gms | German Medical Science

Background: May-Thurner (MTS) and Nutcracker syndromes (NCS) are being diagnosed more with various methods of treatment modalities. Also, there's less awareness of systemic involvement of these syndromes that are not just limited to leg or kidney issues but multitsystemic involvement that include cardiovascular, gastrointestinal, genitourinary, gynocological, neurological and orthopedic-like symptoms that, in lack of primary diagnosis in these systems, have improved or resolved after appropriate interventions. We present 200+ (out of 500 cases) patient series of non-thrombotic MTS patients and 35 patient series of NCS patients with analysis of their multisystemic presentation, diagnostic work up, and treatment methods.

Methods: For MTS, out of 500+ non-thrombotic patients, we interviewed 200 patients so far over the phone or during their follow up visits to evaluate for symptomatic improvement other than leg swelling. Similarly, we have 35+ patient series of NCS patients who were evaluated before and after the surgery on follow ups to gather multisystemic systemic symptoms and improvement of their symptoms as mentioned in the background. These data were analyzed and computed with outcome of the surgical interventions. Diagnostic work up for both involved combination of ultrasound, CT, venograms using intravascular ultrasound (IVUS) as well as celiac and renal hilar blocks. Median arcuate ligament syndrome was concurrently evaluated and treated if indicated. Most of the MTS patients received endovascular stenting, and some had extravascular stents due to nickel alleries. NCS patients either underwent left renal vein transposition or autotransplant. Median arcuate ligament syndrome patients underwent ligament release +/- neurolysis or ligation by general laparoscopic surgeon in another institution.

Results: For MTS, stent patency was 99.5% at the follow up ranging from 6-60 months. Lower back or hip pain was present in 43% of patients with improvement or resolution in 90% of the patients. Gastrointestinal symptoms were present in 25% of the patients and more than 50% of the patients reported improvement or resolution of their issues. Genitourinary symptoms were present in 25% of patients and about 50% of patients improved or resolved their symptoms. What was thought as gynocological symptoms were present in 25% of the patients and about 50% of the patients improved or resolved their symptoms. Cardiovascular symptoms such as, dizziness, fainting, palpitations, and postural orthostatic tachycardia syndrome (POTS) were present in 10% of the patients and 50% of the patients reports resolution of these symptoms. Headaches and migraines were present in 25% of the patients and in lack of true neurologic diagnosis, their symptoms improved in 90% of the patients. Postural orthostatic tachycardia syndrome (POTS), Chronic Fatigue Syndrome (CFS) and Irritable Bowel Syndrome (IBS) patients stood out in their symptomatic improvement or resolution as these syndromes do not have clear etiology of their respective issues.

For NCS, Left Renal Vein Transposition and Autotransplant (done by other institute's transplant surgeons) had similar multisystemic presentations that improved or resolved nicely which includes, chronic headaches, gastrointestinal issues including gastric paresis, pain with eating, nausea and vomitting, pelvic congestion syndrome, left flank pain and hematuria, as well as several other systemic symptoms.

Conclusion: In our institution, we find comprehensive diagnosis of the vascular compression syndromes – May-Thurner, Nutcracker, Median Arcuate Ligament, and Superior Mesenteric Artery Syndrome – are critical in resolving their disease and symptoms. Significant correlations were found when treatment of one compression can make the other compression symptoms worse making it seem like the surgery was not successful. However, when all compressions are addressed, success rate of their symptomatic relief and return to normal life from what can be a devastating disease for many people who go undiagnosed and without treatment. Because of this, we have come to call these connected syndromes as Abdominal Vascular Compression Syndromes (AVCS).

Competing interests: None