Surgical Options and Outcomes for Renal Vein Entrapment

Abstract

Background

Renal vein entrapment is compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta. When symptomatic, this condition is referred to as nutcracker syndrome (NCS).

Methods

This retrospective study reviews outcomes of 53 patients who underwent surgical correction of NCS at a tertiary care university medical center. Preoperatively, each patient underwent outpatient workup, including diagnostic venography with intravascular ultrasound (IVUS).

Results

The patients were 98% female, average age of 33.6 years, and body mass index of 21.5 kg/m². Those who became surgical candidates, had either left flank or left upper quadrant abdominal pain. Preoperative venography and IVUS demonstrated a mean left renal vein (LRV) stenosis of 74%, and dilated LRV collaterals were identified in 64%. Presenting symptoms were provoked with catheter advancement, and with contrast injection into the LRV or its tributaries in 74% and 45% of venograms, respectively. Surgery consisted of renal vein transposition (RVT) in 43 patients, autotransplantation (AT) in 6, and gonadal vein transposition (GVT) in 4. Renal artery denervation was done in 39/47 patients (83%) who had RVT or GVT. LRV reconstruction was needed in 15/43 patients (35%) who had RVT because the vein was too short or scarred for transposition. There were 7 renal vascular complications after RVT (none with AT or GVT), most following bovine pericardial neoconduit. After 11.2 ± 1.2 months of follow up, patients in this study reported that their symptoms had resolved in 43%, improved in 36%, improved then recurred in 13%, and had not changed in 8%. Good outcome was achieved after AT in 100%, after RVT in 79%, and after GVT in 50%.

Conclusions

Algorithm-based surgical management of NCS leads to symptom resolution or improvement in most patients. Renal vein reconstruction with bovine pericardial neoconduit is associated with a high rate of vascular complications.