all cases.Bleeding from the left ureteral orifice was detected by cystoscopy in 6 cases.We treated 8 patients by extravascular stent immobilization with laparoscope.ResultsThe operation was successful in the 8 cases without surgical complications.The average operation time was 63 min.The average blood loss was 14 ml,and the average hospital stay after operation was 6 days.Follow-up of 3 -20 months,there was no hematuria relapse since been relieved in 7 cases,one case remained microscopic hematuria.Color Doppler ultrasound examination in all 8 cases showed the narrowest inner diameter of left renal vein was 7.4 mm (6.5 - 8.7 mm),the blood flow was smooth.The angle between abdominal aorta and superior mesenteric artery become normal.Conclusions Laparoscopic left renal vein extravascular stenting could be a new surgical method to treat left renal vein entrapment syndrome.The method of putting artificial blood vessel around renal vein is simple,safe and effective.

Artificial blood vessel sheath around renal vein for the treatment of left renal vein entrapment syndrome / 中华泌尿外科杂志

Objective To explore the clinical efficacy of artificial blood vessel sheath around re-nal vein for the treatment of left renal vein entrapment syndrome. Methods Eight cases with left re-nal vein entrapment syndrome (7 males and 1 female, mean age, 16 years) with history of gross hema-turia for 6 to 36 months were reviewed. Doppler ultrasound reports suggested compression of the left renal vein at mesenteric angle in all eases. CT scan showed the abnormal angle between aorta and su-perior mesenterie artery in 5 cases. Cystscopy showed hematuria from the left ureteral orifice in 5 ca-ses. All cases with left renal vein entrapment syndrome were treated ,with the method of putting artifi-cial blood vessel as a sheath around left renal vein. Results The operations were all successful. The average operation time was 150 min, the average blood loss was 50 ml, and the average hospital stay after operation was 9 d. No surgical complications occurred. The gross hcmaturia disappeared in 6 ca-ses and Doppler ultrasound showed that left renal vein outflow was normal in 7 when the patients dis-charged from the hospital. The gross hematuria disappeared during 2-24 months' follow-up in 7 pa-tients. Conclusions The surgical aim of renal vein entrapment syndrome is to reduce the compres-sion of renal vein. The method of putting artificial blood vessel around renal vein could be a simple, safe and effective method.

The Role of Left Renal Vein Entrapment Phenomenon in Children with Asymptomatic Non-glomerular Hematuria / 대한신장학회잡지

PURPOSE: Left renal vein entrapment syndrome has been suggested as an etiology for asymptomatic non-glomerular hematuria since it was reported as a cause of unilateral gross hematuria. Reported diagnostic criteria has been controversial since various degrees of left renal vein entrapment was found in normal children. Some of asymptomatic non-glomerular hematuria was not diagnosed even with renal biopsies but was usually known to have self-limited benign course. We analyzed the relationship between asymptomatic non-glomerular hematuria of unknown origin and the degree of left renal vein entrapment phenomenon. METHODS: The renal doppler sonograpy of 92 children with asymptomatic non-glomerular hematuria [gross hematuria(GH) N=44, microscopic hematuria (MH) N=48] were compared to 30 control children with normal renal function and urinalysis who underwent renal doppler sonography for abdominal pain and enuresis from January, 1999 to Febrary, 2000 at Ewha Womans Mokdong Hospital. The narrowed diameter(ND) of the left renal vein between the aorta and superior mesenteric artery and its maximal velocity(NV), and the dilated diameter(DD) of the left renal vein and its maximal velocity(DV) were measured and the DD/ND and NV/DV ratio were compared with those of the control children and the results of several previous reports. RESULTS: The DD/ND ratio was 3.9+/-1.89 in the GH group, 2.4+/-0.62 in the MH group, and 2.0+/-0.48 in the control group. There was a significant difference among GH, MH and control group(p<0.05). The NV/DV ratio was 3.6+/-2.37 in the GH group was significantly higher than 1.9+/-0.60 in the MH group and 1.7+/-0.55 in the control group(p<0.05). There was no significant differences between MH and control groups. Normal cut off values of DD/ND and NV/DV ratio in this study were 3.0 and 2.8 which was different to previous reports. CONCLUSION: Left renal vein entrapment phenomenon should be considered as one of the etiology of asymptomatic non-glomerular hematuria in children and the sonographic diagnostic criteria for Left renal vein entrapment syndrome needs to be revised.

The Role of Left Renal Vein Entrapment Phenomenon in Children with Asymptomatic Non-glomerular Hematuria / 대한신장학회잡지

PURPOSE: Left renal vein entrapment syndrome has been suggested as an etiology for asymptomatic non-glomerular hematuria since it was reported as a cause of unilateral gross hematuria. Reported diagnostic criteria has been controversial since various degrees of left renal vein entrapment was found in normal children. Some of asymptomatic non-glomerular hematuria was not diagnosed even with renal biopsies but was usually known to have self-limited benign course. We analyzed the relationship between asymptomatic non-glomerular hematuria of unknown origin and the degree of left renal vein entrapment phenomenon. METHODS: The renal doppler sonograpy of 92 children with asymptomatic non-glomerular hematuria [gross hematuria(GH) N=44, microscopic hematuria (MH) N=48] were compared to 30 control children with normal renal function and urinalysis who underwent renal doppler sonography for abdominal pain and enuresis from January, 1999 to Febrary, 2000 at Ewha Womans Mokdong Hospital. The narrowed diameter(ND) of the left renal vein between the aorta and superior mesenteric artery and its maximal velocity(NV), and the dilated diameter(DD) of the left renal vein and its maximal velocity(DV) were measured and the DD/ND and NV/DV ratio were compared with those of the control children and the results of several previous reports. RESULTS: The DD/ND ratio was 3.9+/-1.89 in the GH group, 2.4+/-0.62 in the MH group, and 2.0+/-0.48 in the control group. There was a significant difference among GH, MH and control group(p<0.05). The NV/DV ratio was 3.6+/-2.37 in the GH group was significantly higher than 1.9+/-0.60 in the MH group and 1.7+/-0.55 in the control group(p<0.05). There was no significant differences between MH and control groups. Normal cut off values of DD/ND and NV/DV ratio in this study were 3.0 and 2.8 which was different to previous reports. CONCLUSION: Left renal vein entrapment phenomenon should be considered as one of the etiology of asymptomatic non-glomerular hematuria in children and the sonographic diagnostic criteria for Left renal vein entrapment syndrome needs to be revised.

Colour Ultrasonographic Diagnosis of Left Renal Vein Entrapment Syndrome / 中国医师杂志

Purpose To discuss the main index of the colour ultrasonographic diagnosis of children's left Renal Vein Entrapment Sydrome(LRVES).Methods By colour ultrasonography,urine microscope examination and urine Ca/Cr ratio determination,eighty-two LRVES children were diagnosed and compared with forty healthy children.Observed at supine position whether narrow caused by pressure or the expanding phenomenon of LRV after being pressed,to examine the ratio of the abdominal aorta(AO) left internal diameter(a) to the front internal diameter(b) of LRV,by using CDFI,blood flow rate in the left lateral position of LRV was judged.Simultaneously,the angle(?) between superio mesentery artery(SMA) and AO was detected.Then standing upright for twenty minutes,and determined a/b ratio.Results In the LRVES group,the LRV blood vessels become narrower,a/b was over 3 at supine position,after standing upright for twenty minutes,a/b was over 4;and LRV blood flow rate becomes slower,? angle becomes smaller,compared with the healthy group,there was statistical significance.Conclusions The main indexes of the LRVES of ultrasonographic diagnosis is to observe the a/b ratio of LRV before and after being pressed (lying on the back and standing upright for twenty minutes) and to detecte the blood flow rate of LRV before pressure and judege the angle between SMA and AO.

A Case of Nutcracker Syndrome in a Patient with Gross Hermaturia / 대한신장학회잡지

Nutcracker syndrome(renal vein entrapment syndrome) is probably more common than previously suspected. The nutcracker phenomenon refers to compression of left renal vein between aorta and superior mesenteric artery that results in elevation of pressure in left renal vein and develoment of collateral veins. This syndrome occurs in relatively young and previously healthy patients and is characterized by intermittent gross hematuria due to left renal vein hypertension, at times associated with flank pain, abdominal pain or varicocele. We report a 17 years-old male patient with this syndrome presented with flank pain, abdominal pain, and intermittent gross hematuria for 3 months. Urinalysis revealed protein(-), blood(+++), many RBC with only 1% of dysmorphic RBC. IVP and cystoscopy showed no remarkable finding but doppler ultrasonography and abdominal spiral CT revealed compression of left renal vein between aorta and superior mesenteric artery. Renal venography showed compression of left renal vein and collateral circulation to left gonadal vein and the pressure gradient between left renal vein and inferior vena cava was 11mmHg. The nutcracker syndrome should be considered as one of the causes of nonglomerular hematuria. All patients with unexplained severe left flank or abdominal pain, or unilateral hematuria from the left on cystoscopy, should be studied by selective renal venography and pressure measurement in inferior vena cava and renal veins. The patient with this typical syndrome could be treated surgically, by transposition of left renal vein and resection of collateral veins as the procedure of choice to correct the underlying pathologic process and eliminate these troublesome symptoms.

Nutcracker Syndrome Associated with Non-glomerular Hematuria in Childhood / 대한신장학회잡지

PURPOSE: This study was designed to aid the diagnosis and to predict the outcorne by understanding the clinical course of nutcracker syndrome in childhood. METHODS: The clinical, laboratory, radiological and cystoscopic data from the medical records of eleven children who were diagnosed as nutcracker syndrome by gross hematuria and pressure gradient criteria (>3mrnHg) were studied retrospectively and analyzed. RESULTS: Sex ratio of the cases was 7:4, and the median age of onset was 12.8 (3-14.3) years. Six cases showed persistent and 5 cases manifested interrnittent, exercise induced hematuria. Left flank pain (64%), abdominal pain (18%), left varicocele (9%) were associated in some of the children, but hematuria was the only symptom in 36Yo. Left renal vein entrapment was documented in 10 cases by ultrasonography. Out of the 5 cases studied by renal Doppler ultrasonography, 4 and 5 cases showed higher (>5) mean left renal vein diameter ratio (Distal/ Aortomesenteric portion) and mean peak velocity ratio respectively. Unilateral bleeding from left ureteral orifice was documented in 7 of the 9 cases at cystoscopy. The mean pressure gradient between proximal left renal vein and inferior vena cava was 4.4+/-1.6 (3-7) mmHg. Hematuria of 25% and 57% of the cases disappeared spontaneously in 3 and 5 years after onset respectively. Proteinuria disappear- ed in 3 of the 5 initial proteinuric cases. CONCLUSION: Nutcracker syndrome must be considered in the differential diagnosis of non-glomerular, especially gross hematuria in childhood, and Doppler ultrasonography can aid diagnosis non-invasively. The renal function remained stable, but 4396 of the cases continued to show hematuria still 5 years after onset.