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Muacevic A, Adler JR, Benfaida A, Mahi M, Rami A. Fortuitous Discovery of Nutcracker Syndrome During Acute Appendicitis: A Case Report. Cureus 2022; 14:e32109. [PMID: 36601171 PMCID: PMC9805363 DOI: 10.7759/cureus.32109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/02/2022] Open
Abstract
Nutcracker syndrome (NCS) belongs to a group of rare vascular disorders. It refers to compression of the left renal vein (LRV) generally between the abdominal aorta (AA) and the superior mesenteric artery (SMA). It is one of the most unknown causes of chronic abdominal pain. Herein, we present the case of a young patient who came to the emergency department for acute abdominal pain. Patient's history revealed an uncharacterized chronic epigastric pain evolving for 13 years. The imaging showed acute appendicitis and NCS; the latter finding was the principal explanation for the patient's chronic pain. We hope that the concise and synthetized structure of this case report will help physicians acquire the necessary reflexes to notice and diagnose this already underdiagnosed syndrome.
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Haboussi MR, Tabakh H, Mouffak A, Fahl A, Kebbou T, Touil N, Siwane A, Kacimi O, Chikhaoui N. [Nutcracker syndrome: a rare cause of abdominal pain in adults that shouldn't be ignored: a case report]. Pan Afr Med J 2021; 38:288. [PMID: 34122715 PMCID: PMC8180005 DOI: 10.11604/pamj.2021.38.288.28387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 12/01/2022] Open
Abstract
De nos jours, la connaissance des anomalies vasculaires est primordiale pour tous les spécialistes en pratique clinique et peut prévenir de graves complications suite à des interventions précoces. Le syndrome de Casse-Noisette ou Nutcraker syndrome résulte d´une compression de la veine rénale gauche (VRG), généralement dans la fourchette formée par l´aorte abdominale et l'artère mésentérique supérieure (AMS), conduisant à la sténose de la partie aorto-mésentérique de la veine rénale gauche et dilatation de sa partie distale. La symptomatologie reste dominée par des douleurs lombaires, abdominales, pelviennes et hématurie. Son diagnostic est basé essentiellement sur les moyens d´imagerie moderne (tomodensitométrie, échographie-Doppler, phlébographie) et son traitement est controversé. Nous rapportons le cas d´une femme âgée de 43 ans, admise dans le cadre d´un bilan radiologique devant des douleurs épigastriques avec pesanteur pelvienne suite à un syndrome de Casse-Noisette.
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Affiliation(s)
| | - Houria Tabakh
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
| | - Amina Mouffak
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
| | - Amine Fahl
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
| | - Touda Kebbou
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
| | - Najwa Touil
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
| | - Abdellatif Siwane
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
| | - Omar Kacimi
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
| | - Nabil Chikhaoui
- Service de la Radiologie des Urgences, Hôpital Ibn Rochd, Casablanca, Maroc
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Denchev B, Domuschieva E, Jelev G, Govedarski V, Zahariev T. Surgical Treatment of a Patient With Nutcracker Syndrome via Transposition of the Left Renal Vein. EJVES Short Rep 2018; 41:10-12. [PMID: 30450431 PMCID: PMC6226573 DOI: 10.1016/j.ejvssr.2018.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/23/2018] [Accepted: 09/28/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Nutcracker syndrome (NCS) is caused by compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery (SMA) where it passes in the fork formed at the bifurcation of these arteries. NCS leads to LRV hypertension, resulting in left flank and abdominal pain, with or without haematuria and pelvic ureteral varices. Report The patient was a young female with diagnostic criteria of NCS, with severe clinical manifestations. The patient underwent transposition of the LRV approximately 3.0 cm below the original anatomic site and was anastomosed to the inferior vena cava (IVC) outside the meso-aortic compression zone. Conclusion Although NCS is not as common as other clinical scenarios, it may be encountered by physicians in a variety of disciplines, and can cause substantial morbidity and mortality rates. This report addresses the surgical approach used in a particular case, as well as the possible complications and outcomes if not treated in due time. A young female patient with diagnostic criteria of NCS, with severe clinical manifestations. The patient underwent transposition of the LRV approximately 3.5 cm below the original anatomic site. She was then anastomosed to the inferior vena cava (IVC) outside the meso-aortic compression zone. The symptoms were masked for an extended period of time, while the patient deteriorated at a rapid pace. At 36 months of follow-up the patient remained symptom free.
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Affiliation(s)
- Borislav Denchev
- Virgin Mary University Hospital, Clinic of Vascular Surgery, Bourgas, Bulgaria
| | - Elena Domuschieva
- Virgin Mary University Hospital, Clinic of Vascular Surgery, Bourgas, Bulgaria
- Corresponding author.
| | - Galin Jelev
- Virgin Mary University Hospital, Clinic of Vascular Surgery, Bourgas, Bulgaria
| | - Valentin Govedarski
- Saint Ekaterina University Hospital, Clinic of Vascular Surgery, Sofia, Bulgaria
| | - Todor Zahariev
- Saint Ekaterina University Hospital, Clinic of Vascular Surgery, Sofia, Bulgaria
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Nalcacioglu H, Ceyhan Bilgici M, Tekcan D, Genc G, Bostanci Y, Yakupoglu YK, Sarikaya S, Ozkaya O. Nutcracker Syndrome in Children: Role of Doppler Ultrasonographic Indices in Detecting the Pattern of Symptoms. J Clin Med 2018; 7:jcm7080214. [PMID: 30104539 PMCID: PMC6111325 DOI: 10.3390/jcm7080214] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 07/29/2018] [Accepted: 08/08/2018] [Indexed: 12/20/2022] Open
Abstract
The purpose of this study was to evaluate the clinical characteristics of 44 pediatric patients who were diagnosed as having nutcracker syndrome (NCS). We also investigated the left renal vein Doppler ultrasonography (DUS) results, to determine whether or not there was an association between clinical symptoms and DUS findings among these patients. The clinical data from 44 pediatric patients who were diagnosed as having NCS from January 2008 to December 2015 were retrospectively reviewed. We grouped the patients according to the presenting symptoms as symptomatic (loin pain; macroscopic hematuria or both) and non-symptomatic (microscopic hematuria and proteinuria were detected incidentally) and evaluated the left renal vein DUS indices in these two groups separately. Asymptomatic NCS was found in 27 (61.4%) patients; 21 (47.7%) of whom were admitted for the evaluation of proteinuria. The most frequent presenting symptoms were left flank pain (20.5%) and macroscopic hematuria (13.6%); and 2 (4.5%) patients presented with a combination of left flank pain and macroscopic hematuria. The mean ratio of the diameter of the hilar portion of the left renal vein (LRV) to that of the aortomesenteric portion was 4.36 ± 1.55. The mean ratio of the peak velocity (PV) between the two sites of the LRV was 7.32 ± 2.68 (3.1–15.6). The differences in the ratio of the diameters were statistically significant between the two groups and significantly higher in children with asymptomatic NCS (p = 0.025). The PV ratios of the LRV (p = 0.035) were significantly higher in asymptomatic children with NCS than in the symptomatic group. Our study identifies that increased compression ratio of the LRV entrapment is most observed in orthostatic proteinuria and microscopic hematuria.
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Affiliation(s)
- Hulya Nalcacioglu
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Meltem Ceyhan Bilgici
- Pediatric Radiology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Demet Tekcan
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Gurkan Genc
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Yakup Bostanci
- Urology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | | | - Saban Sarikaya
- Pediatric Urology Department, Ondokuz Mayis University Faculty of Medicine, 55220 Samsun, Turkey.
| | - Ozan Ozkaya
- Pediatric Nephrology Department, Istinye University Faculty of Medicine, 34010 Istanbul, Turkey.
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A systematic review on management of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord 2017; 6:271-278. [PMID: 29292117 DOI: 10.1016/j.jvsv.2017.11.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/20/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Although nutcracker syndrome (NS) is rare, patients presenting with symptoms or signs and anatomic compression of the left renal vein (LRV) can be considered for intervention. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the LRV. The paucity of data regarding the management of this uncommon disease process poses a challenge for adequate recommendations of the best treatment modality. Herein, we aim to present a systematic review for the management of NS. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards to systematically search the electronic databases of MEDLINE from October 1982 to July 2017 for articles about the management of NS. Included were studies in English, Spanish, and German in all age groups. RESULTS The literature search provided 249 references. After abstract and full review screening for inclusion, 17 references were analyzed. Eight (47%) described the open surgical approach. The LRV transposition was the most commonly reported technique, followed by renal autotransplantation. Seven (41.11%) described the endovascular technique of stent implantation, and two (11.7%) described the minimally invasive laparoscopic extravascular stent implantation. CONCLUSIONS NS is a rare entity. Multiple techniques have been developed for the treatment of this condition. However, the rarity of this syndrome, the paucity of data, and the short-term follow-up of the existing evidence are the disadvantages that prevent recommendations for the best treatment strategy. Up to now, open surgical intervention, specifically LRV transposition, has been considered by some experts the mainstay for treatment of NS. The endovascular approach is gaining strength as more evidence has become available. However, the long-term patency and durability of this approach remain to be elucidated. Therefore, careful selection of patients is necessary in recommending this technique.
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Siddiqui WJ, Bakar A, Aslam M, Arif H, Bianco BA, Trebelev AE, Kelepouris E, Aggarwal S. Left Renal Vein Compression Syndrome: Cracking the Nut of Clinical Dilemmas - Three Cases and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:754-759. [PMID: 28680033 PMCID: PMC5511006 DOI: 10.12659/ajcr.905324] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Case series Patient: Female, 36 • Female, 41 • Female, 36 Final Diagnosis: Left renal vein compression syndrome Symptoms: Hematuria Medication: — Clinical Procedure: Percutaneous intervention • nephrectomy Specialty: Nephrology
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Affiliation(s)
- Waqas Javed Siddiqui
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, USA.,Hahnemann University Hospital, Philadelphia, PA, USA
| | - Abu Bakar
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Aslam
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Hasan Arif
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, USA.,Hahnemann University Hospital, Philadelphia, PA, USA
| | - Brian A Bianco
- Hahnemann University Hospital, Philadelphia, PA, USA.,Department of Interventional Radiology, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Alexander E Trebelev
- Hahnemann University Hospital, Philadelphia, PA, USA.,Department of Interventional Radiology, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Ellie Kelepouris
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, USA.,Hahnemann University Hospital, Philadelphia, PA, USA
| | - Sandeep Aggarwal
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, USA.,Hahnemann University Hospital, Philadelphia, PA, USA
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Ananthan K, Onida S, Davies A. Nutcracker Syndrome: An Update on Current Diagnostic Criteria and Management Guidelines. Eur J Vasc Endovasc Surg 2017; 53:886-894. [DOI: 10.1016/j.ejvs.2017.02.015] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023]
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Novaes LFC, da Silva Saguia LN, Di Migueli CA, de Castro Perin MA, Loprete FA, Santana NP, Chervin ELN, Sinisgalli LAM, Gimenez MP. Young woman with nutcracker syndrome without main clinic manifestation: Hematuria-Case report. Int J Surg Case Rep 2017; 31:225-228. [PMID: 28189985 PMCID: PMC5304238 DOI: 10.1016/j.ijscr.2017.01.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The nutcracker syndrome occurs due to the compression of the left renal vein between the aorta and the superior mesenteric artery. The diagnosis of the syndrome is often difficult and under diagnosed. The main clinical manifestations are hematuria and pelvic or back pain. PRESENTATION OF CASE A 25 years old female patient with severe abdominal pain in the lower abdomen without hematuria. Diagnosis with nutcracker syndrome after performing computed tomography. Presented the first episode of pain with 17 years old and was diagnosed at age 25. DISCUSSION In the nutcracker syndrome anatomical changes do not generate specific symptoms, causing the disease to be underdiagnosed. In this syndrome, there is increased pressure on the left renal vein, generating several signs and symptoms, and hematuria is one of present. Our patient did not have hematuria. Because of common symptoms, it makes nutcracker syndrome difficult diagnosis, confusing with other diseases, especially with nephrolithiasis. It is usually diagnosed after exclusion of other diseases. CONCLUSION The diagnosis of nutcracker syndrome is done after exclusion of other causes of chronic pelvic pain. In most cases, macroscopic and microscopic hematuria are present but was unobserved in this case. Making it more difficult diagnosis.
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Micro- and macroscopic hematuria caused by renal vein entrapment: systematic review of the literature. Pediatr Nephrol 2016; 31:175-84. [PMID: 25627663 DOI: 10.1007/s00467-015-3045-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/05/2015] [Accepted: 01/05/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Hematuria secondary to renal vein entrapment is mentioned only passing in textbooks and reviews. METHODS We performed a search of the National Library of Medicine database for peer-reviewed publications using the terms "renal vein" or "nutcracker" and "hematuria". RESULTS We identified 187 published reports/studies that covered 736 patients, of whom 288 had microscopic hematuria and 448 had macroscopic hematuria. The patient cohort comprised 159 patients aged ≤17 years. Abdominal pain was absent in approximately 65% of all patients, and a clinically relevant left-sided varicocele was observed in 29% of the male patients. A normal pre-aortic left renal vein and an anomalous anatomy were noted in 680 and 56 patients, respectively. The body mass index (BMI) was lower in patients with renal vein entrapment than in the controls, with a regression of hematuria correlating with an increase in BMI. A surgical procedure was attempted in 34% of the patients, of which the most common were endovascular stenting and transposition of the renal vein distally into the vena cava. CONCLUSIONS In cases of unexplained hematuria with or without abdominal pain, clinicians should consider the diagnosis of renal vein congestion, especially in males with varicocele. Ultrasonic Doppler flow scanning is the recommended initial diagnostic modality in these patients. Expectation management is advised in the great majority of cases.
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Thaveau F, Nicolini P, Lucereau B, Georg Y, Lejay A, Chakfe N. Associated Da Vinci and Magellan Robotic Systems for Successful Treatment of Nutcracker Syndrome. J Laparoendosc Adv Surg Tech A 2015; 25:60-3. [DOI: 10.1089/lap.2013.0532] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Fabien Thaveau
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | | | - Benoit Lucereau
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Yannick Georg
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Nabil Chakfe
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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A case of the nutcracker syndrome developed after delivery. Case Rep Urol 2014; 2014:503017. [PMID: 25140272 PMCID: PMC4129967 DOI: 10.1155/2014/503017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 07/15/2014] [Indexed: 11/18/2022] Open
Abstract
We report a case of nutcracker syndrome that developed after delivery. A 32-year-old woman visited our clinic complaining of gross hematuria 4 months after delivery. Urethrocystoscopic examination failed to show hematuria coming from the ureteral orifice; however, enhanced computed tomography revealed the compression of the left renal vein between the aorta and superior mesenteric artery. Therefore, we diagnosed her with nutcracker syndrome and conservatively observed her. The macrohematuria disappeared by itself after 1 month. This is the first report to describe a case of nutcracker syndrome that developed after delivery.
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Del Canto Peruyera P, Vaquero Lorenzo F, Vallina-Victorero Vazquez MJ, Alvarez Salgado A, Vicente Santiago M, Botas Velasco M, Alvarez Fernandez LJ. Recurrent hematuria caused by nutcracker syndrome. Ann Vasc Surg 2013; 28:1036.e15-9. [PMID: 24321267 DOI: 10.1016/j.avsg.2013.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 05/15/2013] [Accepted: 05/19/2013] [Indexed: 11/26/2022]
Abstract
A 26-year-old woman presented to the emergency department complaining of left flank pain, and proteinuria and hematuria were detected during urinalysis. A renal ultrasound did not reveal any disorder, and after performing a computed tomography angiography scan, compression of the left renal vein between the superior mesenteric artery and the aorta was seen. This compression is known as Nutcracker syndrome. From among the different treatment options available, it was decided, with patient consensus, to use open surgical management, performing a transposition of the left renal vein to a more distal level in the inferior vena cava. The immediate postoperative care progressed without complications and the symptoms resolved; after 1 year of surveillance, the patient continues to be asymptomatic. Nutcracker syndrome is a rare phenomenon, with few cases described. There are different therapeutic options for the treatment of Nutcracker syndrome, such as open surgery, endovascular treatment, or conservative treatment; because of the low prevalence of this syndrome, there are no sufficiently large series at present or with the necessary long-term surveillance to decide on the most suitable treatment. Distal transposition of the left renal vein in the inferior cava vein has proved to offer good long-term results, and this option offers a higher chance of resolution without the need for as many postsurgery controls as would be required with endovascular treatment.
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Affiliation(s)
- Pablo Del Canto Peruyera
- Department of Angiology and Vascular and Endovascular Surgery, Cabueñes Hospital, Asturias, Spain.
| | - Fernando Vaquero Lorenzo
- Department of Angiology and Vascular and Endovascular Surgery, Cabueñes Hospital, Asturias, Spain
| | | | - Andrés Alvarez Salgado
- Department of Angiology and Vascular and Endovascular Surgery, Cabueñes Hospital, Asturias, Spain
| | - María Vicente Santiago
- Department of Angiology and Vascular and Endovascular Surgery, Cabueñes Hospital, Asturias, Spain
| | - Marta Botas Velasco
- Department of Angiology and Vascular and Endovascular Surgery, Cabueñes Hospital, Asturias, Spain
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Endovascular stent placement for the treatment of nutcracker syndrome. Int Urol Nephrol 2011; 44:1097-100. [PMID: 22086468 DOI: 10.1007/s11255-011-0080-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 10/25/2011] [Indexed: 10/15/2022]
Abstract
A patient presented with recurrent macroscopic hematuria, persistent orthostatic proteinuria and intermittent flank pain for 12 months. Doppler ultrasound, computed tomography angiography and selective renal vein phlebography revealed the compression of the left renal vein by the abdominal aorta. The patient was diagnosed with nutcracker syndrome and underwent endovascular stent placement. No intraoperative or postoperative complications occurred. The clinical symptoms completely resolved 14 days after the operation. At a follow-up of 6 months, the patient continued to be asymptomatic.
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Ben Abdallah Chabchoub R, Chabchoub K, Maaloul I, Gargouri L, Ben Mahfoudh K, Nabil Mhiri M, Mhiri R, Mahfoudh A. Le syndrome casse-noisette (Nutcracker) : une cause rare d’hématurie. Arch Pediatr 2011; 18:1188-90. [DOI: 10.1016/j.arcped.2011.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 10/12/2010] [Accepted: 08/08/2011] [Indexed: 11/16/2022]
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Venkatachalam S, Bumpus K, Kapadia SR, Gray B, Lyden S, Shishehbor MH. The nutcracker syndrome. Ann Vasc Surg 2011; 25:1154-64. [PMID: 21439772 DOI: 10.1016/j.avsg.2011.01.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Revised: 01/03/2011] [Accepted: 01/09/2011] [Indexed: 02/07/2023]
Abstract
Left renal vein (LRV) compression, commonly referred to as the nutcracker syndrome or renal vein entrapment syndrome, is a rare and often overlooked condition. Anatomically, the LRV traverses the space between the superior mesenteric artery and the aorta in close proximity to the origin of the artery. In affected individuals, the LRV is subjected to compression between these two structures, resulting in renal venous hypertension. A review of published data on this condition reveals either case reports or small case series. The classic symptoms of nutcracker syndrome include left flank pain with gross or microscopic hematuria. Patients are often children or young adults, with a slight predisposition for women who may also present with pelvic congestion symptoms such as pelvic pain and dyspareunia. Most patients have disease symptoms for many years and nondiagnostic investigations before proper diagnosis can be made. Appropriate diagnostic work-up and treatment may help alleviate patient morbidity from this chronic condition. Although surgical repair has been the standard of care, more recently endovascular intervention has become the first line of therapy. This tabular review compiles published cases in the adult population during the period between 1980 and 2009.
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Zapardiel I, Sanfrutos L, Perez-Medina T, Godoy-Tundidor V, Delafuente-Valero J, Zanagnolo V. Clinical management of Nutcracker's syndrome during pregnancy. J Matern Fetal Neonatal Med 2010. [DOI: 10.3109/14767050903189008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. The nutcracker syndrome (NCS) is the clinical equivalent of nutcracker phenomenon characterized by a complex of symptoms with substantial variations. Depending on specific manifestations, NCS may be encountered by different medical specialists. Although it may be associated with substantial morbidity, the diagnosis of NCS is often difficult and is commonly delayed. Diagnostic and treatment criteria are not well established, and the natural history of NCS is not well understood. We performed an initial review of the literature through MEDLINE, searching from 1950 to date and using the keywords nutcracker syndrome, nutcracker phenomenon, and renal vein entrapment. We performed additional reviews based on the literature citations of the identified articles. We attempted to elucidate clinical relevance of these conditions and their prominent features and to summarize professional experience.
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Bhanji A, Malcolm P, Karim M. Nutcracker syndrome and radiographic evaluation of loin pain and hematuria. Am J Kidney Dis 2009; 55:1142-5. [PMID: 20022679 DOI: 10.1053/j.ajkd.2009.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Accepted: 10/08/2009] [Indexed: 02/07/2023]
Affiliation(s)
- Amir Bhanji
- Department of Renal Medicine, Norfolk and Norwich University Hospital, Norwich, UK
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El Harrech Y, Jira H, Chafiki J, Ghadouane M, Ameur A, Abbar M. [Nutcracker syndrome managed by simple surveillance]. Actas Urol Esp 2009; 33:93-6. [PMID: 19462733 DOI: 10.1016/s0210-4806(09)74010-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Nutcracker syndrome is caused by compression of the left renal vein between the aorta and the superior mesenteric artery where it passes in the fork formed at the bifurcation of these arteries. The phenomenon results in left renal venous hypertension. The syndrome is manifested by left flank and abdominal pain, with or without unilateral haematuria. The nutcracker syndrome has been treated in various ways. We report one case of the syndrome and discuss the place of surveillance in its management.
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Affiliation(s)
- Youness El Harrech
- Departamento de Urología, Hospital Militar Mohammed V. Rabat, Marruecos.
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Mohamed M, Siham S, Souad C, Hassan J, Ahmed A, Mohamed B, Mostapha T, Mohamed A, Mohamed B. [The nutcracker syndrome]. Nephrol Ther 2008; 5:58-60. [PMID: 18809368 DOI: 10.1016/j.nephro.2008.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 06/14/2008] [Accepted: 06/23/2008] [Indexed: 10/21/2022]
Abstract
The nutcracker syndrome refers to compression of the left renal vein between the aorta and the superior mesenteric artery. After a review of the literature, the authors emphasize the uncommon incidence of this pathology, and the interest of imaging in the survey of this affection.
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Affiliation(s)
- Mahi Mohamed
- Services d'imagerie médicale, hôpital militaire d'instruction Mohamed-V, Rabat, Maroc.
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Rao J, Yang J, Liu Z, Wang L, Liu L, Yin Z, Yang L. Right Retrocaval Ureter and Left Nutcracker Syndrome: A Case Report. Urology 2008; 71:1226.e9-11. [DOI: 10.1016/j.urology.2007.11.108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2007] [Revised: 11/06/2007] [Accepted: 11/19/2007] [Indexed: 11/30/2022]
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Zhang H, Li M, Jin W, San P, Xu P, Pan S. The left renal entrapment syndrome: diagnosis and treatment. Ann Vasc Surg 2007; 21:198-203. [PMID: 17349362 DOI: 10.1016/j.avsg.2006.10.021] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Revised: 08/14/2006] [Accepted: 10/19/2006] [Indexed: 12/21/2022]
Abstract
A retrospective analysis was performed to review 20 patients with left renal vein (LRV) entrapment syndrome. All cases were diagnosed based on ultrasonography, magnetic resonance angiography, and renal venography. Technical success was achieved in all patients. Transposition of superior mesenteric artery was performed in three cases, transposition of LRV in two, and stent implantation in the LRV in 15. Stent migration occurred in one case, and stent reimplantation was performed. One case suffered from hematoma after transposition of the superior mesenteric artery, and reoperation was performed. Follow-up was made from 6 months to 6 years after the operation. Abnormalities were not found in the urine test of 18 patients and their symptoms disappeared. Two cases still had microscopic hematuria after exercise. All surgical operations are effective for nutcracker syndrome except excessive invasiveness. Stent may be one of the mainstream therapies because of its minimal invasiveness.
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Affiliation(s)
- Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital of Medical College, Zhejiang University, Hangzhou, China 310003.
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