RESUMEN
Background: Nutcracker syndrome (NCS) is defined as left renal vein (LRV) compression by the superior mesenteric artery. NCS diagnosis is rendered complex by confounding symptoms. The study objective was to perform a prospective observational analysis of the diagnostic and therapeutic criteria of the patients with suspected NCS. When NCS diagnosis was confirmed, transposition of the LRV was carried out by mini-invasive robotic surgery (MIRS). Method: All patients addressed to the vascular surgery department for suspicion of NCS between January 2022 and June 2023 were included in the study. Patients were subsequently assessed by means of a computed tomography scan, dynamic duplex ultrasound and phlebography associated with an occlusion test of the left gonadic vein (LGV). Diagnostic criteria included aorto-mesenteric angle, LGV diameter and reflux, velocity ratios and diameters and the reno-caval gradient. Result: Thirty two patients aged 37 ± 14 years had suspicion of NCS. Twenty presented an aorto-mesenteric angle below 20°, twenty three had a LGV diameter greater than 5 mm and twenty two of the latter patients also had LGV reflux. A significant reno-caval gradient greater than 5 mmHg was found in ten cases, thereby consolidating NCS diagnosis. Overall, thirteen patients neither presented NCS or pelvic varicosities; eight had pelvic congestion syndrome without NCS and were successfully treated by embolization. Eleven patients with confirmed NCS underwent LRV transposition in the inferior vena cava (IVC). Eight of the latter patients received a complementary pelvic varicosity embolization 2 days later. Two months post-operation 100% of transposed LRV were permeable as assessed by duplex ultrasound controls and all of these patients reported an improvement of symptoms. Conclusion: An innovative multidisciplinary decisional algorithm establishes certitude in NCS diagnosis which can subsequently be treated radically by MIRS.
RESUMEN
Introduction: Arteriovenous malformations (AVMs) are rare, especially in elderly patients. Occasionally, AVM can produce aneurysmal degenerations, which can lead to bleeding or rupture. The aim of this case report was to describe the surgical treatment of large arterial and venous aneurysms in the arm associated with an AVM. Report: An 83 year old woman of White ethnicity who was a non-smoker presented with a large pulsatile aneurysm at the left elbow with paresis of the first three fingers. The diagnosis was made by duplex ultrasonography (DUS), computed tomography angiography (CTA), and arteriography. Additional tests confirmed aneurysms of the brachial artery and the outflow veins, with the largest more than 7 cm in diameter. A very proximal brachial artery bifurcation and increased venous flow were noted. DUS confirmed the AVM by showing continuous flow in the axillary vein. The decision for surgical resection involved vascular surgeons, radiologists, angiologists, and anaesthetists. Treatment involved opening and excision of multiple venous aneurysms and AVMs. A short segment of the aneurysmal brachial artery was also resected and repaired with end to end anastomosis. The deep brachial artery which supplied AVMs and venous aneurysms was ligated and excision of these lesions was performed. At one year follow up, there were no complications and the revascularisation was patent. Discussion: Arterial and venous aneurysms occurring together with AVMs are rare and not well documented in the medical literature. In this case, surgical intervention, including resection with direct anastomosis of the arterial aneurysm coupled with excision of venous aneurysms and AVM, proved to be effective, as evidenced by stable post-operative outcomes after one year.