Endovascular management of nutcracker syndrome in an adolescent patient population

• Published in: Pediatric radiology Vol. 51; no. 8; pp. 1487 - 1496
• Main Authors: Cronan, Julie C., Hawkins, C. Matthew, Kennedy, Sabina S., Marshall, Kelley W., Rostad, Bradley S., Gill, Anne E.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-07-2021; Springer Nature B.V
• Subjects: Abdomen; Adolescents; Blanching; Cardiovascular system; Compression; Computed tomography; Demographics; Demography; Diagnostic systems; Electronic health records; Electronic medical records; Feasibility; Hematuria; Imaging; Implants; Kidneys; Magnetic resonance imaging; Medical imaging; Medicine; Medicine & Public Health; Neuroradiology; Nuclear Medicine; Oncology; Original Article; Pain; Patients; Pediatrics; Pelvis; Radiology; Stents; Symptom management; Teenagers; Transposition; Ultrasound; Veins & arteries; United States > US; Endovascular stent; Left renal vein; Nutcracker syndrome; Adolescents; Intravascular ultrasound; Interventional radiology
• ISSN: 0301-0449; 1432-1998
• DOI: 10.1007/s00247-021-04986-0

Background
Nutcracker syndrome is defined as left renal vein compression with concomitant clinical symptoms that include flank pain and hematuria. Historically, pediatric and adolescent patients with mild symptoms of nutcracker syndrome were simply observed while those with more severe symptoms underwent left renal vein transposition. Endovascular stenting of the left renal vein is a potentially efficacious and less invasive alternative for managing nutcracker syndrome in adolescents.
Objective
The purpose of this study was to investigate the technical feasibility, efficacy and safety of left renal vein stenting in adolescents with nutcracker syndrome.
Materials and methods
We conducted a retrospective review of electronic medical records and imaging archives to identify adolescents undergoing endovascular stenting for nutcracker syndrome. We reviewed patient demographics including age, gender, presenting symptoms and diagnostic imaging findings. We compared pre- and post-stent deployment intravascular ultrasound (IVUS) and venography and evaluated patient symptoms in clinic up to 6 months following stent placement.
Results
Ten patients (average age 16 years, range 12–20 years) underwent 13 procedures. Initial symptoms included pain (
n
=10) and gross hematuria (
n
=5). Diagnostic imaging studies included CT abdomen pelvis (
n
=8), retroperitoneal US (
n
=6), MRI abdomen/pelvis (
n
=4), scrotal US (
n
=2), pelvic US (
n
=1) and renal Doppler US (
n
=2). Venography and IVUS demonstrated venous collaterals, proximal blanching at the left-renal-vein–IVC junction, pre-stenotic dilation and intraluminal compression. Most patients (
n
=9) experienced symptomatic resolution; however, three patients required reintervention to achieve asymptomatic status. No periprocedural complications occurred.
Conclusion
In this carefully selected adolescent cohort, left renal vein stenting for nutcracker syndrome was often technically feasible, safe and effective in symptom management.