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JAMA Aug 2022The role of ticagrelor with or without aspirin after coronary artery bypass graft surgery remains unclear. (Comparative Study)
Comparative Study Meta-Analysis
IMPORTANCE
The role of ticagrelor with or without aspirin after coronary artery bypass graft surgery remains unclear.
OBJECTIVE
To compare the risks of vein graft failure and bleeding associated with ticagrelor dual antiplatelet therapy (DAPT) or ticagrelor monotherapy vs aspirin among patients undergoing coronary artery bypass graft surgery.
DATA SOURCES
MEDLINE, Embase, and Cochrane Library databases from inception to June 1, 2022, without language restriction.
STUDY SELECTION
Randomized clinical trials (RCTs) comparing the effects of ticagrelor DAPT or ticagrelor monotherapy vs aspirin on saphenous vein graft failure.
DATA EXTRACTION AND SYNTHESIS
Individual patient data provided by each trial were synthesized into a combined data set for independent analysis. Multilevel logistic regression models were used.
MAIN OUTCOMES AND MEASURES
The primary analysis assessed the incidence of saphenous vein graft failure per graft (primary outcome) in RCTs comparing ticagrelor DAPT with aspirin. Secondary outcomes were saphenous vein graft failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events. A supplementary analysis included RCTs comparing ticagrelor monotherapy with aspirin.
RESULTS
A total of 4 RCTs were included in the meta-analysis, involving 1316 patients and 1668 saphenous vein grafts. Of the 871 patients in the primary analysis, 435 received ticagrelor DAPT (median age, 67 years [IQR, 60-72 years]; 65 women [14.9%]; 370 men [85.1%]) and 436 received aspirin (median age, 66 years [IQR, 61-73 years]; 63 women [14.5%]; 373 men [85.5%]). Ticagrelor DAPT was associated with a significantly lower incidence of saphenous vein graft failure (11.2%) per graft than was aspirin (20%; difference, -8.7% [95% CI, -13.5% to -3.9%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P < .001) and was associated with a significantly lower incidence of saphenous vein graft failure per patient (13.2% vs 23.0%, difference, -9.7% [95% CI, -14.9% to -4.4%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P < .001). Ticagrelor DAPT (22.1%) was associated with a significantly higher incidence of BARC type 2, 3, or 5 bleeding events than was aspirin (8.7%; difference, 13.3% [95% CI, 8.6% to 18.0%]; OR, 2.98 [95% CI, 1.99 to 4.47]; P < .001), but not BARC type 3 or 5 bleeding events (1.8% vs 1.8%, difference, 0% [95% CI, -1.8% to 1.8%]; OR, 1.00 [95% CI, 0.37 to 2.69]; P = .99). Compared with aspirin, ticagrelor monotherapy was not significantly associated with saphenous vein graft failure (19.3% vs 21.7%, difference, -2.6% [95% CI, -9.1% to 3.9%]; OR, 0.86 [95% CI, 0.58 to 1.27]; P = .44) or BARC type 2, 3, or 5 bleeding events (8.9% vs 7.3%, difference, 1.7% [95% CI, -2.8% to 6.1%]; OR, 1.25 [95% CI, 0.69 to 2.29]; P = .46).
CONCLUSIONS AND RELEVANCE
Among patients undergoing coronary artery bypass graft surgery, adding ticagrelor to aspirin was associated with a significantly decreased risk of vein graft failure. However, this was accompanied by a significantly increased risk of clinically important bleeding.
Topics: Aged; Aspirin; Coronary Artery Bypass; Female; Graft Occlusion, Vascular; Hemorrhage; Humans; Male; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Saphenous Vein; Ticagrelor; Treatment Outcome
PubMed: 35943473
DOI: 10.1001/jama.2022.11966 -
The Cochrane Database of Systematic... Apr 2022Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous... (Review)
Review
BACKGROUND
Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous catheter (CVC). CVC use is related to frequent complications such as venous stenosis and infection. Venous stenosis occurs mainly due to trauma caused by the entrance of the catheter into the venous lumen and repeated contact with the vein wall. A biofilm, a colony of irreversible adherent and self-sufficient micro-organisms embedded in a self-produced matrix of exopolysaccharides, is associated with the development of infections in patients with indwelling catheters. Despite its clinical relevance, the treatment of catheter-related bloodstream infections (CRBSIs) in patients receiving maintenance HD remains controversial, especially regarding catheter management. Antibiotic lock solutions may sterilise the catheter, treat the infection and prevent unnecessary catheter procedures. However, such treatment may also lead to antibiotic resistance or even clinical worsening in certain more virulent pathogens. Catheter removal and delayed replacement may remove the source of infection, improving infectious outcomes, but this approach may also increase vascular access stenosis, thrombosis or both, or even central vein access failure. Catheter guidewire exchange attempts to remove the source of infection while maintaining access to the same vein and, therefore, may improve clinical outcomes and preserve central veins for future access.
OBJECTIVES
To assess the benefits and harms of different interventions for CRBSI treatment in patients receiving maintenance HD through a permanent CVC, such as systemic antibiotics alone or systemic antibiotics combined with either lock solutions or catheter guidewire exchange or catheter replacement.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Register of Studies up to 21 December 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) and quasi-RCTs evaluating the management of CRBSI in permanent CVCs in people receiving maintenance HD.
DATA COLLECTION AND ANALYSIS
Two authors independently selected studies for inclusion, assessed their risk of bias, and performed data extraction. Results were expressed as risk ratios (RR) or hazard ratios (HR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with their 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE.
MAIN RESULTS
We identified two RCTs and one quasi-RCT that enrolled 760 participants addressing the treatment of CRBSIs in people (children and adults) receiving maintenance HD through CVC. No two studies compared the same interventions. The quasi-RCT compared two different lock solutions (tissue plasminogen activator (TPA) and heparin) with concurrent systemic antibiotics. One RCT compared systemic antibiotics alone and in association with an ethanol lock solution, and the other compared systemic antibiotics with different catheter management strategies (guidewire exchange versus removal and replacement). The overall certainty of the evidence was downgraded due to the small number of participants, high risk of bias in many domains, especially randomisation, allocation, and other sources of bias, and missing outcome data. It is uncertain whether an ethanol lock solution used with concurrent systemic antibiotics improved CRBSI eradication compared to systemic antibiotics alone (RR 1.61, 95% CI 1.16 to 2.23) because the certainty of this evidence is very low. There were no reported differences between the effects of TPA and heparin lock solutions on cure rates (RR 0.92, 95% CI 0.74 to 1.15) or between catheter guidewire exchange versus catheter removal with delayed replacement, expressed as catheter infection-free survival (HR 0.88, 95% CI 0.43 to 1.79). To date, no results are available comparing other interventions. Outcomes such as venous stenosis and/or thrombosis, antibiotic resistance, death, and adverse events were not reported.
AUTHORS' CONCLUSIONS
Currently, there is no available high certainty evidence to support one treatment over another for CRBSIs. The benefit of using ethanol lock treatment in combination with systemic antibiotics compared to systemic antibiotics alone for CRBSIs in patients receiving maintenance HD remains uncertain due to the very low certainty of the evidence. Hence, further RCTs to identify the benefits and harms of CRBSI treatment options are needed. Future studies should unify CRBSI and cure definitions and improve methodological design.
Topics: Adult; Catheter-Related Infections; Central Venous Catheters; Child; Heparin; Humans; Renal Dialysis; Sepsis
PubMed: 35363884
DOI: 10.1002/14651858.CD013554.pub2 -
Pediatric Nephrology (Berlin, Germany) Feb 2016Hematuria secondary to renal vein entrapment is mentioned only passing in textbooks and reviews. (Review)
Review
BACKGROUND
Hematuria secondary to renal vein entrapment is mentioned only passing in textbooks and reviews.
METHODS
We performed a search of the National Library of Medicine database for peer-reviewed publications using the terms "renal vein" or "nutcracker" and "hematuria".
RESULTS
We identified 187 published reports/studies that covered 736 patients, of whom 288 had microscopic hematuria and 448 had macroscopic hematuria. The patient cohort comprised 159 patients aged ≤17 years. Abdominal pain was absent in approximately 65% of all patients, and a clinically relevant left-sided varicocele was observed in 29% of the male patients. A normal pre-aortic left renal vein and an anomalous anatomy were noted in 680 and 56 patients, respectively. The body mass index (BMI) was lower in patients with renal vein entrapment than in the controls, with a regression of hematuria correlating with an increase in BMI. A surgical procedure was attempted in 34% of the patients, of which the most common were endovascular stenting and transposition of the renal vein distally into the vena cava.
CONCLUSIONS
In cases of unexplained hematuria with or without abdominal pain, clinicians should consider the diagnosis of renal vein congestion, especially in males with varicocele. Ultrasonic Doppler flow scanning is the recommended initial diagnostic modality in these patients. Expectation management is advised in the great majority of cases.
Topics: Adolescent; Adult; Child; Constriction, Pathologic; Female; Hematuria; Humans; Male; Renal Nutcracker Syndrome; Renal Veins; Young Adult
PubMed: 25627663
DOI: 10.1007/s00467-015-3045-2 -
Critical Care Medicine Mar 2004In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for severe sepsis and septic shock that... (Review)
Review
OBJECTIVE
In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.
DESIGN
The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.
METHODS
We used a modified Delphi methodology for grading recommendations, built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.
RESULTS
Key recommendations, listed by category and not by hierarchy, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition; appropriate diagnostic studies to ascertain causative organisms before starting antibiotics; early administration of broad-spectrum antibiotic therapy; reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate; a usual 7-10 days of antibiotic therapy guided by clinical response; source control with attention to the method that balances risks and benefits; equivalence of crystalloid and colloid resuscitation; aggressive fluid challenge to restore mean circulating filling pressure; vasopressor preference for norepinephrine and dopamine; cautious use of vasopressin pending further studies; avoiding low-dose dopamine administration for renal protection; consideration of dobutamine inotropic therapy in some clinical situations; avoidance of supranormal oxygen delivery as a goal of therapy; stress-dose steroid therapy for septic shock; use of recombinant activated protein C in patients with severe sepsis and high risk for death; with resolution of tissue hypoperfusion and in the absence of coronary artery disease or acute hemorrhage, targeting a hemoglobin of 7-9 g/dL; appropriate use of fresh frozen plasma and platelets; a low tidal volume and limitation of inspiratory plateau pressure strategy for acute lung injury and acute respiratory distress syndrome; application of a minimal amount of positive end-expiratory pressure in acute lung injury/acute respiratory distress syndrome; a semirecumbent bed position unless contraindicated; protocols for weaning and sedation/analgesia, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening; avoidance of neuromuscular blockers, if at all possible; maintenance of blood glucose <150 mg/dL after initial stabilization; equivalence of continuous veno-veno hemofiltration and intermittent hemodialysis; lack of utility of bicarbonate use for pH > or =7.15; use of deep vein thrombosis/stress ulcer prophylaxis; and consideration of limitation of support where appropriate. Pediatric considerations included a more likely need for intubation due to low functional residual capacity; more difficult intravenous access; fluid resuscitation based on weight with 40-60 mL/kg or higher needed; decreased cardiac output and increased systemic vascular resistance as the most common hemodynamic profile; greater use of physical examination therapeutic end points; unsettled issue of high-dose steroids for therapy of septic shock; and greater risk of hypoglycemia with aggressive glucose control.
CONCLUSION
Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that are hoped to translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually and even more rapidly as some important new knowledge becomes as available.
Topics: Adult; Age Factors; Algorithms; Child; Evidence-Based Medicine; Humans; Sepsis; Shock, Septic
PubMed: 15090974
DOI: 10.1097/01.ccm.0000117317.18092.e4 -
Journal of Human Hypertension Oct 2022The study aims to compare clinical outcomes following renal denervation (RDN) in hypertensive patients with atrial fibrillation (AF). Three online databases were... (Meta-Analysis)
Meta-Analysis Review
The study aims to compare clinical outcomes following renal denervation (RDN) in hypertensive patients with atrial fibrillation (AF). Three online databases were searched (MEDLINE, EMBASE and PubMed) for literature related to outcomes of RDN on hypertension and AF, between January 1, 2010, and June 1, 2021. Where possible, risk ratios (RR) and mean differences (MD) were combined using a random effects model. Significance was set at p ≤ 0.05. Seven trials were included that assessed the effect of adding RDN to pulmonary vein isolation (PVI) in patients with hypertension and AF. A total of 711 patients (329 undergoing PVI + RDN and 382 undergoing PVI alone), with an age range of 56 ± 6 to 68 ± 9 years, were included. Pooled analysis showed a significant lowering of AF recurrence in the PVI + RDN (31.3%) group compared to the PVI-only (52.9%) group (p < 0.00001). Pooled analysis of patients with resistant hypertension showed a significant mean reduction of systolic blood pressure (SBP) (-9.42 mm Hg, p = 0.05), but not diastolic blood pressure (DBP) (-4.11 mm Hg, p = 0.16) in favor of PVI + RDN. Additionally, the pooled analysis showed that PVI + RDN significantly improved estimated glomerular filtration rate (eGFR) (+10.2 mL/min per 1.73 m, p < 0.001) compared to PVI alone. RDN procedures in these trials have proven to be both safe and efficacious with an overall complication rate of 6.32%. Combined PVI and RDN is beneficial for patients with hypertension and AF. Combined therapy showed improvement in SBP and eGFR, reducing the risk of AF recurrence. RDN may serve as an innovative intervention in the treatment of AF.
Topics: Atrial Fibrillation; Catheter Ablation; Humans; Hypertension; Recurrence; Renal Artery; Sympathectomy; Treatment Outcome
PubMed: 35094013
DOI: 10.1038/s41371-022-00658-0 -
International Journal of Surgery... Sep 2023The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus... (Meta-Analysis)
Meta-Analysis
Perioperative and oncologic outcomes of minimally-invasive surgery for renal cell carcinoma with venous tumor thrombus: a systematic review and meta-analysis of comparative trials.
BACKGROUND
The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus (MI-RNTT) with open radical nephrectomy with tumor thrombus (O-RNTT).
METHODS
This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library database) were systematically searched to identify relevant studies published in English up to December 2022. The primary outcomes were perioperative results, complications, and oncologic outcomes. Review Manager 5.4 was used for this analysis.
RESULTS
In total, eight retrospective trials with a total of 563 patients were included. Compared to O-RNTT, MI-RNTT had shorter hospitalization time [weighted mean difference (WMD) -3.58 days, 95% CI: -4.56 to -2.59; P <0.00001), lower volumes of blood loss (WMD -663.32 ml, 95% CI: -822.22 to -504.42; P <0.00001), fewer transfusion rates (OR 0.18, 95% CI: 0.09-0.35; P <0.00001), fewer overall complications (OR 0.33, 95% CI: 0.22-0.49; P <0.00001), and fewer major complications s (OR 0.49, 95% CI: 0.24-1.00; P =0.05). However, operative time, intraoperative complications, mortality rate (intraoperative, within 30 days, and total mortality), overall survival, recurrence-free survival, and cancer-specific survival did not significantly differ between the two groups.
CONCLUSIONS
MI-RNTT possesses more benefits than O-RNTT in terms of length of hospital stay, blood loss, and complications and provides comparable mortality rates and oncologic outcomes. However, more comprehensive and rigorous research is warranted to further validate the outcomes, which should include a larger sample size and comprehensive data from high-volume medical centers.
Topics: Humans; Carcinoma, Renal Cell; Retrospective Studies; Treatment Outcome; Veins; Kidney Neoplasms; Postoperative Complications
PubMed: 37526108
DOI: 10.1097/JS9.0000000000000405 -
Journal of Arrhythmia Jun 2020This systematic review and meta-analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone...
Efficacy and safety of renal denervation in addition to pulmonary vein isolation for atrial fibrillation and hypertension-Systematic review and meta-analysis of randomized controlled trials.
INTRODUCTION
This systematic review and meta-analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone for treating atrial fibrillation (AF) with hypertension.
METHODS
A systematic literature search from several electronic databases was performed up until January 2020. The primary outcome was AF recurrence defined as AF/atrial flutter (AFL)/atrial tachycardia (AT) ≥30 seconds at 12-month follow-up and the secondary outcome was procedure-related complications.
RESULTS
There were 568 subjects from five studies. AF recurrence was 90/280 (32.1%) in the RDN + PVI group and 142/274 (51.8%) in the PVI group. RDN + PVI was associated with a lower incidence of AF recurrence (RR 0.62 [0.51, 076], < .001; : 0%). Pooled analysis of HR showed that RDN + PVI was associated with reduced AF recurrence (HR 0.51 [0.38, 0.70], < .001; : 0%). Complications were 7/241 (2.9%) in the RDN + PVI group and 8/237 (3.4%) in the PVI group. The rate of complications between the groups was similar (RR 0.87 [0.33, 2.29], = .77; : 0%). In the subgroup analysis of paroxysmal AF, RDN + PVI was shown to reduce AF recurrence (RR 0.64 [0.49, 0.82], < .001; : 0% and HR 0.56 [0.38, 0.82], = .003; : 0%) compared to PVI alone. RDN + PVI has a moderate certainty of evidence in the reducing AF recurrence with an absolute reduction of 197 fewer per 1000 (from 254 fewer to 124 fewer).
CONCLUSION
RDN in addition to PVI, is associated with reduced 12-month AF recurrence and similar procedure-related complications compared to PVI alone.
PubMed: 32528562
DOI: 10.1002/joa3.12353 -
The Journal of Vascular Access 2015The aim of this study is to determine the optimal range of cephalic vein and radial artery diameter following preoperative duplex imaging to enhance maturation and... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The aim of this study is to determine the optimal range of cephalic vein and radial artery diameter following preoperative duplex imaging to enhance maturation and primary patency of Brescia-Cimino radiocephalic arteriovenous fistula.
METHODS
A systematic review and meta-aggregation of literature from 1966 to January 2015 in English language and adult subjects in Pubmed, OVID, CINHAL and Cochrane database was conducted.
RESULTS
This search produced a total of thirty-six (n = 36) articles. Following the application of recruitment criteria, only twelve articles (n = 12) were found eligible. Their quality was assessed by Oxford Critical Appraisal skills Programme (CASP) and their recommendation for practice was examined through National Institute for Health and Care Excellence (NICE).
CONCLUSIONS
The current literature suggests that the optimal range of radial artery for maximum performance (maturation and primary patency) of RCAVF is at least 2 mm (level 2, grade a). The cephalic vein diameter of at least 2 mm (non-augmented) can result in best maturation and primary patency outcomes (level 2, grade a) and threshold below 1.5 mm is not advocated (level 2, grade b).
Topics: Arteriovenous Shunt, Surgical; Brachiocephalic Veins; Humans; Practice Guidelines as Topic; Predictive Value of Tests; Radial Artery; Renal Dialysis; Treatment Outcome; Ultrasonography, Doppler, Duplex; Vascular Patency
PubMed: 26109534
DOI: 10.5301/jva.5000413 -
Journal of Clinical Hypertension... Jul 2020The present meta-analysis aims to compare renal arterial and venous Doppler parameters in women with preeclampsia and healthy pregnant controls. Medline, Scopus,... (Meta-Analysis)
Meta-Analysis Review
The present meta-analysis aims to compare renal arterial and venous Doppler parameters in women with preeclampsia and healthy pregnant controls. Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and Google Scholar databases were systematically searched from inception to December 04, 2019. All observational studies reporting renal resistive index, pulsatility index, renal interlobar vein impedance, or pulse transit time among preeclamptic and healthy pregnant women were held eligible. Subgroup analysis was conducted on the basis of disease onset and side of measurement. Both pair-wise and network meta-analysis were performed using Review Manager 5.3 and R-3.4.3 software. Fourteen studies were included, with a total of 1118 women. No difference of renal resistive (MD: 0.00, 95% CI: [-0.03, 0.04]) and pulsatility index (MD: -0.01, 95% CI: [-0.14, 0.12]) was evident between the two groups. Renal interlobar vein impedance was estimated to be significantly higher in preeclampsia (MD: 0.07, 95% CI: [0.06, 0.09]), while venous pulse transit time was significantly lower (MD: -0.10, 95% CI: [-0.14, -0.05]) in women with the disease. Subgroup analysis indicated that early-onset preeclampsia was associated with significantly elevated renal interlobar vein impedance and lower venous pulse transit time than late-onset disease. The outcomes of the present meta-analysis suggest that preeclampsia is characterized by venous hemodynamic dysfunction as it is associated with significantly elevated renal interlobar vein impedance and shorter venous pulse transit time. Future large-scale prospective studies should introduce cutoff values and determine the optimal timing of measurement in order to achieve optimal predictive accuracy.
Topics: Female; Hemodynamics; Humans; Kidney; Pre-Eclampsia; Pregnancy; Prospective Studies
PubMed: 32644302
DOI: 10.1111/jch.13940 -
Journal of Vascular Surgery. Venous and... Nov 2022Nutcracker syndrome (NCS) is an increasingly recognized venous compressive disease. Although people with NCS can experience debilitating symptoms, making an accurate... (Review)
Review
OBJECTIVE
Nutcracker syndrome (NCS) is an increasingly recognized venous compressive disease. Although people with NCS can experience debilitating symptoms, making an accurate diagnosis can often be challenging owing to the broad spectrum of clinical presentations and radiologic findings. In the present systematic review, we assessed the most frequent clinical and radiologic criteria used in establishing a diagnosis of NCS and have proposed a comprehensive framework for clinical decision-making.
METHODS
We performed a systematic review to identify all observational studies or case series conducted within the previous 10 years that had studied patients with a clinical and radiologic diagnosis of NCS. The extracted data included details related to the study design, participant demographics, presenting clinical features, and radiologic criteria. These details were compared between studies and synthesized to establish a comprehensive diagnostic framework that would be applicable to clinical practice.
RESULTS
In the present review, we included 14 studies with a total of 384 patients with NCS. The most common clinical features of NCS were hematuria (69.5%), left flank or abdominal pain (48.4%), pelvic pain (23.1%), and varicocele (15.8%). Computed tomography and ultrasound were the most commonly used imaging modalities, with a threshold for left renal vein stenosis of >80% the most frequently used diagnostic parameter. Eight studies had used venography, with the renocaval pressure gradient the most commonly measured parameter. Two studies had reported using intravascular ultrasound. The findings from our review have shown that a thorough clinical workup of NCS should include critical evaluation of the presenting clinical features and exclusion of alternative diagnoses. All patients should undergo duplex ultrasound with or without the addition of computed tomography or magnetic resonance imaging. Any patient considered for therapeutic intervention should also undergo diagnostic venography with measurement of the renocaval pressure gradient and, if available, intravascular ultrasound with measurement of the left renal vein diameters.
CONCLUSIONS
NCS is a challenging condition in terms of the diagnosis and management both. We have proposed a comprehensive diagnostic framework based on the currently available literature to aid in clinical decision-making.
Topics: Algorithms; Constriction, Pathologic; Humans; Male; Renal Nutcracker Syndrome; Renal Veins; Vascular Diseases
PubMed: 36007798
DOI: 10.1016/j.jvsv.2022.08.003