Endovascular Treatment of Nutcracker Syndrome: A Case Report
Anthony Rios, M.D., Pouria Parsa, M.D., John Eidt, M.D., Stephen Hohmann, M.D., Bradley Grimsley, M.D..
Baylor University Medical Center, Dallas, TX, USA.
OBJECTIVES: Nutcracker Syndrome, caused by left renal vein (LRV) compression as it passes between the superior mesenteric artery and aorta, causes ongoing symptoms ranging from hematuria and orthostatic proteinuria to pelvic congestion syndrome. While an attempt at medical management works for some, others experience ongoing symptoms. LRV transposition has remained the treatment of choice although endovascular LRV stent placement has been advocated with variable success and some complications including stent migration. We present two patients successfully treated with endovascular stent placement with immediate resolution of symptoms, remaining symptom-free after one-year follow-up. METHODS: First is a 32-year-old healthy female presenting with several months of left flank pain. She underwent venography, revealing a 90% stenosis of the medial portion of the LRV with robust collateral network (Figure 1). The stenotic portion was pre-dilated with a 14 mm x 20 mm high pressure balloon (Armada, Abbott) before placing a 14 mm x 60 mm self-expanding stent (Protege™ GPS™, Covidien) and post-dilating with the same balloon. Second is a 48-year-old male with no medical comorbidities presenting with ongoing left flank pain and hematuria. His serum creatinine measured 1.2 mg/dL. Venography revealed a 99% stenosis of the medial portion of the LRV. The lesion was treated with angioplasty, using a 14 mm x 20 mm high pressure balloon (Armada, Abbott) before placing a 14 mm x 40 mm self-expanding stent (Protege™ GPS™, Covidien) and post-dilating with a 14 mm x 4 cm angioplasty balloon (XXL™, Boston Scientific). RESULTS: The 32-year-old female treated with LRV stenting showed no residual stenosis on completion venography and postoperative duplex ultrasound revealed laminar flow and no evidence of stenosis. The 48-year-old male treated with LRV stenting also showed no stenosis on completion venography. Follow up computed tomography with intravenous contrast showed a widely patent stent. Flank pain resolved immediately in both patients. CONCLUSIONS: Our case report confirms Nutcracker Syndrome may be treated through endovascular means, eliminating symptoms and providing a durable alternative to open surgery.
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