Left Renal Vein Decompression and Left Renal Artery Denervation is a Novel Treatment for Nutcracker Syndrome and Shows Improvement in Quality of Life and Chronic Pain
Vascular Surgeon University of Maryland Medical Center Baltimore, Maryland, United States
Objective: Nutcracker syndrome (NCS) refers to the compression of the left renal vein (LRV) between the aorta and superior mesenteric artery that leads to chronic pain. The compression causes an outflow obstruction leading to venous hypertension which causes the development of venous tributaries, pelvic venous and lumbar venous reflux. Diagnostic renal hilar nerve blocks have been performed successfully to alleviate pain associated with NCS. Herein, we present initial and midterm results for a novel surgical technique to address this venous compression and chronic pain, left renal venous decompression and arterial denervation.
Methods: We performed a retrospective chart review of all patients who underwent left renal vein decompression and renal artery denervation surgery between February 2021 and March 2022. Eleven patients diagnosed with NCS underwent surgical decompression of the LRV and arterial denervation. Baseline demographic, surgical details, and post-operative courses were assessed and analyzed. As part of their standard care for NCS, all patients were given a validated survey pre- and post- operatively as well as during their three month follow up assessments. The Numerical Rating Scale (NRS) survey, Pain intensity scale, and the VascuQoL-6 survey were utilized pre- and post-operatively to assess the health-related quality of life.
Results: The patients were 100% female with the average age 28.6 years old (18-56), and underwent surgical LRV decompression and left renal artery denervation. Other medical history included POTS in 73% (8 out of 11), MALS in 82% (9 out of 11), SMAS in 18% (2 out of 11). Pre-operatively, LRV compression was confirmed with venogram using intravascular ultrasound (IVUS), with average stenosis 75% (range 57%-91.1%). The patients experienced chronic abdominal pain for an average of 3.8 years (1-8 years) prior to surgical intervention. The average NRS for pain before intervention was 8.9 (range 9.6-7.6) which improved to pain rating 5.6 (range 1-6.6) at the 3 month follow up. Pain intensity before intervention was very severe to severe and improved too mild to severe. VascuQoL-6 survey scores before intervention averaged 8.5 (range 6-11) improved to an average of 15.7 (range 9-19). Nine of the patients have been followed for more than 3 months post operatively and report pain score average pain score 1 (range 2.5-0), pain intensity mild to no pain, and VascuQol-6 score 22.1 (range 13-24).
Conclusions: Left renal vein decompression and left renal artery denervation for treatment of NCS addresses both venous compression, tributary flow with deep pelvic and lumbar vein reflux and chronic pain. This novel approach has some a significant improvement in quality of life for these patients with chronic pain.