DISCLOSURES Investor, Adient Medical Consultant, Trisalus Medical - - PDF document

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4/4/2019 Nutcracker Syndrome: Who To Treat and What Works Best UCSF Vascular Symposium 2019 K. Pallav Kolli, MD Associate Professor of Clinical Radiology University of California, San Francisco 1 DISCLOSURES Investor, Adient Medical

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Nutcracker Syndrome: Who To Treat and What Works Best

UCSF Vascular Symposium 2019

K. Pallav Kolli, MD

Associate Professor of Clinical Radiology University of California, San Francisco

DISCLOSURES

Investor, Adient Medical
Consultant, Trisalus Medical

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THE NUTCRACKER SYNDROME

Flank pain
Hematuria (microscopic or

macroscopic)

Orthostatic proteinuria
Pelvic pain or varicocele

Quality of Life Problem ANATOMIC CONSIDERATIONS: PCS

Anterior Nutcracker Posterior Nutcracker

Shi Y e ta l. Clinical Radiology 2018

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Lamba R et al. Radiographics 2014

ANATOMIC CONSIDERATIONS: SMA SYNDROME WHO DEVELOPS NCS?

Prevalence unknown

– Young/middle-aged, F > M?

Overlap exists between symptomatic and

asymptomatic patients with similar imaging findings

– 1957 May and Thurner described findings in 430 cadavers

22% cadavers had intraluminal thickening directly related to

external compression of L iliac vein between R iliac artery against 5th lumbar vertebral body

– Nutcracker Phenomenon seen on 11-27% of CT scans

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HOW DO WE DIAGNOSE NCS?

Ananthan K et al. Eur J Vasc Endovasc Surg 2017

HOW DO WE DIAGNOSE NCS?

Normal Nutcracker PHENOMENON

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4/4/2019 5 Ratio of LRV hilum:narrowing > 4.9 Sensitivity 66.7%, Specificity 100%*

Fong JKK AJR 2014

HOW DO WE IDENTIFY NCP?

Kim KW et al. Eur J Radiol 2011

HOW DO WE IDENTIFY NCP?

BEAK Sign

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HOW DO WE IDENTIFY NCP?

Normal Aortomesenteric Angle Normal ~90° < 41° 100% sensitive, 55.6% specific*

Fong JKK AJR 2014

HOW DO WE IDENTIFY NCP?

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MEASUREMENTS, MEASUREMENTS, MEASUREMENTS

Y un SJ et al Abdom Radiol 2016

CAN WE DISTINGUISH NCP AND NCS?

Enlarged perirenal and/or gonadal vessels

Eliahou R et al. RadioGraphics 2012

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DO COLLATERALS HELP?

Y un SJ et al Abdom Radiol 2016

HOW DO WE DIAGNOSE NCS?

Ananthan K et al. Eur J Vasc Endovasc Surg 2017

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VENOGRAPHY VENOGRAPHY

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VENOGRAPHY IVUS

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NCP -> NCS

Ananthan K et al. Eur J Vasc Endovasc Surg 2017

Treatment of Nutcracker Syndrome

Velasquez CA et al. J Vasc Surg: Venous and Lym Dis 2018)

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Treatment of Nutcracker Syndrome

Ananthan K et al. Eur J Vasc Endovasc Surg 2017

Conservative approach

Growing individuals may experience resolution

because of an increase in intra-abdominal and retroperitoneal fat -> emphasize weight gain

Some propose conservative management for

24 months in adolescents and 6 months in adults

Treatment of Nutcracker Syndrome

Velasquez CA et al. J Vasc Surg: Venous and Lym Dis 2018

N = ~300

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Treatment of Nutcracker Syndrome

Velasquez CA et al. J Vasc Surg: Venous and Lym Dis 2018

Treatment of Nutcracker Syndrome

Velasquez CA et al. J Vasc Surg: Venous and Lym Dis 2018)

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Endovascular Treatment of NCS

Lamba R et al. Radiographics 2014

Endovascular Treatment of NCS

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Endovascular Treatment of NCS

Wu Z et al. J Vascu Surg: Venous and Lym Dis 2016

Migration Isn’t Immediate!!!

Wu Z et al. J Vascu Surg: Venous and Lym Dis 2016

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