Monocentric prospective study to valid multidisciplinary diagnostic and therapeutic approach for Nutcracker syndrome

Gwenaël John, Frederic Wilhelm, Louis Magnus, Mathilde Burgaud, Tristan Leterrier, Olivier Rouyer, Hélène Thiel, Philippe Nicolini, Pascal Chabrot, Fabien Thaveau
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Abstract

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.
单中心前瞻性研究,验证胡桃夹子综合征的多学科诊断和治疗方法
背景:胡桃钳综合征(NCS)是指肠系膜上动脉压迫左肾静脉(LRV)。NCS的诊断因症状的混杂而变得复杂。本研究旨在对疑似 NCS 患者的诊断和治疗标准进行前瞻性观察分析。在确诊为 NCS 后,通过微创机器人手术 (MIRS) 进行 LRV 转位。手术方法研究对象包括 2022 年 1 月至 2023 年 6 月期间因怀疑患有 NCS 而到血管外科就诊的所有患者。随后,通过计算机断层扫描、动态双相超声和静脉造影以及左性腺静脉(LGV)闭塞试验对患者进行评估。诊断标准包括主动脉-肠系膜夹角、LGV 直径和回流、速度比和直径以及雷诺-空腔梯度。结果32 名患者怀疑患有非结肠炎,年龄为 37 ± 14 岁。其中 20 名患者的主动脉-肠管夹角低于 20°,23 名患者的 LGV 直径大于 5 毫米,22 名患者的 LGV 也有回流。在十例患者中发现了大于 5 mmHg 的明显内腔-腔梯度,从而巩固了非结肠炎的诊断。总体而言,13 名患者既没有出现非结肠炎也没有出现盆腔静脉曲张;8 名患者有盆腔充血综合征,但没有出现非结肠炎,并成功接受了栓塞治疗。11 名确诊为 NCS 的患者接受了下腔静脉 (IVC) LRV 置换术。其中八名患者在两天后接受了盆腔静脉曲张辅助栓塞术。术后两个月,经双相超声对照评估,100% 的转位 LRV 都是通畅的,所有这些患者都表示症状有所改善。结论创新的多学科决策算法为非结肠炎的诊断提供了依据,随后可通过 MIRS 进行根治。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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