Venous compression syndromes The Phlebology Clinic / Venous compression syndromes Introduction Description of the condition Risk factors Treatment options Frequently asked questions Pelvic venous insufficiency in women Pelvic venous insufficiency in men Introduction Venous compression syndromes (venous compression syndromes) are a broad group of vascular conditions, congenital and secondaryIn which the outflow of venous blood is impaired due to pressure on the venous vessels. This compression can be caused by adjacent anatomical structures such as arteries, muscles or ligaments (tendons), as well as by pathological changes within the venous vessels themselves (e.g. vascular septa). For this reason, developmental disorders of the venous vessels (e.g. hypoplasia of the venous trunk) are also lumped into this bag, as it gives similar clinical symptoms. The most common examples of venous compression syndromes are the "nutcracker" syndrome (nutcracker syndrome, NCS) and May-Thurner syndrome (May-Thurner syndrome, MTS). These conditions represent an important clinical problem due to their serious circulatory and thromboembolic consequences. They cause abnormal venous blood outflow, secondary redistribution of the circulation and often massive venous blood stasis, which results in the development of pelvic venous insufficiency (in both men and women) and secondary venous insufficiency of the lower limbs. Phenomenon or venous compression syndrome? A prerequisite for the occurrence of symptoms of venous compression syndrome is the occurrence of some anatomical phenomenon or other pathophysiological mechanism. Venous compression phenomenon can be compared to a cause, while venous compression syndrome to an effect that is characterised by certain symptoms (more precisely, the presence of a certain spectrum of symptoms). Sometimes one encounters a constellation of causative phenomena rather than a single identifiable cause. This should be kept in mind when diagnosing patients with suspected venous compression syndrome. Pressure phenomenon (or. entrapment phenomenon functionally manifesting) may initially be a purely haemodynamic process, often asymptomatic (this is the case in childhood). It is only its long-term effects, human development and progressive decompensation of the venous system that lead to a series of adverse symptoms, defining the venous compression syndrome in question. A chronically compressed vessel (which may also be initially narrow) becomes thinner. Over time, it may become fibrotic and undergo irreversible changes. Venous compression phenomena in the human body are quite numerous (we have illustrated some of them in the diagram opposite), but only a few are clinically relevant and frequent enough that every physician should be aware of their occurrence. Anatomical diagram showing the most common compression phenomena and anatomical changes leading to venous blood outflow in the human body. Author: Dr Cezary Szary, M.D. © The Phlebology Clinic The most common venous compression syndromes include: subclavian vein compression syndrome (TOS) - The compression phenomenon is due to the existence of compression of the subclavian vein by the osteochondral structures of the upper thoracic orifice. The venous syndrome itself is manifested by pain, paresthesias, swelling and bruising of the upper limb. nutcracker syndrome (NCS) - In this case, the compressive phenomenon is chronic compression of the left renal vein by the superior mesenteric artery. This is due to the rather narrow angle of departure of the superior mesenteric artery from the abdominal aorta and the usually low fat content in the retroperitoneal space. This leads over time to the development of symptoms, or 'nutcracker' syndrome (e.g. low back pain, colic on running, haematuria in childhood, painful and heavy menstruation, lower abdominal pain, varicose veins early in life or venous insufficiency of the lower limbs before the age of 25). May-Thurner syndrome (MTS) - Here, the compression phenomenon results from the close anatomical relationship between the left common iliac vein and the right common iliac artery. Long-term compression of the vein to the spine at L4/L5 results in a syndrome of symptoms including: pain and swelling of the left lower limb, later development of symptoms typical of pelvic venous insufficiency, and finally to thrombotic changes in the left iliac-femoral axis (the highest risk of the thrombotic form of May-Thurner syndrome occurs in pregnant women). Factors that increase the risk occurrence of venous compression syndrome congenital vascular anomalies (abnormal departure of vessels, their course or angle of bifurcation) presence of additional anatomical structures body build (tall and slim people are more predisposed) structural defects of the spine (e.g. scoliosis or an accentuated L/S lordosis) female gender number of pregnancies and deliveries malignant disease (e.g. lymphoma) aneurysms, tortuous arterial system degenerative changes (generative) of the lumbar spine, less commonly of the thoracic spine vertebrosis of the lumbar spine Mechanism of the "nutcracker" syndrome Hypoplasia of the left renal vein is a more common cause of the so-called 'nutcracker' syndrome than the classic (historical) variant presented in textbooks, involving compression of the renal vein by the superior mesenteric artery. Let us remember that this syndrome was first described in 1937, in an era of no diagnostic imaging. This important developmental factor, involving incomplete formation of the renal vein during the embryonic period, results in narrowing of its lumen and impaired renal outflow from the kidney from an early age. This becomes most noticeable to the body during puberty and rapid growth. It is during this period that the following occur first symptomssuch as left-sided pain, exertional colic (e.g. when running), back pain descending to the lower abdomen or painful and heavy menstruation in young women (often identified with endometriosis, which usually appears after the age of 20). Haematuria, which is a laboratory finding, occurs transiently and is usually of little clinical significance. In the male population, left renal vein outflow abnormalities are most often associated with rapidly progressive left testicular vein insufficiency and fairly large varicocele in 12-16-year-old boys. The diagnosis of a compression phenomenon within the left renal vein, or its developmental stenosis, is based on imaging studies and careful correlation of radiological findings with clinical symptoms. The gold standard for diagnosis is the examination of the Doppler ultrasound of the veins of the abdomen and small pelvis performed fasting in the patient's supine and standing position with various positions and breath tests. Tests CT venography and MR venography are usually used for treatment planning. The diagnosis of nutcracker syndrome should never begin with this type of examination. Intravascular ultrasonography (IVUS) is an unhelpful test, as it falsifies the image of the vessel and does not provide a complete answer on the mechanism of stenosis and the presence of a collateral circulation, which is the essence of the disease. Did you know? Hypoplasia (congenital stenosis) left renal vein, rather than its compression by the superior mesenteric artery, is much more likely to cause the "nutcracker" syndrome. Symptoms pelvic venous insufficiency - Secondary to abnormalities of blood outflow from the renal vein - are much more troublesome for young women and often occur from the first menstrual periods. dr n. med. Cezary Szary Imaging diagnosis of venous compression phenomena Doppler ultrasonography - is the 'gold standard' for detecting venous compression phenomena; it is a non-invasive technique that allows the exact location of the compression to be visualised and blood flow disturbances to be assessed. Doppler ultrasound can be performed in any body position. CT venography (CTV) and MR venography (MRV) - are 'second-choice' imaging examinations, performed with the administration of an intravenous contrast agent, which perfectly visualise the spatial relationships between veins and adjacent structures. Crucial for planning further surgical or interventional treatment. intravascular ultrasound (IVUS) - an invasive method performed together with phlebography, used intraoperatively. It allows the diameter of the vessel to be measured and the degree of stenosis to be assessed "from the inside". In our Team's experience, it is of little use in the diagnosis and treatment of nutcracker syndrome. digital phlebography - is an invasive examination using a contrast agent and X-ray equipment, performed during the procedure itself. It confirms the diagnosis, defines the anatomy of the veins and allows 'mapping' of the collateral circulation. Phlebography should not be used at the initial diagnostic stage. Imaging modalities such as Doppler ultrasound of the venous system and much less invasive venography techniques performed using computed tomography (CT) and high-field magnetic resonance imaging (MRI-3T) equipment serve this purpose. (1) hypoplasia of the left renal vein (LRV) on Doppler ultrasound (2) compression of the LRV on phlebography (3) hypoplasia of the LRV on MR venography (4) collateral circulation in the LRV runoff on phlebography prior to its embolisation. © Department of Phlebology Treatment methods for venous compression phenomena Treatment of patients with venous compression syndromesmi includes two main therapeutic approaches: conservative treatment and surgical treatment, which we divide into intravenous (minimally invasive) and surgical. The choice of the appropriate treatment strategy depends on the severity of the symptoms, the venous disease complications that have arisen and the degree of venous outflow impairment and the patient's general health. Conservative treatment venous compression syndromes is the initial stage of therapy and is used in all patients, irrespective of any further management plan. It aims to alleviate symptoms, improve the patient's quality of life and prevent thromboembolic complications. Conservative treatment is based on compression therapy, i.e. the use of compression devices (stockings, knee socks, wraps or bandages), increasing the patient's physical activity and the use of phlebotropic and anticoagulant drugs. "The gold standard" for treating patients with venous compression syndromes is now the minimally invasive, endovascular approach using, techniques such as: implantation of venous stents (venous stenting), balloon venoplasty (widening of veins from the inside using high pressure) and various types of variants venous embolisation. Examples of intravenous interventions in patients with nutcracker syndrome (NCS) and May-Thurner syndrome (NCS). (1) septated insufflated ovarian veins and varicose peripheral circulation (2) venous stents in a post-thrombotic left iliac segment in a patient with MTS. Intravenous procedures is performed under the guidance of low-dose fluoroscopy and with the aid of ultrasonography. Catheters with high-compression balloons are inserted into the stenosed vessels (hypoplastic or compressed), which then expands to dilate the lumen of the stenosed venous vessel. In appropriate cases, implantation of venous stents with self-expanding stents is used to prevent recurrence of the stenosis. In cases where endovascular access is impossible or contraindicated (e.g. with a tortuous course of the vein or its obstruction), the use of surgical treatment using vascular surgery techniques. It involves excision or transection of the renal vein, or alternatively decompression of the vein by removing structures compressing it from the outside (e.g. transection of the arch ligament in upper thoracic orifice syndrome). Surgical procedures are performed under general anaesthesia, either via laparotomy or laparoscopic access. Surgical methods, due to the high risk of complications, are now used less and less frequently. Treatments venous embolisation (intravenous controlled closure of insufficient veins using chemical agents or mechanically, e.g. using embolisation spirals, so-called coils) is used for patients with venous compression syndromes who have features of congestive venous insufficiency of the pelvis or lower limb veins. Treatments of this type are aimed at redirecting blood to the correct pathways and relieving pressure on the reservoir venous plexuses located retroperitoneally, in the small pelvis folk in the perineum or vulva. Venous embolisation procedures eliminate the main pathway of retrograde blood flow, leading to a significant reduction in clinical symptoms resulting from venous stasis. Venoplasty with simultaneous venous embolisation - how does the procedure work? Treatment venoplasty (balloon angioplasty) left renal vein with simultaneous embolisation of the insufficient ovarian veins is a minimally invasive procedure performed with percutaneous access (no incisions), under local anaesthesia, resulting in improved venous outflow from the constricted left renal vein, while relieving the symptoms resulting from pelvic congestion caused by insufficient ovarian veins. This procedure is used both in non-pregnant women (pelvic venous insufficiency arises in them as a result of congenital anatomical abnormalities) and in women in whom to ovarian venous insufficiency occurred post-pregnancy from intra-pregnancy compression. The team at the Phlebology Clinic is a pioneer in performing this type of procedure. Doctors performing these procedures dr n. med. Cezary Szary - phlebologist, radiologist Phlebology, Radiology and Imaging Diagnostics Dr Dominika Plucińska - phlebologist, radiologist radiology and diagnostic imaging, phlebology Tomasz Grzela, MD - phlebologist, surgeon General surgery, phlebology dr n. med. Jerzy Leszczyński - vascular surgeon General surgery, vascular surgery dr n. med. Justyna Wilczko – flebolog, internista Phlebology, internal medicine, radiology and diagnostic imaging Dr Krzysztof Celejewski - phlebologist, surgeon general surgery, phlebology dr n. med. Łodyga Małgorzata - phlebologist, cardiologist cardiology, phlebology, Doppler ultrasonography Dr Marcin Napierała - phlebologist, surgeon general surgery, phlebology Dr Michał Zawadzki, MD - interventional radiologist radiology and diagnostic imaging, interventional radiology Mostlyquestions asked What is the main difference between 'nutcracker' syndrome (NCS) and May-Thurner syndrome (MTS)? The main difference between 'nutcracker' syndrome and May-Thurner syndrome lies in the location of the compression phenomenon and the draining venous areas. In 'nutcracker' syndrome, the compression involves the left renal vein, which drains blood from the kidney, the left adrenal gland, the retroperitoneal space, the paravertebral space and the adnexal region. Hence the renal, spinal and pelvic symptoms. In May-Thurner syndrome, on the other hand, the left common iliac vein is compressed by the right common iliac artery, resulting in obstructed outflow from the left common iliac and internal iliac veins and the left lower limb. Therefore, symptoms such as swelling, pain and bruising of the left leg, varicose veins of the lower limb or eventually ulceration and venous thrombosis predominate. What are the advantages of intravenous treatment over classical surgery in venous compression syndromes? Intravenous treatment is currently preferred in patients with venous compression syndromes due to its many advantages over classical surgery. The undoubted advantages include: minimally invasive - percutaneous puncture access to the peripheral vein using ultrasound equipment without an extensive surgical wound; can be performed under local anaesthesia, without general anaesthesia; shorter operative time and lower risk of perioperative complications; faster recovery; the possibility of repeating the procedure in the event of recurrent stenosis or the formation of a collateral circulation; lower cost compared to open surgery. I have heard of the 'back' nutcracker syndrome. What is it? Rear "nutcracker" assembly (posterior nutcracker syndrome) is a rare vascular condition in which the left renal vein runs posteriorly from the abdominal aorta (known as the retroaortic position) is compressed between the largest abdominal artery and the vertebral column. This is particularly significant in pregnant women. This can cause typical symptoms as in classic nutcracker syndrome. This is in contrast to 'anterior' nutcracker syndrome, in which compression occurs between the superior mesenteric artery and the abdominal aorta. Explore our latest publications and research papers. The scientific activities of the team at the Department of Phlebology make a significant contribution to the development of modern phlebology. Our scientific research and publications confirm the effectiveness of innovative and proprietary treatment methods, setting new standards in the treatment of venous diseases. 1 / Do patients with recurrent venous disease benefit more from sequential treatment than patients without previous venous interventions? The doctors of the Phlebology Clinic have pioneered the causal treatment of venous disease worldwide. Our proprietary treatment methods, validated by scientific research and prestigious publications, have opened up new possibilities for all phlebology patients. 2 / Can the number of pregnancies be a predictor of venous disease progression and influence the effectiveness of treatment? The introduction of a proprietary haemodynamic and radiological classification used in the assessment of ovarian venous insufficiency has facilitated treatment planning for patients with pelvic venous insufficiency. This proprietary method allows for a precise assessment of blood flow abnormalities, enabling clinicians to select the optimal therapeutic strategy. 3 / Radiological-haemodynamic classification of ovarian venous insufficiency. The doctors of the Phlebology Clinic were pioneers in the use of the varicose vein bonding method in Poland. We were the first to introduce this innovative, minimally invasive technique into clinical practice in our country. We encourage you to read the results of a study comparing the effectiveness of adhesive and intravenous laser ablation in the treatment of venous insufficiency of the lower limbs. 4 / A 2-year follow-up study evaluating treatment of limbic venous insufficiency using cyanoacrylate glue and intravenous laser ablation Dr Venus: virtual patient advisor Looking for an answer to your vein question? Ask our Dr. Venus! Ask Dr Venus a question Does 'nutcracker' syndrome affect young women? Yes, 'nutcracker' syndrome can affect young ladies, and is particularly common in women aged 18-28. 01 / Vascular spider veins Dilated subcutaneous capillaries and reticular veins are a common symptom heralding the development of venous insufficiency. Their occurrence should not be underestimated. 02 / Varicose veins of the lower limbs They are the most common symptom of venous insufficiency of the lower limbs. Their occurrence should not be underestimated. At the Phlebology Clinic, we treat venous disease causally. 03 / Venous edema of the shin An enlargement of the shin circumference that increases in the evening, accompanied by a feeling of heaviness, is usually a symptom of venous insufficiency. Think about having a venous Doppler ultrasound examination! 04 / Pelvic venous insufficiency Painful and prolonged periods, heaviness in the legs during menstruation, pain during intercourse and burning in the intimate area are just some of the symptoms of pelvic venous insufficiency. Find out more! 05 / Venous compression syndromes It is a group of anatomically determined venous disorders leading to early onset of pelvic venous insufficiency and varicose veins on the legs. It affects both ladies and gentlemen! 06 / Venous disease in pregnancy Not sure when to start wearing compression stockings? Do you suspect vulvar varicose veins or have noticed sudden swelling of a limb during pregnancy! Don't wait to develop venous disease - consult our phlebologist for your symptoms. 07 / Varicose veins of the spermatic cord Up to 40% cases of male infertility may be related to varicose veins of the seminal vagina. This form of pelvic venous insufficiency is one of the more common causes of varicose veins on the legs and a cause of discomfort in the groin and scrotum. Early diagnosis increases the chance of a full cure! 08 / Venous thrombosis Swelling of the leg, pain and redness are alarm signals that should not be ignored. Venous thrombosis is an emergency condition that requires immediate diagnosis by Doppler ultrasound. If untreated, it can lead to life-threatening pulmonary embolism. 01 / 08 Modern vein treatment We offer treatment both on an outpatient basis and in day ward admissions. The stay is of short duration. The patient spends between 1 and 5 hours in the Clinic. Make an appointment
