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Endovascular management of nutcracker syndrome in an adolescent patient population

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Abstract

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.

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Authors and Affiliations

  1. Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA

    Julie C. Cronan, C. Matthew Hawkins & Anne E. Gill

  2. Division of Pediatric Radiology, Department of Radiology and Imaging Science, Emory University School of Medicine, Atlanta, GA, USA

    C. Matthew Hawkins, Kelley W. Marshall, Bradley S. Rostad & Anne E. Gill

  3. Emory + Children’s Pediatric Institute, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA, USA

    C. Matthew Hawkins, Sabina S. Kennedy, Kelley W. Marshall, Bradley S. Rostad & Anne E. Gill

  4. Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA

    Sabina S. Kennedy

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  1. Julie C. Cronan
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  2. C. Matthew Hawkins
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  3. Sabina S. Kennedy
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  4. Kelley W. Marshall
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Correspondence to Julie C. Cronan.

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Cronan, J.C., Hawkins, C.M., Kennedy, S.S. et al. Endovascular management of nutcracker syndrome in an adolescent patient population. Pediatr Radiol 51, 1487–1496 (2021). https://doi.org/10.1007/s00247-021-04986-0

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  • DOI: https://doi.org/10.1007/s00247-021-04986-0

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