In most cases, compression of the left renal vein is between the abdominal aorta the main artery in the abdomen and the superior mesenteric artery, which brings blood. Pelvic venous congestion is a commonly overlooked condition that can be severely painful and debilitating for many women. Pelvic congestion syndrome ultrasound exam, risk factors. This condition results in chronic pelvic pain, estimated to affect onethird of women in the united states pelvic congestion syndrome is caused by dilatation of the ovarian andor. Ncp ultrasound criteria, and 7 ultrasound grades with criteria for definite, probable, and. Symptomatic hemodynamic compressions generate specific ultrasound criteria. Nutcracker syndrome renal vein entrapment findings axial contrastenhanced ct of the abdomen demonstrated compression of the left renal vein between the superior mesenteric artery sma and the aorta as the left renal vein crosses midline figure 1. Testing for venous disease and evaluation of hemodialysis access. The presence of increased flow within collateral vessels is further evidence of renal. Doppler ultrasonography us has been commonly used for the diagnosis of ncs. The condition may cause chronic pain, such as a constant dull ache, which can be worsened by standing or sex.
Venous compression syndromes, including pagetschroetter syndrome, nutcracker syndrome, maythurner syndrome and popliteal venous compression will be discussed. Nutcracker syndrome an overview sciencedirect topics. Nutcracker syndrome complicated by left renal vein thrombosis. Nutcracker syndrome servier phlebolymphologyservier. A venous duplex ultrasound examination can confirm the presence of venous obstruction or valvular incompetence as the cause of venous hypertension and is used for planning venous ablation procedures but is not necessary in all cases of suspected venous insufficiency where intervention is not being considered. Transabdominal pelvic venous duplex examination jill. Cgsurg106 venous angioplasty with or without stent. Transabdominal pelvic venous duplex examinations are performed to assess abnormal blood flow in the abdominal and pelvic veins excluding the portal venous system.
The term pelvic congestion syndrome specifically refers to the condition first described by louis alfred richet in 1857 and characterized by chronic, dull pelvic pain, pressure, and heaviness that persist for more than 6 months with no other cause. The treatments will also relieve painful symptoms associated with varicose veins, often as soon as the procedure is completed. Role of transabdominal and transperineal venous duplex. Pelvic ultrasound scan revealed predominantly distended varicose veins in the. Nutcracker syndrome is an underdiagnosed occurrence that can also result in ovarian vein insufficiency. No consensus diagnostic criteria exist to guide endovascular treatment. Numerous attempts have been made to improve doppler ultrasound diagnostic. Venous disorders of the abdomen and pelvis are often referred to as a number of syndromes, including pelvic congestion, maythurner, and nutcracker syndrome ncs, which are of historical significance, but inadequately reflect the underlying pathophysiology of these disorders. Nutcracker syndrome represents the constellation of symptoms caused by extrinsic compression of the left renal vein between the aorta and superior mesenteric artery, producing left renal venous. For evaluation the role of transabdominal and transperineal venous duplex ultrasound in cases of pelvic congestion syndrome, fifty patients with pelvic congestion syndrome were included in the current research. Intermittent hematuria and orthostatic proteinuria with or without abdominal or flank pain are the common clinical manifestations. Effect of renal doppler ultrasound on the detection of.
This study was based on a population of 16 patients with nutcracker syndrome who were compared with a control population. Meissner, peter gloviczki, in atlas of endovascular venous surgery second edition, 2019. Chronic venous insufficiency or cvi is often the underlying reason why varicose veins form. Venous angioplasty has been studied to treat a variety of other conditions, including but not limited to the treatment of ms or ccsvi, chronically occluded iliac veins, iliofemoral venous thrombosis, idiopathic intracranial hypertension and nutcracker syndrome. While the condition is believed to be due to blood flowing back into pelvic. Nutcracker syndrome is a vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric. Ncs can also lead to atypical varicose veins because of collateral development, and venous insufficiency of the lower limb 2,3. Lower extremity venous duplex ultrasound chronic venous insufficiency duration.
Renal nutcracker syndrome ncs is a condition that occurs when the left renal vein the vein that carries blood purified by the left kidney becomes compressed. Accf 20 appropriate use criteria for peripheral vascular ultrasound and physiological testing part ii. Ultrasound imaging can often demonstrate the compressed renal vein and allow for measurement of the vein diameter and stenosis secondary to the compression fig. Nutcracker syndrome, vascular imaging with ultrasound longdom. New appropriate use criteria auc released by the acc and developed in collaboration with 10 other leading professional societies provides detailed criteria to help clinicians optimize the appropriate use of peripheral vascular ultrasound and physiological testing when caring for patients with known or suspected venous disease. The importance of venous anatomy for the reflux ultrasound examination.
The nutcracker syndrome ncs results most commonly from the compression of the left renal vein lrv between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. Multidetector ct of vascular compression syndromes in the. Venous insufficiency syndromes are most commonly caused by valvular incompetence in the lowpressure superficial venous system but may also be caused by valvular incompetence in the hi. Doppler us and ct diagnosis of nutcracker syndrome ncbi. Nutcracker phenomenon ncp, also known as left renal vein entrapment, is characterized by impeded outflow from the left renal vein lrv into the inferior vena cava ivc due to extrinsic lrv compression, often accompanied by demonstrable lateral hilar dilatation and medial mesoaortic narrowing schematic representation of ncpnutcracker syndrome ncs in figure 1. To assess diagnosis of the nutcracker renal vein entrapment syndrome with doppler ultrasonography us. Nutcracker syndrome in children with gross haematuria. Transcutaneous ultrasound investigation in chronic deep. However, obstruction of the gonadal outflow may produce similar symptoms. Nutcracker syndrome ns refers to symptomatic compression of the left renal vein lrv between the abdominal aorta and superior mesenteric artery with potential symptoms including hematuria, proteinuria, left flank pain, and renal venous hypertension.
Duplex ultrasound investigation in pelvic congestion. Imaging diagnosis, treatment approaches, and therapeutic issues m. Mesoaortic compression of the left renal vein nutcracker syndrome produces both obstruction and reflux, resulting in symptoms of pelvic congestion. Nutcracker phenomenon and nutcracker syndrome ncbi. The objective is to assess the inferior vena cava ivc. It is characterized by left renal vein entrapment between the abdominal aorta and the superior mesenteric artery causing renal venous hypertension. Nutcracker syndrome occurs more frequently in women by the 3rd or 4th decades. The name derives from the fact that, in the sagittal plane andor transverse plane, the sma and aa with some imagination appear to be a nutcracker crushing a nut the renal vein. Pelvic congestion syndrome pcs, also known as pelvic vein incompetence or pelvic vein reflux, is a chronic medical condition in women caused by varicose veins in the lower abdomen. A case report of a young girl with recurrent hematuria. For diagnosis, after a clinical examination and blood examination. Nutcracker syndrome is characterized by gross haematuria caused by left renal vein lrv entrapment. Nutcracker syndrome is a variation of nutcracker phenomenon or renal vein entrapment syndrome, in which the arteries near the kidney compress the left renal kidney vein. Another common and simple test of venous insufficiency is venous filling time in which the time taken for the veins to refill following elevation of the limb for one minute or until.
It is a commonly missed and potentiallytreatable cause of chronic abdominopelvic pain. Diagnosis of the nutcracker syndrome with color doppler sonography. In venous insufficiency states, venous blood escapes from its normal antegrade path of flow and refluxes backward down the veins into an already congested leg. Nutcracker syndrome wikimili, the free encyclopedia. Anterior nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery and the aorta, with subsequent development of venous varicosities of the renal pelvis, ureter, and the gonadal vein. Pelvic congestion syndrome radiology reference article. Portal hypertension and acquired inferior vena cava syndrome may be related to the development of secondary pelvic venous congestion 2, 5, 6. Symptoms of pelvic venous congestion chronic pelvic pain, dyspareunia, dysuria, and dysmenorrhea have been attributed to massive gonadal reflux. The criteria for diagnosing varicoceles in men are relatively straight forward. Venous compression syndromes are a unique group of disorders characterized by anatomical extrinsic venous compression, typically in young and otherwise healthy individuals. Acc releases new auc for peripheral vascular ultrasound.
Venous duplex of the upper extremities for patency and thrombosis. All were evaluated by transabdominal and transperineal venous duplex. To assess the role of lrv ultrasonography in the diagnosis of the nutcracker syndrome in children. The nutcracker syndrome ncs results most commonly from the compression of the left renal vein lrv between the abdominal aorta aa and superior. Renal vein entrapment the nutcracker syndrome brandon t. Duplex ultrasound is firstline imaging for all patients presenting with signs or symptoms of pelvic venous insufficiency.
Because of the variability of symptoms and the absence of consensus regarding diagnostic criteria, the exact prevalence of nutcracker. Digital subtraction venography dsv is the imaging modality of choice for a number of venous conditions, including pelvic and gonadal vein insufficiency, 14, 15 venous malformations, 16 and may. Degree of left renal vein compression predicts nutcracker. The third step should look for indirect ultrasound criteria of venous obstruction. Duplex ultrasound for superficial venous insufficiency. The left kidney vein has to cross over the left sided aorta to get to the right sided vena cava. Khilnani is the director of fibroid treatment and the codirector of vein treatment and dr. Doppler ultrasound is the gold standard for evaluation of the venous system and is performed as a threepart test consisting of resting, augmentation, and reflux. Effect of renal doppler ultrasound on the detection of nutcracker syndrome in children with hematuria 19 october 2006 european journal of pediatrics, vol. Pelvic congestion syndrome some prefer pelvic venous insufficiency 9 is a condition that results from retrograde flow through incompetent valves in ovarian veins.
This condition occurs when small valves inside the vessels become damaged or simply wear out over. Renal nutcracker syndrome genetic and rare diseases. Chronic pelvic venous insufficiency is a common pathology, but it is overlooked and underdiagnosed as it sits on the edge of two medical specialties. Nutcracker syndrome, vascular imaging with ultrasound a case report svensson c 1,2. On rare occasions the kidney vein will go behind the aorta. Nutcracker syndrome ncs refers to the clinical manifestations of ncp.
When the two ratios are combined, sensitivity and specificity are 90% and 100%. Nutcracker phenomenon refers to compression of the left renal vein, most. Bryant radiology, 1 south street, kogarah, new south wales, 2217, australia. The following report examines two case studies where a diagnosis of ncp was made from. Search for anatomical and hemodynamic criteria of the nutcracker syndrome ncs. We aimed to evaluate the specificity of lrv compression to ns symptoms. When the kidney vein goes in front of the aorta, it may be pinched by the intestinal artery sma superior mesenteric artery anterior nutcracker syndrome. The true prevalence of nutcracker syndrome remains unknown and it might be underdiagnosed. Some people may not have symptoms, while others develop severe and.
Nutcracker syndrome is a vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric artery sma and aorta, although other variations can exist 1. This can lead to renal venous hypertension, resulting in rupture of thinwalled veins into. Anatomical development of symptoms the anatomy of the ivc bifurcation is noted when, in contrast to the right iliac vein which ascends almost vertically to the ivc, the left common iliac vein. While uncommon, they may cause serious complications including pain, swelling, deep venous thrombosis dvt, pulmonary embolism, and postthrombotic syndrome. Nutcracker syndrome ncs is a syndrome caused by compression of the left renal vein lrv, between the abdominal aorta and the superior mesenteric artery, resulting in hypertension of the lrv and hematuria. Sonographic view of pelvic congestion syndrome marie. Nutcracker syndrome 4 is a condition in which the left renal vein is compressed by the abdominal aorta and the superior mesenteric artery, resulting in a variable degree of left renal vein obstruction. Diagnosis and treatment of the nutcracker syndrome. Pelvic congestion syndrome, also known as pelvic vein incompetence, is a long term condition in women believed to be due to enlarged veins in the lower abdomen. Venous angioplasty with or without stent placement in adults. The underlying anatomic anomaly, first described by gant in 1937, can lead to left renal venous. Min is the director of vein treatment, cornell vascular, weill medical college of cornell university, new york, ny recent advances in the diagnosis and treatment of superficial venous insufficiency svi have provided new enthusiasm for the care of this prevalent medical condition. Our protocol for transabdominal pelvic vein duplex ultrasound. Nutcracker syndrome is an easily missed cause of hematuria in children.
1191 518 78 854 204 233 1516 350 12 1226 1278 659 531 1257 1048 883 484 1419 1434 103 1463 1282 548 1156 673 1466 239 908 278 466 932 878 834 1306 195 418 913 345 823 344