目的:胡桃夹综合征是一种罕见的疾病,由于主动脉和肠系膜上动脉之间的左肾静脉阻塞而发生。它通常与诸如左侧腹疼痛等症状有关,血尿,蛋白尿,盆腔充血.目前的治疗方法可能是保守的,在存在可耐受的症状,以及在存在无法忍受症状的情况下,按优先顺序进行手术或混合和支架置入手术。这项研究的目的是回顾我们的经验,以评估本系列中两种方法的结果,在这些方法中,我们更倾向于手术而不是支架置入。
方法:回顾性分析2019年7月至2030年10月连续行左肾静脉转位和左肾静脉支架置入术的胡桃夹综合征患者的临床资料。根据治疗方法将患者分为两组:手术和支架置入。对于程序选择,主要推荐LRV转座,向那些拒绝的人提供支架。主要终点是发病率和死亡率。次要终点包括晚期并发症,通畅,免于再干预,和症状的解决。采用标准的基本统计和生存分析方法。
结果:19例胡桃夹综合征患者(女性-100%)接受了LRV支架(n=5)和左肾静脉转位(n=14)治疗。平均年龄为24(20-27,IQR)岁。平均随访23个月(9-32,IQR)。两种手术后均无重大并发症和死亡率。与左肾静脉卡压相关的最常见的体征和症状是左侧腹疼痛100%(n=19),蛋白尿88%(n=15),血尿占47%(n=9)。多普勒超声检查的平均峰值速度比为6.13(6-6.44,IQR)。主肠系膜角,喙角(喙标志),计算机断层扫描的平均直径比为26°(22.6-28.5,IQR),25°(23.9-28,IQR),和5.3(5-6,IQR),分别。静脉压测量仅用于确定支架置入组5例患者的诊断。测得的肾腔梯度为4(3.9-4.4,IQR)mmHg。在这两个程序之后,经典的症状,包括左翼疼痛,蛋白尿,血尿,解决了89.5%(n=17),57.8%(n=11),82.3%(n=15)的病例,分别。共有4名患者需要再次干预,3例LRV转位后患者(闭塞,n=2;狭窄,n=1),支架置入后1名患者(闭塞,n=1)。19例患者的1年和3年原发性通畅率分别为87%和80%,分别。三年初级辅助通畅率为100%。同样,一年和三年的再干预自由率为83%和72%,分别。此外,手术组的1年和3年主要通畅率分别为91%和81%,分别,支架组的1年和3年主要通畅率为75%.
结论:如果腰痛和血尿不能与肾脏疾病有关,则应牢记胡桃夹综合征。放射学证据必须伴有严重的症状,以便通过左肾静脉转位和血管内支架置入手术开始治疗胡桃夹综合征。这两个程序,以及它们各自的优点和缺点,可优选作为胡桃夹综合征的主要治疗方法。我们的研究表明,这两个程序都可以安全有效地执行,产生良好的结果。
BACKGROUND: Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting.
METHODS: The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed.
RESULTS: Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%.
CONCLUSIONS: Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.