V04-11: Robot-assisted laparoscopic extravascular stent for nutcracker syndrome
Minimally invasive treatment options are a safe and feasible alternative for treatment of nutcracker syndrome. Endovascular stenting has shown promising long-term resolution of symptoms but can be complicated by stent migration or thrombosis. Laparoscopic extravascular stent placement has shown promising results with the potential to avoid these complications. We report the first case of extravascular stent placement using the robotic approach for the treatment of nutcracker syndrome.
The da Vinci Si robot system was used to perform the procedure. The left renal vein was completely dissected out from its origin on the IVC to the lateral insertion of the gonadal vein. A 2 cm Polytetrafluoroethylene (ePTFE) externally supported (ringed) vascular graft was split longitudinally and wrapped around the left renal vein. The edges of the split graft were re-approximated with interrupted 4-0 Vicryl sutures. The graft was also secured to the adventitia of the aorta to prevent migration.
The estimated blood loss was minimal and total procedure time was 118 minutes. Post-operative course was uncomplicated and patient noted that her pain was relieved on day 1. Relieving the LRV compression also resolved her symptoms of pelvic congestion and no further procedures on the gonadal vein were required.
Extravascular stenting of the left renal vein appears to be a safe and effective alternative treatment for nutcracker syndrome. It avoids the potential high risk complications of venous reconstruction or migration/thrombosis related to endovascular stenting. The robotic approach offers several advantages over laparoscopy with improved visualization and precise suturing around critical sutures.