Background: Nutcracker syndrome (NCS) is defined as left renal vein (LRV) compression by the superior mesenteric artery. NCS diagnosis is rendered complex by confounding symptoms. The study objective was to perform a prospective observational analysis of the diagnostic and therapeutic criteria of the patients with suspected NCS. When NCS diagnosis was confirmed, transposition of the LRV was carried out by mini-invasive robotic surgery (MIRS). Method: All patients addressed to the vascular surgery department for suspicion of NCS between January 2022 and June 2023 were included in the study. Patients were subsequently assessed by means of a computed tomography scan, dynamic duplex ultrasound and phlebography associated with an occlusion test of the left gonadic vein (LGV). Diagnostic criteria included aorto-mesenteric angle, LGV diameter and reflux, velocity ratios and diameters and the reno-caval gradient. Result: Thirty two patients aged 37 ± 14 years had suspicion of NCS. Twenty presented an aorto-mesenteric angle below 20°, twenty three had a LGV diameter greater than 5 mm and twenty two of the latter patients also had LGV reflux. A significant reno-caval gradient greater than 5 mmHg was found in ten cases, thereby consolidating NCS diagnosis. Overall, thirteen patients neither presented NCS or pelvic varicosities; eight had pelvic congestion syndrome without NCS and were successfully treated by embolization. Eleven patients with confirmed NCS underwent LRV transposition in the inferior vena cava (IVC). Eight of the latter patients received a complementary pelvic varicosity embolization 2 days later. Two months post-operation 100% of transposed LRV were permeable as assessed by duplex ultrasound controls and all of these patients reported an improvement of symptoms. Conclusion: An innovative multidisciplinary decisional algorithm establishes certitude in NCS diagnosis which can subsequently be treated radically by MIRS.
CaladoRBrazMLoboL, et al.Síndrome de Nutcracker. Hematúria sem diagnóstico Acta Médica Port2011; 24: 695–698.
2.
ZuckerEJGanguliSGhoshhajraBB, et al.Imaging of venous compression syndromes. Cardiovasc Diagn Ther2016; 6: 519–532.
3.
AvgerinosEDMcEnaneyRChaerRA. Surgical and endovascular interventions for nutcracker syndrome. Semin Vasc Surg2013; 26: 170.
4.
AnanthanKOnidaSDaviesAH. Nutcracker syndrome: an update on current diagnostic criteria and management guidelines. Eur J Vasc Endovasc Surg2017; 53: 886–894.
5.
KurklinskyAKRookeTW. Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc2010; 85: 552–559.
6.
ThaveauFNicoliniPLucereauB, et al.Associated da Vinci and magellan robotic systems for successful treatment of nutcracker syndrome. J Laparoendosc Adv Surg Tech2015; 25: 60–63.
7.
NastasiDRFraserARWilliamsAB, et al.A systematic review on nutcracker syndrome and proposed diagnostic algorithm. J Vasc Surg Venous Lymphat Disord2022; 10: 1410–1416.
8.
ShinJIBaekSYLeeJS, et al.Follow-up and treatment of nutcracker syndrome. Ann Vasc Surg2007; 21: 402.
9.
MacedoGLDSantosMADSarrisAB, et al.Diagnóstico e tratamento da síndrome de quebra-nozes (nutcracker): revisão dos últimos 10 anos. J Vasc Bras2018; 17: 220–228.
10.
ChaitJSenIKalraM. Nutcracker syndrome: how to diagnose it and when/how should it be treated in the pelvic venous disease population. Tech Vasc Intervent Radiol2021; 24: 100734.
11.
KimSH. Doppler US and CT diagnosis of nutcracker syndrome. Korean J Radiol2019; 20: 1627–1637.
12.
OtekiTNagaseSHirayamaA, et al.Nutcracker syndrome associated with severe anemia and mild proteinuria. Clin Nephrol2004; 62: 62–65.
13.
QuevedoHCArainSAAbi RafehN. Systematic review of endovascular therapy for nutcracker syndrome and case presentation. Cardiovasc Revascularization Med2014; 15: 305–307.
14.
ReedNRKalraMBowerTC, et al.Left renal vein transposition for nutcracker syndrome. J Vasc Surg2009; 49: 386–393.
15.
KimKWChoJYKimSH, et al.Diagnostic value of computed tomographic findings of nutcracker syndrome: correlation with renal venography and renocaval pressure gradients. Eur J Radiol2011; 80: 648–654.
16.
KimSHChoSWKimHD, et al.Nutcracker syndrome: diagnosis with Doppler US. Radiology1996; 198: 93–97.
17.
BeinartCSnidermanKWSaddekniS, et al.Left renal vein hypertension: a cause of occult hematuria. Radiology1982; 145: 647–650.
18.
TakebayashiSUekiTIkedaN, et al.Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography. AJR Am J Roentgenol1999; 172: 39–43.
19.
MenardMT. Nutcracker syndrome: when should it Be treated and how?Perspect Vasc Surg Endovasc Ther2002; 21: 117–124.
20.
HeYWuZChenS, et al.Nutcracker syndrome—how well do we know it?Urology2014; 83: 12–27.
