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PVSS15. Left Renal Vein Transposition (LRVT) for Nutcracker Syndrome: Patient Selection, Early and Late Outcomes

Nanette R. Reed, Manju Kalra, Audra Duncan, T.C. Bower, T.J. Vrtiska, M.L. Blute, G.S. Oderich, J.J. Ricotta, P. Gloviczki.
Mayo Clinic Department of Vascular Surgery, Rochester, Minn.

OBJECTIVES: Nutcracker syndrome, caused by compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta, results in left renal and gonadal venous hypertension. Several treatment options have been described to relieve associated symptoms. The purpose of this study was to evaluate late results of LRVT and identify risk factors affecting outcomes.

METHODS: Clinical data from 22 consecutive patients diagnosed with nutcracker syndrome from January 1996 to October 2007 were retrospectively reviewed.

RESULTS: There were 10 males and 12 females (median age 22 years; range 14-67) with radiological evidence of LRV compression. On ultrasound evaluation (16/22 patients), the mean ratio of LRV peak systolic velocity measured at the site of compression and the renal hilum was 7.5 (range, 2.5-12). On venography (13/22 patients), the mean renocaval pressure gradient was 4 mmHg (range 2-6 mmHg). Eleven patients with atypical abdominal pain (n=4), transient hematuria (n=4), and varicocele (n=6) were managed expectantly. Eleven patients underwent LRV transposition through a transperitoneal exposure. Symptoms in these patients were more prominent and included severe left flank pain (n=10), hematuria (n=7), and varicocele (n=3). In 2/11 patients, the LRV was found to be occluded at operation. There were no early post-operative complications. All conservatively managed patients remained stable or improved. Over a mean follow-up of 39 months (range 0.13 - 144 months) in surgically managed patients, symptoms of flank pain and hematuria resolved or improved in 8/10 and 7/7, respectively. Varicoceles recurred in 2/3 patients in spite of resolution of flank pain. Both pre-operatively occluded LRVs re-thrombosed; 1 underwent thrombolysis with stenting, the other underwent reimplantation of the left gonadal vein into the IVC.

CONCLUSIONS: Left renal vein transposition is a safe, effective procedure in selected patients with persistent, severe symptoms. Patients with progression to occlusion of the LRV should be considered for alternative therapeutic procedures. Varicoceles, in the setting of nutcracker syndrome, may need independent repair.