Endovenous removal of dislodged left renal vein stent in a patient with nutcracker syndrome

Stent migration and dislodgment is a potential complication after endovenous stenting of the left renal vein (LRV) for nutcracker syndrome. Our purpose is to describe the technique for endovenous removal of such a dislodged stent that was used in a 36-year-old woman with nutcracker syndrome initially treated with renal vein transposition. Recurrent renal vein compression and symptoms developed and a 14 × 20-mm self-expanding stent was placed in the LRV and was noted to be dislodged into the inferior vena cava on the first post-procedure day. Through right internal jugular access, the stent was stabilized by cannulating a cell of the stent using a guide wire and an angled angiographic catheter. A 20Fr sheath was then placed via right femoral vein access into the inferior vena cava. The stent lumen was cannulated from femoral approach and the stent straightened with a stiff wire. An 18-mm angioplasty balloon was then used to capture the stent. The stent was then compressed with two 25-mm loop snares while simultaneously deflating the balloon as it was pulled into the 20Fr sheath and removed. The LRV was restented with an 18 × 40-mm self-expanding stent. Stenting of LRV for nutcracker syndrome can result in stent migration. Endovenous removal of such a dislodged self-expanding stent is feasible. Our technique emphasizes stent stabilization with cell cannulation and capture over a larger diameter balloon.     

左肾静脉支架植入治疗胡桃夹综合征

目的探讨介入治疗胡桃夹综合征的效果。方法 4例胡桃夹综合征男性患者,年龄17～26岁,临床表现为肉眼血尿和镜下蛋白尿;B超示左肾静脉受压,狭窄处血流加快,CT示腹主动脉与肠系膜上动脉夹角处（〈30°）左肾静脉狭窄。对所有患者均采取介入治疗,行左肾静脉造影并测压后,经股静脉或颈静脉途径于左肾静脉植入长60mm、直径16～18mm自膨式血管支架。结果对4例患者介入治疗均取得成功。术后支架形态良好,血管受压现象消失,左肾静脉狭窄两端压力差由10～16mmHg下降为0～3mmHg,患者临床症状明显改善。随访6～12个月,除1例出现一过性镜下血尿外,余3例未见其他临床症状。结论采用介入方法治疗胡桃夹综合征具有微创、安全、治疗效果好的优点,对部分患者可替代手术治疗。     

Posterior nutcracker syndrome with left renal vein duplication: An uncommon cause of hematuria

INTRODUCTIONPosterior Nutcracker syndrome (NCS) is a rare anomaly in which the left renal vein passes behind the aorta which compresses it against the vertebral column, restricting the venous drainage of the left kidney.PRESENTATION OF CASEA 46 year-old lady presented with intermittent painless hematuria for 6 years. Urinalysis showed microscopic hematuria. An abdominal CT scan showed left renal vein duplication with the retroaortic branch trapped between the vertebral column and the aorta at the level of the aortic bifurcation, suggestive of posterior NCS. There were multiple small cortical cysts, sand-like stones in the left kidney and duplication of both right and left renal arteries.DISCUSSIONPosterior NCS in a patient with a duplicated left renal vein may not show all the clinical features of a typical NCS as the elevated pressure due to compression is dissipated through the pre-aortic branch of the duplicated renal vein. CT Angiography can be helpful in such a patient with multiple abnormalities. Management can range from simple surveillance to nephrectomy depending on the symptoms and renocaval pressure gradient.CONCLUSIONAlthough posterior NCS is a rare anomaly of the left renal vein, it should be considered in the differential diagnosis of haematuria.     

腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床分析

目的 探讨腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者5例.男4例,女1例.年龄20～35岁,平均25岁.肉眼血尿3例,活动后加重,合并蛋白尿1例;左腰酸痛伴左精索静脉曲张2例.术前彩色多普勒超声及CT三维血管重建均提示左肾静脉压迫明显.扩张段与受压段直径比值均＞3.膀胱镜检查3例可见左输尿管口喷血尿.5例均于全麻下行腹腔镜下左肾静脉受压段外支架固定术治疗,术中用人造血管固定于下腔静脉与生殖静脉之间形成血管外支架以克服左肾静脉受压.结果 5例手术均顺利完成.手术时间65～70 min,平均67 min.术中出血量10～15 ml,平均13 ml.术中术后无明显外科并发症,术后恢复顺利,术后5～6 d出院.肉眼血尿消失3例,左精索静脉曲张减轻2例.术后随访9～39个月,平均28个月,1例术前肉眼血尿、术后仍有轻微镜下血尿,4例尿常规检查正常.5例其余症状均消失,超声检查示左肾静脉血流通畅、受压现象消失.结论 腹腔镜下左肾静脉外支架固定术采用人造血管环绕左肾静脉抵抗肠系膜上动脉压迫,是治疗左肾静脉压迫综合征的一种可供选择的微创技术,手术简单、方便、安全有效,创伤小、痛苦少、恢复快.

Abstract：

Objective To report the experience in the use of laparoscopic extravascular stent for the treatment of the nutcracker syndrome. Methods Five patients (4 men and 1 woman) aged 20 to 35 years (mean 25) underwent laparoscopic extravascular stent of the left renal vein (LRV) for treatment of nutcracker syndrome associated with severe recurrent gross hematuria and left gonadal vein varices. All patients met the criteria for establishing the diagnosis of nutcracker syndrome. Ultrasonography, computed tomography, and magnetic resonance imaging revealed visible entrapment of the LRV between the superior mesenteric artery and aorta. Bleeding from the left ureteral orifice was detected by cystoscopy in 3 cases. An externally reinforced graft was selected to form an external stent around the LRV to relieve the compression. Results The mean operation time was 67 min (65-70min). No complications occurred during surgery. The postoperative follow-up was 9 to 39 months (mean 28). Total relief was achieved in 4 men without a relapse of symptoms and abnormalities were not found in urine tests. There was partial relief for the female patient due to microscopic hematuria after the operation. In all the 5 cases, Color Doppler ultrasonography showed that the blood outflow was smooth, the inner diameter and flow velocity of the aortomesenteric portion of the LRV were both decreased, and the gonadal vein varices had diminished in diameter. Conclusions The laparoscopic extravgscular stent of the renal vein could be a feasible approach for re-establishing free renal venous outflow in patients with nutcracker syndrome. This slightly invasive treatment could eliminate the symptoms of the condition.     

腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床分析

目的 探讨腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者5例.男4例,女1例.年龄20～35岁,平均25岁.肉眼血尿3例,活动后加重,合并蛋白尿1例;左腰酸痛伴左精索静脉曲张2例.术前彩色多普勒超声及CT三维血管重建均提示左肾静脉压迫明显.扩张段与受压段直径比值均＞3.膀胱镜检查3例可见左输尿管口喷血尿.5例均于全麻下行腹腔镜下左肾静脉受压段外支架固定术治疗,术中用人造血管固定于下腔静脉与生殖静脉之间形成血管外支架以克服左肾静脉受压.结果 5例手术均顺利完成.手术时间65～70 min,平均67 min.术中出血量10～15 ml,平均13 ml.术中术后无明显外科并发症,术后恢复顺利,术后5～6 d出院.肉眼血尿消失3例,左精索静脉曲张减轻2例.术后随访9～39个月,平均28个月,1例术前肉眼血尿、术后仍有轻微镜下血尿,4例尿常规检查正常.5例其余症状均消失,超声检查示左肾静脉血流通畅、受压现象消失.结论 腹腔镜下左肾静脉外支架固定术采用人造血管环绕左肾静脉抵抗肠系膜上动脉压迫,是治疗左肾静脉压迫综合征的一种可供选择的微创技术,手术简单、方便、安全有效,创伤小、痛苦少、恢复快.     

腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床分析

目的 探讨腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者5例.男4例,女1例.年龄20～35岁,平均25岁.肉眼血尿3例,活动后加重,合并蛋白尿1例;左腰酸痛伴左精索静脉曲张2例.术前彩色多普勒超声及CT三维血管重建均提示左肾静脉压迫明显.扩张段与受压段直径比值均＞3.膀胱镜检查3例可见左输尿管口喷血尿.5例均于全麻下行腹腔镜下左肾静脉受压段外支架固定术治疗,术中用人造血管固定于下腔静脉与生殖静脉之间形成血管外支架以克服左肾静脉受压.结果 5例手术均顺利完成.手术时间65～70 min,平均67 min.术中出血量10～15 ml,平均13 ml.术中术后无明显外科并发症,术后恢复顺利,术后5～6 d出院.肉眼血尿消失3例,左精索静脉曲张减轻2例.术后随访9～39个月,平均28个月,1例术前肉眼血尿、术后仍有轻微镜下血尿,4例尿常规检查正常.5例其余症状均消失,超声检查示左肾静脉血流通畅、受压现象消失.结论 腹腔镜下左肾静脉外支架固定术采用人造血管环绕左肾静脉抵抗肠系膜上动脉压迫,是治疗左肾静脉压迫综合征的一种可供选择的微创技术,手术简单、方便、安全有效,创伤小、痛苦少、恢复快.     

左肾静脉下移术治疗左肾静脉压迫综合征(附3例报告)

目的 探讨改进治疗左肾静脉压迫综合征（即胡桃夹综合征-NCS）的手术方法。方珐对3例明确诊断为左肾静脉压迫综合征的患者采用左肾静脉下移与下腔静脉端侧吻合术。结果术中肾动脉阻断时间分别为20min、21min及16min。肉眼血尿消失时间分别在术后第3天、第5天及第4天，镜下血尿消失时间分别在术后第5天、第7天及第6天。随访4—6月，血尿均未复发。结论左肾静脉下移与下腔静脉行端侧吻合治疗左肾静脉压迫综合征，疗效满意。     

Laparoscopy-assisted left ovarian vein transposition to treat one case of posterior nutcracker syndrome

We report one case of posterior nutcracker syndrome treated by left ovarian vein (LOV) transposition. A 36-year-old woman was suffering from nutcracker syndrome associated with pelvic congestion syndrome. Color duplex scan, computed tomographic scan, and angiography demonstrated a stenosis of a retroaortic left renal vein with proximal dilatation and incompetence of the LOV. The renocaval pullback gradient was 10 mm Hg. The LOV was harvested laparoscopically and transposed into the inferior vena cava. Completion angiography showed a patent reconstruction with no significant gradient. At day 4, an asymptomatic thrombosis was treated by thromboaspiration. Forty months later, the patient remained asymptomatic with a patent transposition. Posterior nutcracker syndrome is a rare condition. When associated with pelvic congestion syndrome due to LOV reflux, it can be treated by LOV transposition.     

腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的疗效分析

目的 探讨腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者8例,男5例,女3例.年龄13 ～31岁,平均27岁.血尿病史3 ～46个月,均合并蛋白尿.8例彩色多普勒超声检查:左肾静脉狭窄段内径1.0～3.0 mm,平均2.4mm;扩张段内径5.3 ～ 14.9 mm,平均9.1 mm.扩张段与狭窄段比值均＞3.8例CT三维血管重建检查:左肾静脉受压明显,血流速度0.52 ～1.15 m/s,平均0.75 m/s;腹主动脉与肠系膜上动脉夹角9.3.～23.8.,平均18.6°.膀胱镜检查6例,均可见左侧输尿管口喷血.8例均行腹腔镜下左肾静脉外支架固定术治疗,术中将长5～8 cm直径1 cm的带外支撑环的e-PTFE人造血管固定于下腔静脉与肾门之间的左肾静脉外,以抵抗肠系膜上动脉的压迫,减轻肾静脉受压. 结果 8例患者手术顺利.手术时间55 ～140 min,平均63 min.术中出血量10 ～ 30 ml,平均14 ml.术中术后未发生外科并发症.术后恢复顺利,住院5～7 d,平均6d出院.术后随访3～20个月,血尿消失后未复发7例,7例尿常规检查正常.1例仍间断出现镜下血尿.8例彩色多普勒超声复查显示左肾静脉狭窄段内径6.5～8.7 mm,平均7.4 mm;扩张段与狭窄段比值1.1 ～1.4,平均1.3;流速0.23 ～0.42 m/s,平均0.31 m/s;腹主动脉与肠系膜上动脉夹角为51°～65°,平均57°. 结论 腹腔镜下人造血管外支架固定术是治疗左肾静脉压迫综合征的一种新术式,术中需暂时阻断肾动脉,无需离断左肾静脉或肠系膜上动脉等血管,设计巧妙,创伤小,恢复快,疗效满意.     

The posterior "nutcracker": hematuria secondary to retroaortic left renal vein

Retroaortic left renal vein is an uncommon variant in the renal venous system. Recently a patient with such anomaly presented to us with hematuria.     

肾静脉外支架固定术治疗左肾静脉压迫综合征

目的 探讨肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者8例.男7例,女1例.平均年龄16(6～25)岁.血尿病史6～36个月,合并蛋白尿2例.均行彩色多普勒超声检查,左肾静脉狭窄段平均直径2.2 mm、最大流速0.7 m/s,扩张段平均直径8.6 mm、最大流速0.2 m/s,扩张段与狭窄段直径比值均3(正常比值<2).CT三维血管重建检查5例示腹主动脉与肠系膜上动脉夹角30°～40°(正常值45°～60°).膀胱镜检查5例可见左输尿管口喷血尿.8例均行肾静脉外支架同定术治疗,取一段长5～10 cm、直径1 cm的人造血管纵行切开,环绕左肾静脉一端至肾门,另一端越过肠系膜上动脉与主动脉间夹角形成一隧道样外支架以减轻肾静脉受压.结果 8例手术均顺利完成.平均手术时间150 min.平均术中出血量50ml.术中术后无明显外科并发症,术后恢复顺利,平均9 d出院.肉眼血尿消失6例、减轻2例.彩色多普勒超声检查7例显示左肾静脉血最大流速0.4～0.7 m/s、无明显受压.术后随访2～24个月,平均10个月,除1例时有活动性肉眼血尿、超声检查显示左肾静脉仍有受压征象外,余7例症状消失、尿常规检查正常、超声检查示左肾静脉血流通畅、受压现象消失.结论 左肾静脉外支架固定术采用人造血管环绕肾静脉抵抗肠系膜上动脉压迫,设计巧妙、损伤小、疗效满意,是治疗左肾静脉压迫综合征的理想方法.