Extravascular stent management for migration of left renal vein endovascular stent in nutcracker syndrome

Abstract

BackgroundNutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the superior mesenteric artery, which leads to symptoms of hematuria or left flank pain. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or embolization.Case presentationA 30-year-old female was diagnosed with nutcracker syndrome for severe left flank pain. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. She underwent successful extravascular stenting with complete symptom resolution.ConclusionThe extravascular stenting is an alternative option after migration of left renal vein endovascular stenting. The computed tomographic imaging was closely correlated to therapeutic interventions and stent migration.

3D-Printed PEEK Extravascular Stent in the Treatment of Nutcracker Syndrome: Imaging Evaluation and Short-Term Clinical Outcome

“…They reported that symptoms resolved in 10 patients and improved in 2, though one patient developed recurrent gross hematuria because of stent migration. Tian et al (2015) first reported one case of extravascular stent management that acted as a remedial measure for the migration of LRV endovascular stents in NCS. Importantly, however, these artificial blood vessels were not designed to serve as external vascular stents, and the single design hardly matches the diversity of anatomical features of the compressed portion of the LRV among individuals.…”

Diagnóstico e tratamento da síndrome de quebra-nozes (nutcracker ): revisão dos últimos 10 anos

“…It showed that in the years following these procedures, all patients treated with stents were asymptomatic, although two had persistent microscopic hematuria after physical exercise and one stent migrated to the right atrium, requiring surgery. 28,29 At least 150 successful cases of endovascular treatment have been reported in the medical literature. 27 However, information on long-term follow-up is still lacking, which justifies the reluctance to use it with young patients.…”

“…The reasons for migration may be the effect of cardiac movements, activities too soon after surgery, incompatibility between the diameter of the LRV and the diameter of the stent, or incorrect positioning. 29 The first-line, and safest, option for treatment of stent migration is percutaneous removal. 32 However, under certain circumstances, such as migration to the heart, use of a special stent, or endothelization in an inappropriate location, percutaneous removal may be difficult or impossible, requiring surgical intervention, which is a procedure associated with high morbidity rates.…”

“…The extravascular device is an alternative option for maintaining the device in the correct position. 29…”

Nutcracker syndrome: how are we cracking the nuts and whose nuts are we cracking?

“…In other small series, migration occurred in 17%-20% of cases ( 8 , 12 ). And almost all of these cases, migration occurred to the vena cava or to the heart, in many cases with serious complications requiring open heart surgery and even valvar replacement ( 11 , 13 , 14 ).…”