Visceral compression syndromes causing paresis and paraparesis in young individuals
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1 Visceral compression syndromes causing paresis and paraparesis in young individuals W. Sandmann 1, 2, 3, 4 T. Scholbach 5 K. Verginis 2, 3, 4 J. Al-Maqablah 2, 3 S. Jacobi (stud. med.) 2, 3, 4 1 HH Universität Düsseldorf 2 Evangelisches Klinikum Mettmann 3 Evangelisches Niederrhein Klinikum Duisburg 4 St. Bernhard Hospital Kamp-Lintfort 5 Leipzig
2 Retroperitoneal and Visceral Compression Syndromes Anatomical Localisation Between Diaphragm and inguinal Ligament Compressed Structures Arteries Veins Intestinum Nervs Etiology Vertebral Architecture Symptomatology intermittently permanent
3 Retroperitoneal and Visceral Compression Syndromes Arterial Celiac Trunc (DUNBAR, MALS) Superior mesenteric artery (SMACS, van DONGEN) Renal artery Lumbar arteries (GOMBERT) Venous Left renal vein ant./ post. (NUTCRACKER) Left common iliac vein (MAY-THURNER) Pelvic venous compression (NCS; MTS; int. Iliac vein) Intestinum WILKIE Nervs Solar plexus Vagus nerv Spinal Pudendus nerv (Alcocks Canal)
4 Coiling and left common iliac vein stenting (1) Previous decompression (1) Stabilisation of vertebral column (EHLERS-DANLOS) (1) None (2) Venous Compression Syndromes (retroperitoneal) Patients with neurological Deficit Pat. 5/110 = 4,5%, female 100% Paresis left face side (1) Paresis both legs, left < right (3) Paresis arms and legs (1) Previous Treatment Visceral compression syndromes causing
5 Venous Compression Syndromes (retroperitoneal) Impaired (obstructed) venous drainage pelvic venous congestion Development of Collaterals Ovaric/ Spermatic Veins Shunting Vv. Iliacae int. left to right Collaterals around the Uterus Para- and intraspinal Collaterals Connection to azygos- hemiazygos System Tronc Reno-Rachidien (HENLE 1868, LEJARS 1888; GILLET 1968, ABOULKER 1971)
6 Pelvic Congestion Definition: Stasis and obstructed pelvic venous outflow
7 Venous Compression Syndromes (retroperitoneal) Patients with neurological Deficit (n=5/110) Therapy for Decompression - SMA Transposition - Curved vein patch left renal vein into IVC - Straight vein patch left common iliac vein into IVC - Lengthening right common iliac artery with Interposition Graft (Vein, PTFE)
8 NUTCRACKER-Syndrome Definition: NCS anterior Diameter reduction of the left renal vein crossing the Aorta between the SMA NCS posterior squeezing of the left renal vein between the Aorta and the lumbar spine
9 NUTCRACKER-Syndrome Therapy (1): Transposition of the SMA from above the renal arteries to below into the infrarenal Aorta (as for the WILKIE-Syndrome)
10 NUTCRACKER-Syndrome Therapy (2): Hockey racket shaped patch from the venous patch from left renal vein into the IVC
11 MAY-THURNER-Syndrome Definition: Compression of the left common iliac vein between the promontorium and the right common iliac artery
12 MAY-THURNER-Syndrome Therapy: 1) Decompression by extending the right common iliac artery with PTFE 2,5 cm, ø 8 mm Interposition graft 2) Enlarging the mouth of the left common iliac vein by implantation of a straight venous patch extended into the IVC 3) Temporary protective a.-v. fistula (shunt) between the left GSV and the femoral artery
13 MAY-THURNER-Syndrome
14 MAY-THURNER-Syndrome
15 Venous Compression Syndrome (retroperitoneal) Pat Pat n= 110 (total) n= 50 (total) With neurological Deficit Pat. n=5 (female) sensitive 1 motoric 4 Age (y) 14-60; Mean 30,5 y Gender: female/ male 9:1
16 Venous Compression Syndrome (retroperitoneal) Patients with neurological Deficit Operative Results Paresis and Paraparesis disappeared (one patient arrived on crutches, went home without, 3 patients arrived in a wheel chair, went home walking) Conclusion The decompression of the left renal vein and of the left common iliac vein reduced the pressure within the para- and intraspinal collaterals and leads to normal function of the spinal nervous system.
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