Nutcracker syndrome (a Delphi consensus)

Floor Heilijgers; Peter Gloviczki; Gerry O'Sullivan; Bertrand Chavent; Efthymios D Avgerinos; Karem Harth; Stephen A Black; Young M Erben; Joris I Rotmans; Toby Richards; Rabih A Chaer; Laurencia Villalba; Arjun Jayaraj; Rafael D Malgor; Ramesh K Tripathi; Anahita Dua; Erin Murphy; Simon Rinckenbach; Suresh Vedantham; Jaap F Hamming; Joost R van der Vorst

doi:10.1016/j.jvsv.2024.101970

Nutcracker syndrome (a Delphi consensus)

J Vasc Surg Venous Lymphat Disord. 2024 Oct 2:101970. doi: 10.1016/j.jvsv.2024.101970. Online ahead of print.

Authors

Floor Heilijgers¹, Peter Gloviczki², Gerry O'Sullivan³, Bertrand Chavent⁴, Efthymios D Avgerinos⁵, Karem Harth⁶, Stephen A Black⁷, Young M Erben⁸, Joris I Rotmans⁹, Toby Richards¹⁰, Rabih A Chaer¹¹, Laurencia Villalba¹², Arjun Jayaraj¹³, Rafael D Malgor¹⁴, Ramesh K Tripathi¹⁵, Anahita Dua¹⁶, Erin Murphy¹⁷, Simon Rinckenbach¹⁸, Suresh Vedantham¹⁹, Jaap F Hamming¹, Joost R van der Vorst²⁰

Affiliations

¹ Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands.
² Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
³ Department of Interventional Radiology, Galway University Hospital, Galway, Ireland.
⁴ Department of Vascular Surgery, Clinique Générale, Annecy, France.
⁵ Department of Vascular Surgery, Athens Medical Center, University of Athens, Athens, Greece.
⁶ Department of Vascular Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve, Cleveland, OH.
⁷ Department of Vascular Surgery, Ashtead Hospital, Ashtead, UK.
⁸ Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
⁹ Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands.
¹⁰ Department of Anesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Surgery, School of Health, Sport & Bioscience University of East London, London, UK.
¹¹ Institute of Clinic Trials and Methodology, University College London, London, UK.
¹² Department of Vascular Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia.
¹³ Department of Vascular Surgery, The Rane Center for Venous and Lymphatic Disorders, Jackson, MS.
¹⁴ Department of Vascular Surgery, University of Colorado Anschutz Medical Center, Aurora, CO.
¹⁵ Department of Vascular Surgery, University of Queensland, Brisbane, Queensland, Australia.
¹⁶ Department of Vascular Surgery, Massachusetts General Hospital and Harvard University, Boston, MA.
¹⁷ Department of Vascular Surgery, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC.
¹⁸ Department of Vascular and Endovascular Surgery, University of Franche Comté, Besançon, France.
¹⁹ Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO.
²⁰ Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands. Electronic address: [email protected].

PMID: 39362632
DOI: 10.1016/j.jvsv.2024.101970

Abstract

Background: Nutcracker syndrome (NCS) describes the symptomatic compression of the left renal vein between the aorta and superior mesenteric artery. Whereas asymptomatic compression is a common radiological finding, patients with NCS can report a range of symptoms. There are no specific diagnostic criteria and interventions include a range of open surgical and endovascular procedures. Therefore, we wished to develop an international consensus document covering aspects of diagnosis, management, and follow-up for patients with NCS.

Methods: A three-stage modified Delphi consensus was performed. A steering committee developed 37 statements covering 3 categories for patients with NCS: diagnosis, management, and follow-up. These statements were reported individually by 20 international experts in the management of venous disease, using a 5-point Likert scale. Consensus was defined if ≥70% of respondents rated the statement between 1 and 2 (agreement) and between 4 and 5 (disagreement). Those statements without consensus were recirculated in a second round of voting. A third round of the questionnaire was performed with 14 additional statements to clarify diagnostic values of NCS.

Results: Responses were returned by 20 of 20 experts (100%) in round one and 17 of 20 (85%) in round two. Initial consensus was reached in 24 of 37 statements (65%) spread over all categories. Round two achieved a further consensus on 5 out of 10 statements (50%). No categories reported consensus on all statements. In round two consensus was reached in the category of follow-up (4/5 statements [80%]). The final round reached consensus on 5 out of 14 statements (36%). Experts agreed that imaging is obligated to confirm NCS. Experts did not agree on specific diagnostic cut-off values. There was a consensus that the first choice of operative treatment is left renal vein transposition and that the risk of stent migration outweighs the advantages of a percutaneous procedure.

Conclusions: Consensus was achieved on most statements concerning the assessment and management of NCS. This Delphi consensus identified those areas in which further research is needed, such as antiplatelet therapy, endovascular treatment, and renal autotransplantation. A rare disease registry to improve data and reports of patient outcomes is warranted.

Keywords: EVS Renal Autotransplantation; LRV LRV transposition Endovascular Stenting; NCS Delphi consensus Left Renal Vein; Nutcracker Syndrome.

Publication types

Review