Treatment of nutcracker syndrome with left renal vein transposition and endovascular stenting.

Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency towards surgery instead of stenting. The clinical data of consecutive patients with nutcracker syndrome who underwent left renal vein transposition and left renal vein stenting between July 2019 and October 2023were retrospectively reviewed. The patients were divided into two groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary endpoints were morbidity and mortality. Secondary endpoints included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed. 19 patients with nutcracker syndrome (female-100% ) were treated with LRV stentings (n=5) and left renal vein transposition (n=14). The mean age was 24 (20-27, IQR) years. The mean follow-up was 23(9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with left renal vein entrapment were left flank pain 100% (n=19), proteinuria 88% (n=15), and hematuria 47% (n=9). The mean peak velocity ratio on doppler ultrasonography were 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mmHg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n=17), 57.8% (n=11), and 82.3% (n=15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The one and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary assisted patency was 100%. Similarly, the one and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the one and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the one and 3-year primary patency for the stenting group was 75%. Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms in order to initiate the treatment of nutcracker syndrome with left renal vein transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.

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