Contemporary Management of Nutcracker Syndrome: A Systematic Review

Area of Science:

• Vascular Surgery
• Interventional Radiology
• Nephrology

Background:

• Nutcracker syndrome (NCS) is a rare vascular condition involving left renal vein (LRV) compression.
• Management options range from conservative approaches to open, laparoscopic, robotic, and endovascular interventions.
• Optimal treatment selection is challenging due to NCS rarity and variable outcomes.

Purpose of the Study:

• To systematically evaluate current treatment strategies for Nutcracker syndrome (NCS).
• To compare the effectiveness and reintervention rates of various NCS interventions.

Main Methods:

• Systematic review of studies on NCS treatments including conservative management, LRV/LGV transposition, renal autotransplantation (RAT), and stenting.
• Literature search conducted in PubMed/MEDLINE, Cochrane Library, and Web of Science (August 2014 - January 2025).
• Data collection followed PRISMA guidelines, assessing symptom resolution, pain/hematuria improvement, and reintervention needs.

Main Results:

• 24 studies with 578 patients were analyzed; interventions included endovascular stenting (76% resolution), RAT (69%), extravascular stenting (80%), LRV transposition (92%), LGV transposition (61%), and conservative management (52%).
• Extravascular stenting significantly increased the aortomesenteric angle (AMA) from 20.6° to 44.5° (P < 0.001).
• LRV transposition had the highest reintervention rate (28.5%), while extravascular stenting, LGV transposition, and hybrid procedures reported no reinterventions.

Conclusions:

• A wide array of therapeutic options exists for NCS beyond traditional LRV transposition.
• Individualized treatment selection based on patient anatomy and clinical profile is crucial.
• Limited data, short follow-up, and inconsistent reporting impede standardized treatment algorithm development.