AbstractObjectives Nutcracker syndrome (NCS) is an uncommon vascular disease, characterized by anatomic compression of the left renal vein (LRV). Associated symptoms include flank and pelvic pain, as well as hematuria and varicocele. Our objective was to examine the contemporary management of NCS including diagnostic work-up and outcomes of non-operative and operative treatments. Methods Patients diagnosed with NCS between 2000-2024 were identified through the Vascular Low Frequency Disease Consortium (VLFDC). Demographic, diagnostic, and treatment modalities were reported, including primary and secondary patency, reintervention, and symptom resolution/recurrence. Patient characteristics were reported using descriptive statistics and Kaplan-Meier analysis was used to report outcomes. Results NCS was diagnosed in 250 patients at 17 institutions. Mean age at diagnosis was 37±15 years, 90% were female, and 83% were White. Presenting symptoms and findings included non-positional flank pain (58%), chronic pelvic pain/dyspareunia (49%), hematuria (48%), non-positional abdominal pain (47%), and varicocele (3.3%). Diagnostic work-up of NCS included CT imaging of the abdomen/pelvis (84%), venogram (63%), duplex ultrasound (35%), and MRI (17%). Imaging demonstrated a mean aorto-superior mesenteric artery angle of 27.7 degrees. On duplex ultrasound, mean peak systolic velocity of the LRV was 108.9±99.0 cm/s at the compression point and 21.7±9.5 cm/s at the hilum with a PSV ratio of 4.98, while venography demonstrated a mean reno-caval pressure gradient of 3.92±2.40 mmHg. Nonoperative treatment with oral analgesics (29%), nutritional counseling/feeding regimen (16%), or simple expectant management (55%) was used in 116 patients and successful in 90 (78%) of patients with a mean follow-up of 328 days. Indications for non-operative management included mild symptoms (64%), young age (10%), and patient preference (8.4%). Of the 26 (22%) patients that failed non-operative treatment, 20 were subsequently managed with surgery. In the 134 patients who underwent surgery, either as initial treatment or after non-operative failure, 60 (44%) had a LRV transposition, 43 (31%) underwent a gonadal/ovarian vein transposition, 18 (12%) underwent renal auto-transplantation, and 19 (13%) underwent endovascular therapy. The overall three-year primary patency and secondary patency were 65% (95%CI, 51-76) and 96% (95%CI, 88-99), respectively. Three-year freedom from reintervention and symptom recurrence were 67% (95%CI, 53-78) and 60% (95%CI, 48-70), respectively. Patients who underwent endovascular intervention had inferior primary patency and freedom from symptom recurrence: 35% (95%CI, 1.22-78) and 46% (95%CI, 7.99-79), respectively. Conclusions Approximately 20% of patients with NCS initially managed non-operatively progressed to operative intervention. Surgery was associated with excellent secondary patency, but a substantial number of patients required reinterventions and 40% developed symptom recurrence by three years, highlighting the need for judicious patient selection for surgery through pre-operative counseling and shared decision-making. Endovascular therapy was associated with significantly worse results for all outcomes and therefore is not appropriate as initial treatment.
Suckow et al. (Wed,) studied this question.