Evidence map›Paper›PMID 41985840›Full record

ArticleJournal of vascular surgery. Venous and lymphatic disorders2026

Open surgery appears to be the preferred treatment in patients with nutcracker syndrome: A vascular low frequency disease consortium analysis.

Bjoern D Suckow, Aravind Ponukumati, Lily Wang, Jesse Columbo, David Stone, Richard Powell, Lauren N West-Livingston, Cynthia K Shortell, Yana Etkin, Samuel P R Paci and 28 more

Abstract readMulticenter Study
PubMed Full text at PMC Publisher
In one paragraph

Article in Journal of vascular surgery. Venous and lymphatic disorders, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. The continuing challenge of Nutcracker syndrome.Journal of vascular surgery. Venous and lymphatic disorders · 2026
    Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

38 authors.

Bjoern D SuckowDepartment of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH. Electronic address: bds@hitchcock.org.
Aravind PonukumatiDepartment of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Lily WangDepartment of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Jesse ColumboDepartment of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
David StoneDepartment of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Richard PowellDepartment of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Lauren N West-LivingstonDivision of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Burham, NC.
Cynthia K ShortellDivision of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Burham, NC.
Yana EtkinDivision of Vascular and Endovascular Surgery, Department of Surgery, Northwell Health, New Hyde Park, NY.
Samuel P R PaciDivision of Vascular and Endovascular Surgery, Department of Surgery, Northwell Health, New Hyde Park, NY.
Jake F HemingwayDivision of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WC.
Mark H MeissnerDivision of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WC.
Clara M Gomez-SanchezDivision of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA.
Collen P FlanaganDivision of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA.
Paul G BoveDivision of Vascular Surgery, Department of Surgery, Corewell Health East William Beaumont University Hospital, Royal Oak, MI.
Graham W LongDivision of Vascular Surgery, Department of Surgery, Corewell Health East William Beaumont University Hospital, Royal Oak, MI.
Brigitte K SmithDivision of Vascular Surgery, Department of Surgery, University of Utah, Salt Lake City, UT.
Alexander GombertDepartment of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany.
Mohammad Esmaeil BarbatiDepartment of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany; Department of Vascular Surgery, Ludwig Maximilian University Hospital, Munich, Germany.
Bernadette AulivolaDivision of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL.
Francesco StiloDivision of Vascular Surgery, Department of Medicine and Surgery, Campus BioMedico University, Fondazione Policlinico Campus BioMedico, Rome, Italy.
Nunzio MontelioneDivision of Vascular Surgery, Department of Medicine and Surgery, Campus BioMedico University, Fondazione Policlinico Campus BioMedico, Rome, Italy.
Giovanni De CaridiDivision of Vascular Surgery, Department of Biomorphological Sciences, University of Messina, Messina, Italy.
Filippo BenedettoDivision of Vascular Surgery, Department of Biomorphological Sciences, University of Messina, Messina, Italy.
Katharine L McGinigleDivision of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Mohammad AlsaarayrehDivision of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Zoltan SzeberinDepartment of Vascular and Endovascular Surgery, Semmelweis University Heart and Vascular Centre, Budapest, Hungary.
Dora Z ZatykoDepartment of Vascular and Endovascular Surgery, Semmelweis University Heart and Vascular Centre, Budapest, Hungary.
Kwame S AmankwahDivision of Vascular and Endovascular Surgery, Department of Surgery, University of Connecticut Healthcare Center, Farmington, CT.
Jin Hyun JohDivision of Transplantation and Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea.
Sungsin ChoDivision of Transplantation and Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea.
Marc L SchermerhornDivision of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
Sai Divya YadavalliDivision of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
Wei ZhouDivision of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ.
Jeffrey TolsonDivision of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ.
Peter LawrenceDivision of Vascular and Endovascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angles, CA.
Karen WooDivision of Vascular and Endovascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angles, CA.
Vascular Low Frequency Disease Consortium

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectivesNutcracker syndrome (NCS) is an uncommon vascular disease, characterized by anatomical compression of the left renal vein (LRV). Associated symptoms include flank and pelvic pain, as well as hematuria and varicocele. Our objective was to examine the contemporary management of NCS including diagnostic workup for and outcomes of nonoperative and operative treatments.

methodsPatients diagnosed with NCS between 2000 and 2024 were identified through the Vascular Low Frequency Disease Consortium. Demographic, diagnostic, and treatment modalities were reported, including primary and secondary patency, reintervention, and symptom resolution/recurrence. Patient characteristics were reported using descriptive statistics and Kaplan-Meier analysis was used to report outcomes.

resultsNCS was diagnosed in 250 patients at 17 institutions. The mean patient age at diagnosis was 37 ± 15 years, 90% were female, and 83% were White. Presenting symptoms and findings included nonpositional flank pain (58%), chronic pelvic pain/dyspareunia (49%), hematuria (48%), nonpositional abdominal pain (47%), and varicocele (3.3%). Diagnostic workup of NCS included computed tomography scan of the abdomen/pelvis (84%), venogram (63%), duplex ultrasound examination (35%), and magnetic resonance imaging (17%). Imaging demonstrated a mean aortosuperior mesenteric artery angle of 27.7°. On duplex ultrasound examination, the mean peak systolic velocity of the LRV was 108.9 ± 99.0 cm/s at the compression point and 21.7 ± 9.5 cm/s at the hilum, with a peak systolic velocity ratio of 4.98, whereas venography demonstrated a mean renocaval pressure gradient of 3.92 ± 2.40 mm Hg. Nonoperative treatment with oral analgesics (29%), nutritional counseling/feeding regimen (16%), or simple expectant management (55%) was used in 116 patients and successful in 90 patients (78%) with a mean follow-up of 328 days. Indications for nonoperative management included mild symptoms (64%), young age (10%), and patient preference (8.4%). Of the 26 patients (22%) who failed nonoperative treatment, 20 were subsequently managed with surgery. In the 134 patients who underwent surgery, either as initial treatment or after nonoperative failure, 60 (44%) had a LRV transposition, 43 (31%) underwent a gonadal/ovarian vein transposition, 18 (12%) underwent renal autotransplantation, and 19 (13%) underwent endovascular therapy. The overall 3-year primary patency and secondary patency were 65% (95% confidence interval [CI], 51-76) and 96% (95% CI, 88-99), respectively. The 3-year freedom from reintervention and symptom recurrence were 67% (95% CI, 53-78) and 60% (95% CI, 48-70), respectively. Patients who underwent endovascular intervention had inferior primary patency and freedom from symptom recurrence: 35% (95% CI, 1.22-78) and 46% (95% CI, 7.99-79), respectively.

conclusionsApproximately 20% of patients with NCS initially managed nonoperatively progressed to operative intervention. Surgery was associated with excellent secondary patency, but a substantial number of patients required reinterventions and 40% developed symptom recurrence by 3 years, highlighting the need for judicious patient selection for surgery through preoperative counseling and shared decision-making. Endovascular therapy was associated with significantly worse results for all outcomes and, therefore, is not appropriate as initial treatment.

Indexed as

Renal Nutcracker SyndromeVascular Surgical ProceduresAdultFemaleHumansMaleMiddle AgedRecurrenceRenal VeinsRetrospective StudiesRisk FactorsTime FactorsTreatment OutcomeVascular PatencyYoung AdultNutcracker syndromeOvarian/gonadal vein transpositionRenal autotransplantationRenal vein compression syndromeRenal vein stentingRenal vein transpositionVascular Low Frequency Disease ConsortiumVenous compression syndromes

Identifiers

PMID41985840
PMCPMC13191235

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