 Hi, I'm Kristen Whitney with the University of Maryland Medical Center today. We're discussing vascular compression syndrome with assistant professor of surgery Dr. K. J. Nagar sheath an expert vascular surgeon and co-director of the University of Maryland limb preservation program. Thanks for being here today. Hi, thanks for having me. And thanks for all of you watching at home. We invite you to submit your questions by commenting below and leaving a comment. We'll answer those shortly. First, I'm hoping you can share about vascular compression syndromes. That sounds pretty complex. What exactly are they? So vascular compression syndromes are a constellation of different signs and symptoms that people experience that come together due to compression of blood vessels by either other blood vessels or other structures within the abdomen. Wonderful. And are they common? They're actually very common and they're really underdiagnosed. And some of the problems is that people go through a whole battery of tests and work up and never get to the root of their problems including pain, the abdomen or their pelvis and it's because these are just overlooked. What are some of the different types of compression syndromes? So there's three major types of compression syndromes pertaining to the vasculature. One is called May-Therner syndrome, which is a compression of the left ciliac vein, which is in the pelvis going from the leg up to the abdomen. The other one is nutcracker syndrome or left renal vein entrapment, which is compression of the vein coming from the left kidney, back to the vena cava going back to the heart, and that's compressed by another artery running over it. And the third one that's most common is called median archaeo ligament syndrome, which has to do with a tendon that comes from the diaphragm or a breathing muscle that wraps around one of the arteries going to the intestine and the stomach. Genetics play a factor in this disease? Somewhat, not necessarily. It actually is more of a gender thing as opposed to genetics. So tends to be women that are more affected by this just because of the shape of the pelvis and the shape of the vessels going through it. So you mentioned some abdominal pain earlier. What kinds of other problems could one experience if they have one of these compression syndromes? So the most common symptoms associated with these things are going to be nausea, abdominal pain, dizziness, difficulty with breathing, loss of appetite, getting full very early, even fainting can occur. Headaches are probably the most common sign and symptom that's associated with this, and then people can have things like diarrhea, even constipation. Abdominal pains typically are related to pain the left side of the back, or in the middle of the back, or it could be even from the chest and radiating down to the back. And how do the symptoms develop? Are there certain common symptoms you could look out for? So it really depends on the person, and I like to think that each person is somewhat individualized and no two people present the same way. I've had people present with these nutcracker type syndromes with just headaches and some slight back pain. Other people have blood in their urine, other people have severe swelling of their legs. And I've heard about nutcracker syndrome. I'm wondering how, how was that diagnosed, and what about M-A-L-S, or do you shorten that to malls? And what about Maytherner syndrome? So nutcracker syndrome is typically diagnosed with someone who's having some sort of symptoms, and we do certain tests looking at the urine since we're talking about the vein coming from the left kidney. And we also look at other symptoms such as problems with eating and transit of food through the intestine. So we look at those sort of things. We also do special ultrasounds and a special diagnostic studies called a vinaigram, where we look at the vein from within the vein with a special ultrasound catheter. In terms of malls or a median archaeal ligament syndrome, it's a very similar kind of workup. We look at people's transit of food through their stomach and through their intestines. We look at the blood flow through that artery that's wrapped around by that tendon coming from the breathing muscle. We look at that with an ultrasound. And then we do what's known as an angiogram, looking at blood flow through it, and we do it dynamically, meaning we have our person that we're evaluating breathe in and out very deeply while we're doing it to see if the artery blocks off during breathing. For Maytherner, it's also very often based on their symptoms and their history. So people with leg swelling pain, severe varicose veins stuff like that, that aren't getting proper resolution of their symptoms from conservative measures. We worry about compression of the vein in the pelvis. This is typically in people that have had multiple children and given birth several times, that sort of thing. But then we also do a vinaigram for them to look at the vein from the inside with a special ultrasound catheter to see if there's severe narrowing. I was wondering, are these symptoms permanent? So yeah, I mean they are, they do last for the course of someone's life. That being said, these kind of anatomic relationships, these compression, they don't cause symptoms in everybody. And so just because you have this particular relationship between two different blood vessels or compression doesn't necessarily indicate that you're going to have problems with it. They can reserve the treatment for people that are actually having symptoms that we can associate with these sort of compressions, but they do last the life of a person. And what are those treatments? So the treatments oftentimes for certain things like Maytherner can be a minimally invasive treatment, which is a simple as a stent. It can be for a median arc or ligament syndrome. Depending on what needs to happen, it can be minimally invasive with a robotic surgery performed to remove the tendon or release the tendon, and then followed by a stent that's performed minimally invasive as well. For the nutcracker syndrome, it's one that has several different treatment options. And again, I don't think there's a single treatment option that's ideal for every person, so we do it very individualized. We do it in a very multidisciplinary team using looking at patients via a urologic perspective from a transplant perspective and a vascular perspective. And for that, it could be a minimally invasive movement of the kidney from where it's located up in the abdomen to down the pelvis to remove the compression. And a traditional open operation where we just reroute the blood flow from where the kidney is going to where it needs to go lower down on the vena cava. Or it could be with a stent if it's appropriate for the person. So it's really the treatment is individualized to the person as opposed to one size fits all. And what would you suggest if someone has been diagnosed with this rare disease? Well, I think it's important to go and get evaluated by people that do this regularly. There's a lot of people that can do a lot of things out there, but I think it's best to get any kind of treatment for a fairly uncommon disease by people that do it regularly. And I can say with a great deal of certainty, we do it very regularly here. Wonderful. How do these symptoms, excuse me, how do these syndromes tend to impact someone's livelihood? So I can tell you anecdotally, based on what my patients have experienced, the vast majority of people that I've seen with these problems have been kind of bounced around from one person to another one specialist to another. Many of them have had to leave their jobs and kind of gone into a severe depression, because many of them are told that the symptoms are in their head, for lack of a better term, that there's no physical finding of pain or discomfort. Right. And so they're being told that we can't find a reason for this. There's no nerve issue. There's no neurologic reason why you have pain. And these things are overlooked because they're not super common. You know, I mean, we see it a lot in people, but they're not diagnosed because a lot of practitioners out there don't know the diagnosis. They don't know the workup and they don't know what they're looking for. And so unfortunately by the time people come to see me, many of them have had issues with depression or issues with healthcare where they've been either misguided or they've been pushed aside and told that this is stuff they're making up. And so I can tell, I can tell most of the people I take care of that have this. It's not in their head. There's a real reason why they're having this pain. What, what a relief though that you're able to help them out with something that faced for so long and not gotten answers to. Yeah, I mean, I think that's really the benefit of going somewhere where we see a lot of this. I particularly see a lot of these syndromes and take care of patients with it and relieve the compression syndromes. Many of their symptoms go away, if not all of them. That's wonderful to hear. And Dr. Nagashree, I was curious, do you tend to treat patients for their entire lives? If someone's diagnosed, do they tend to see a vascular surgeon for the rest of their, or excuse me, a vascular specialist for the rest of their lives? Yeah, I think that's one of the benefits of being a vascular surgeon is that I see people for their entire life. I once I start seeing somebody I become their surgeon but I also become almost an internist where I help manage a lot of things that are going on with them because vascular disease is not something that goes away. It's something that has to be followed. And as soon as you reroute blood flow and you manipulate arteries and veins, that person needs to be followed lifelong. And are you prone to other problems if you have one of these compressive syndromes? So it's very interesting you asked that because many of these travel together. So people with, for example, a nutcracker, most of them will have some sort of iliac vein compression in Maytherner. And some of them will have pelvic congestion syndrome where the veins of the pelvis get engorged. And so a lot of these things go hand in hand and identifying one and treating one is almost never the answer. You have to know what's happening and which of these are actually contributing to their symptoms before you start treatment. Have there been any recent breakthroughs for vein diseases like nutcracker syndrome or Maytherner syndrome? Well, for Maytherner in particular, the breakthrough has been the development and the adoption of stents made specifically for the vein. These have only been around for a couple of years. Anyone who's been treated for these syndromes before was treated with a stent that was not actually designed for the vein. It was treated with a stent designed for the trachea or the esophagus because they're big enough for it, right? But in the last few years we've had stents that have come onto the market that are FDA approved that are made specifically for the vein anatomy and specifically for that disease process. So that's been one advance. In terms of nutcracker, the advantage is the adoption of robotic surgery and laparoscopic surgery to help move some of the blood vessels around and to help with the dissection. It actually helps speed up the recovery in people if it's appropriate. Now, not everyone's going to be appropriate if the nutcracker is so severe that the vein is so damaged and it's been ongoing for such a long time. It's probably not the best candidate for robotic surgery. It needs an open surgery. But, again, each person is fairly individualized and we never treat two people the same. And how is the University of Maryland unique in its approach to patient care? So I think especially with nutcracker, one of the unique parts about it is that it's very multidisciplinary. It's never just one person dictating the care. All the people that we see are discussed between several different specialties. So it's discussed between transplant surgery, vascular surgery, and occasionally urology, depending on what needs to happen for the patient. And the other thing that's kind of unique to us is that we don't send people away. When it comes to us with a problem, we figure out a way to fix it for them. We don't outsource, we don't refer out because we do everything. And we'll do everything from the beginning, from the first time we see you, all the way through to after your surgery and indefinitely after that. And it sounds like it could be an 80 year long relationship. I mean, many of the people are young. They're in their 20s and 30s. So it could be an 80 year relationship, absolutely. Wonderful. Well, thank you so much for your time today. I really appreciate it. For more information on vascular care at the University of Maryland Medical Center, please visit our website, umm.edu slash heart, or you can call us at 410-328-5840. Thank you for watching.