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Cardiovascular Diagnosis and Therapy Oct 2021Nutcracker syndrome (NCS) is an extrinsic compression of the left renal vein (LRV) by the superior mesenteric artery (SMA) anteriorly and aorta posteriorly resulting in... (Review)
Review
Nutcracker syndrome (NCS) is an extrinsic compression of the left renal vein (LRV) by the superior mesenteric artery (SMA) anteriorly and aorta posteriorly resulting in renal vascular congestion manifesting as hematuria, proteinuria, orthostatic hypotension, pain, or even renal dysfunction. Long-standing venous compression can encourage collateral drainage pathways through gonadal and pelvic veins, which may explain reported symptom and syndrome overlap with pelvic congestion syndrome. Diagnosis can be challenging and variable, frequently involving a combination of ultrasound Doppler, cross-sectional, and invasive imaging. Often, intravascular pressure measurements are required to prove a renocaval pressure gradient to aid in a definitive diagnosis. Conservative management is appropriate, especially in children, who tend to outgrow the disorder. In the interim, medical management with angiotensin converting enzyme inhibitors (ACEIs) is a useful therapy to manage orthostatic hypotension in the pediatric population. In adults, invasive therapies are more frequently pursued. These are aimed at relieving the extrinsic compression on the LRV. The standard of care is renal vein transposition, with renal autotransplantation reserved for recalcitrant cases. Endovascular stenting is a less invasive option. Laparoscopic placement of an exovascular stent is a newer therapy intended to minimize trauma to the LRV. In this review, we will discuss the clinical manifestations, diagnostic criterion, imaging features, and conservative and surgical therapies for this condition.
PubMed: 34815965
DOI: 10.21037/cdt-20-160 -
Techniques in Vascular and... Dec 2022The vascular lab (VL) provides vital information for dialysis access to guide management. This article discusses the indication, protocol, and diagnostic criteria for...
The vascular lab (VL) provides vital information for dialysis access to guide management. This article discusses the indication, protocol, and diagnostic criteria for the evaluation of arteriovenous fistulas and grafts. An arteriovenous (AV) dialysis access is made by creating a connection between an artery and vein (AV fistula [AVF]) or by interposing a conduit between an artery and a vein (AV graft [AVG]) to provide high flow circuit for hemodialysis. A normal mature AV dialysis access has a thrill or vibration from turbulent flow in the graft or vein. The nomenclatures at our institution for an AVF and AVG are in the Figure 1 A and B diagrams.
Topics: Humans; Arteriovenous Shunt, Surgical; Renal Dialysis; Arteriovenous Fistula; Veins; Arteries
PubMed: 36404066
DOI: 10.1016/j.tvir.2022.100864 -
JAMA Jan 2020Renal denervation can reduce cardiac sympathetic activity that may result in an antiarrhythmic effect on atrial fibrillation. (Randomized Controlled Trial)
Randomized Controlled Trial
Effect of Renal Denervation and Catheter Ablation vs Catheter Ablation Alone on Atrial Fibrillation Recurrence Among Patients With Paroxysmal Atrial Fibrillation and Hypertension: The ERADICATE-AF Randomized Clinical Trial.
IMPORTANCE
Renal denervation can reduce cardiac sympathetic activity that may result in an antiarrhythmic effect on atrial fibrillation.
OBJECTIVE
To determine whether renal denervation when added to pulmonary vein isolation enhances long-term antiarrhythmic efficacy.
DESIGN, SETTING, AND PARTICIPANTS
The Evaluate Renal Denervation in Addition to Catheter Ablation to Eliminate Atrial Fibrillation (ERADICATE-AF) trial was an investigator-initiated, multicenter, single-blind, randomized clinical trial conducted at 5 referral centers for catheter ablation of atrial fibrillation in the Russian Federation, Poland, and Germany. A total of 302 patients with hypertension despite taking at least 1 antihypertensive medication, paroxysmal atrial fibrillation, and plans for ablation were enrolled from April 2013 to March 2018. Follow-up concluded in March 2019.
INTERVENTIONS
Patients were randomized to either pulmonary vein isolation alone (n = 148) or pulmonary vein isolation plus renal denervation (n = 154). Complete pulmonary vein isolation to v an end point of elimination of all pulmonary vein potentials; renal denervation using an irrigated-tip ablation catheter delivering radiofrequency energy to discrete sites in a spiral pattern from distal to proximal in both renal arteries.
MAIN OUTCOMES AND MEASURES
The primary end point was freedom from atrial fibrillation, atrial flutter, or atrial tachycardia at 12 months. Secondary end points included procedural complications within 30 days and blood pressure control at 6 and 12 months.
RESULTS
Of the 302 randomized patients (median age, 60 years [interquartile range, 55-65 years]; 182 men [60.3%]), 283 (93.7%) completed the trial. All successfully underwent their assigned procedures. Freedom from atrial fibrillation, flutter, or tachycardia at 12 months was observed in 84 of 148 (56.5%) of those undergoing pulmonary vein isolation alone and in 111 of 154 (72.1%) of those undergoing pulmonary vein isolation plus renal denervation (hazard ratio, 0.57; 95% CI, 0.38 to 0.85; P = .006). Of 5 prespecified secondary end points, 4 are reported and 3 differed between groups. Mean systolic blood pressure from baseline to 12 months decreased from 151 mm Hg to 147 mm Hg in the isolation-only group and from 150 mm Hg to 135 mm Hg in the renal denervation group (between-group difference, -13 mm Hg; 95% CI, -15 to -11 mm Hg; P < .001). Procedural complications occurred in 7 patients (4.7%) in the isolation-only group and 7 (4.5%) of the renal denervation group.
CONCLUSIONS AND RELEVANCE
Among patients with paroxysmal atrial fibrillation and hypertension, renal denervation added to catheter ablation, compared with catheter ablation alone, significantly increased the likelihood of freedom from atrial fibrillation at 12 months. The lack of a formal sham-control renal denervation procedure should be considered in interpreting the results of this trial.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01873352.
Topics: Aged; Antihypertensive Agents; Atrial Fibrillation; Catheter Ablation; Combined Modality Therapy; Drug Resistance; Female; Humans; Hypertension; Kidney; Male; Middle Aged; Pulmonary Veins; Secondary Prevention; Single-Blind Method; Sympathectomy
PubMed: 31961420
DOI: 10.1001/jama.2019.21187 -
Journal of Radiology Case Reports May 2022Nutcracker syndrome (NCS) is a rare condition caused by the compression of the left renal vein between the abdominal aorta and the superior mesenteric artery. NCS may...
Nutcracker syndrome (NCS) is a rare condition caused by the compression of the left renal vein between the abdominal aorta and the superior mesenteric artery. NCS may present with unexplained hematuria. This case report presents a 43-year-old healthy female without any complaints who had newly-detected hematuria in urinalysis during her annual examination. Her physical examination and the whole abdominal ultrasonography failed to explain the cause of hematuria. Further investigation with contrast-enhanced upper abdominal computed tomography revealed a NCS. In unexplained cases of asymptomatic hematuria NCS should be taken into account after excluding other preliminary diagnoses.
Topics: Adult; Female; Hematuria; Humans; Mesenteric Artery, Superior; Renal Veins; Syndrome; Tomography, X-Ray Computed
PubMed: 35711687
DOI: 10.3941/jrcr.v16i5.4339 -
Cancers Nov 2023Cancer is associated with an increased risk of developing venous thromboembolism, due to its direct influence on the three pillars of Virchow's triad (e.g., compression... (Review)
Review
Cancer is associated with an increased risk of developing venous thromboembolism, due to its direct influence on the three pillars of Virchow's triad (e.g., compression on the blood vessels by the tumour, blood vessels invasion, and cytokine release), together with the effect of exogenous factors (such as chemotherapy, radiotherapy, surgery). In cancer patients, the risk of thrombosis at unusual sites, such as splanchnic, ovarian and renal vein thrombosis, is also increased. Abdominal vein thromboses are frequently incidental findings on abdominal imaging performed as part of the diagnostic/staging workup or the follow-up care of malignancies. There is little evidence on the management of unusual site venous thromboembolism in cancer patients since there are only a few specific recommendations; thus, the management follows the general principles of the treatment of cancer-associated deep vein thrombosis and pulmonary embolism. This narrative review summarises the latest evidence on cancer-associated abdominal vein thrombosis, i.e., thrombosis of the splanchnic, ovarian and renal veins.
PubMed: 37958466
DOI: 10.3390/cancers15215293 -
Indian Journal of Nephrology 2020Nutcracker phenomenon (NCP) refers to compression of the left renal vein (LRV), most frequently between the aorta and the superior mesenteric artery, with impaired blood...
Nutcracker phenomenon (NCP) refers to compression of the left renal vein (LRV), most frequently between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. The nutcracker syndrome (NCS) is the terminology used when the nutcracker phenomenon is accompanied by a complex of symptoms such as pain (abdominal, flank, and pelvic), hematuria and orthostatic proteinuria. Diagnosis can be made with Doppler ultrasound (DUS), computed tomography (CT), magnetic resonance imaging (MRI), and venography. We describe a case of a young female adult who was identified with NCP by DUS, after a first CT had found no abnormalities. She presented with flank pain and severe hematuria causing a drastic decrease in hemoglobin levels. The management of NCS depends upon the clinical presentation and the severity of the LRV hypertension. The treatment options range from conservative to nephrectomy. Treatment decision should be based on the age of patients, severity of symptoms, and their expected reversibility. This case describes an underreported disorder that presents with non-specific symptoms, demonstrating the difficulties of the diagnostic approach of NCS, as well as the challenges in the appropriate management, given the lack of standardized treatment.
PubMed: 33840963
DOI: 10.4103/ijn.IJN_286_19