The nutcracker syndrome: its role in the pelvic venous disorders

Outcomes of conservative management in patients with nutcracker syndrome

OBJECTIVE

This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions.

METHODS

This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms.

RESULTS

Sixteen patients (75% female and mean age 24.4 ± 3.5 years) underwent conservative management. Over a mean follow-up of 27.3 months [13-42, interquartile range (IQR)], the diameter ratio (5.5 [5-6.5, IQR] vs 4.3 [4.1-6], p = NS), the peak velocity ratio (6 [5-7, IQR] vs 4.8 [4.8-5.8], p = NS), beak angle (27° [24-30, IQR] vs 29° [24-32]; p = NS), and aortomesenteric angle (26° [23-29, IQR] vs 28° [24-30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged.

CONCLUSIONS

This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms.

Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting

BACKGROUND

Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting.

METHODS

The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed.

RESULTS

Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%.

CONCLUSIONS

Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.

Surgical treatment of nutcracker syndrome results in improved pain and quality of life

BACKGROUND

Left renal vein (LRV) compression, or nutcracker phenomenon, describes the compression of the LRV, most commonly between the aorta and the superior mesenteric artery. The outflow obstruction that occurs from the compression causes venous hypertension leading to the development of pelvic collaterals, lumbar vein engorgement and gonadal vein reflux. The symptoms associated with LRV compression include abdominal pain, left flank pain, back pain, headache, pelvic pain/pressure, and hematuria. Symptomatic LRV compression can cause chronic pain and disability that impedes activities of daily living. Left renal auto transplantation (LR-AT) is one mode of treatment, leading to decreased pain with no significant vascular or urological complications. Herein we present a five patient case series with symptomatic LRV compression who underwent LR-AT with improved pain and quality of life after surgery.

METHODS

Five patients underwent LR-AT between June 2020-December 2020 to resolve their symptomatic LRV compression. These patients were given three validated surveys pre- and post- intervention, then again at their three month follow up visit to assess their pain and health-related quality of life.

RESULTS

The five patients were all female with the average age of 36.8 years old (36-41) and underwent LR-AT to treat their symptomatic LRV compression. The average Numeric Rating Scale (NRS) pain score pre intervention was 8.3 (range 6.7 to 10) which improved to pain rating 5.22 (range 2.7 to 6) post intervention, p-value = 0.013. The average pain NRS score at 3 month follow up was 3.86 (range 1.3-6), p-value = 0.006 when compared to pre-intervention pain scores. The average pain intensity pre intervention was 4.5 (4 to 5) and 2.7 (1 to 4.3) post intervention, p-value = 0.024. The average pain intensity score at 3 month follow up was 2.24 (range 1.3-3.3), p-value = 0.002 when compared to pre-intervention. The VascuQoL-6 survey score pre intervention averaged score of 9.6 (range 7-12) which improved to an average score of 20.6 (range 18-24), p-value = 0.001. The average VascuQoL score at 3 month follow up was 22.6 (range 22-24), p-value = < 0.001 when compared to pre intervention QoL scores all showing a statistically significant improvement of health-related quality of life.

CONCLUSION

The diagnosis of LRV compression can be challenging due to the non-descript symptoms and overall lack of awareness. Understanding venous tributary pathways and drainage can help clarify why patients present with unusual symptoms. Surgical treatment of LRV compression through LR-AT can improve patients' pain and improve vascular quality of life.

How I treat nutcracker syndrome

Anatomic compression of the left renal vein in the angle between the aorta and superior mesenteric artery may be asymptomatic or may result in symptoms, including flank pain, hematuria, or pelvic pain and/or congestion. Patients can be referred to a vascular surgeon due to symptoms and/or radiologic findings. Because symptoms of nutcracker syndrome can be vague and/or nondiagnostic, careful evaluation, assessment, and counseling with patients are required before undertaking intervention, which is often an open surgical procedure. The definitive diagnosis is ideally confirmed with diagnostic venography, including pressure measurements from the left renal vein and inferior vena cava. The optimal treatment includes open decompression of the left renal vein with renal vein transposition or gonadal vein transposition, with or without concomitant management of pelvic varicosities if symptomatic. Because most patients with nutcracker syndrome are young, long-term follow-up with scheduled ultrasound examinations should be maintained.

Microvascular Doppler-assisted Microsurgical Left Spermatic-inferior Epigastric Vein Anastomosis for Treating Nutcracker Syndrome-associated Varicocele

Background

Nutcracker syndrome (NCS) is a rare cause of varicocele and its treatment is still controversial.

Objective

To summarize the surgical strategy and outcomes of microvascular Doppler (MVD)-assisted microsurgical left spermatic-inferior epigastric vein anastomosis (MLSIEVA) with microsurgical varicocelectomy (MV) at the same incision for treating NCS-associated varicocele.

Design setting and participants

A retrospective analysis of 13 cases of NCS-associated varicocele between July 2018 and January 2022 was performed.

Surgical procedure

A small incision in the body projection corresponding to the deep inguinal ring was chosen as the surgical incision. All patients underwent MLSIEVA and MV with the assistance of MVD.

Measurements

Patients received real-time Doppler ultrasound (DUS) before and after surgery; urine red blood cells and protein were tested, with a follow-up time of 12-53 mo.

Results and limitations

All patients had no intraoperative complications, and all postoperative symptoms of hematuria or proteinuria, scrotal swelling, and low back pain disappeared. Comparing pre- and postoperative DUS, two patients did not show any improvement in their postoperative measurements. However, in the remaining patients, the internal diameter of the renal vein at the hilum portion and at the aortomesenteric angle portion, as well as their ratio, improved significantly compared with preoperative measurements. No complications or recurrence of varicocele was observed during postoperative follow-up.

Conclusions

Our study suggests that MVD-assisted MLSIEVA with MV is feasible with no major short-term complication and effective regarding the treatment of varicocele and NCS.

Patient summary

We investigated microsurgery mediated by microultrasound for the treatment of varicocele associated with nutcracker syndrome. We found this procedure to be safe and effective with good long-term results.

Systematic review of endovascular versus laparoscopic extravascular stenting for treatment of nutcracker syndrome

OBJECTIVE

The aim of the present study was to assess the current strategies of endovascular and laparoscopic extravascular stenting for symptomatic compression of the left renal vein (LRV), most frequently between the aorta and superior mesenteric artery (nutcracker syndrome [NCS]).

METHODS

We performed a systematic review of all studies of endovascular and laparoscopic extravascular LRV stenting for NCS using the PubMed/MEDLINE, Scopus, Embase, Cochrane, Science Citation Index Expanded, Emerging Sources Citation Index, and Epistemonikos databases. Data were collected in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidelines. The English, Spanish, and German language literature was searched from January 1, 1946 to February 9, 2022. The outcomes assessed included symptom resolution, hematuria resolution, and reintervention at follow-up.

RESULTS

The search yielded 3498 reports. After removing the duplicates and those without the full text available, 1724 studies were screened. Of these, 11 studies were included in the present review. Of the 11 studies, 7 were on endovascular stenting and 4 on laparoscopic extravascular stenting; all 11 studies were retrospective, single-center case series. Of the 233 patients, 170 (80 women) had undergone endovascular stenting and 63 (9 women) had undergone extravascular stenting. The follow-up period varied from 1 to 60 months after endovascular stenting and 3 to 55 months after extravascular stenting. The symptoms had resolved in 76% (range, 50%-100%) after endovascular stenting and 83% (range, 71%-100%) after extravascular stenting. Hematuria had resolved in 86% (range, 60%-100%) after endovascular stenting and 89% (range, 77%-100%) after extravascular stenting. Of 185 patients, 9 had required reintervention after endovascular stenting and none after extravascular stenting.

CONCLUSIONS

Endovascular and laparoscopic extravascular stenting are less invasive and, thus, more attractive treatment options that have been more recently developed for the management of NCS. The results from the present study have shown that symptom and hematuria resolution must be provided before they can be considered preferred management options for patients affected by NCS. Given the limited number of patients involved, no definitive conclusion could be drawn regarding the superiority of one technique compared with the other.

Insights into pelvic venous disorders

Pelvic venous disorders (PeVD), sometimes referred to as pelvic congestion syndrome (PCS), widely impact affected patients-mainly young women's quality of life, causing puzzling, uncomfortable symptoms sometimes requiring months or years to get an explanation, while simply remaining undiagnosed in other cases. Because pelvic pain is a non-specific symptom, an appropriate diagnosis requires a careful patient workup, including a correlation between history and non-invasive imaging. Invasive imaging is frequently required to confirm the diagnosis and plan treatment. Current therapeutic approaches principally rely on minimally invasive techniques delivered through endovascular access. However, while comprehensive descriptive classifications such as the symptoms-varices-pathophysiology (SVP) classification exist, universally accepted guidelines regarding therapy to apply for each SVP category are still lacking. This review strongly focuses on PeVD imaging and discusses available therapeutic approaches with regard to pathophysiological mechanisms. It proposes a new classification scheme assisting clinical decision-making about endovascular management to help standardize the link between imaging findings and treatment.

Comprehensive overview of the venous disorder known as pelvic congestion syndrome

Pelvic venous disorders (PeVD) also known as Pelvic Congestion Syndrome (PCS) affect a great number of women worldwide and often remain undiagnosed. Gynecological symptoms caused by vascular background demand a holistic approach for appropriate diagnosis. This is a relevant cause of chronic pelvic pain and atypical varicose veins. The diagnosis is based on imaging studies and their correlation with clinical presentation. Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation. The following paper describes an in-depth overview of anatomy, pathophysiology, symptoms, diagnosis and treatment of PCS. In recent years, minimally invasive interventions have become the method of first choice for the treatment of this condition. The efficacy of a percutaneous approach is high and it is rarely associated with serious complications.Key MessagesPelvic venous disorders demand a holistic approach for appropriate diagnosis.This article takes an in-depth look at existing therapies of Pelvic Congestion Syndrome and pathophysiology of this condition.Embolisation is an effective and safe treatment option.

Fortuitous Discovery of Nutcracker Syndrome During Acute Appendicitis: A Case Report

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.

Associations of left renal vein entrapment with IgA nephropathy and Henoch-Schönlein purpura nephritis

Objectives

The aims of the study were to identify whether left renal vein (LRV) entrapment was more prevalent in IgA nephropathy (IgAN) and Henoch–Schönlein purpura nephritis (HSPN) compared with other types of renal diseases, and the association of LRV entrapment with glomerular incidental IgA and galactose-deficient-IgA1 (Gd-IgA1) deposition.

Methods

A total of 797 patients with biopsy-proven kidney diseases have been screened for LRV entrapment by color Doppler ultrasound, and the prevalence of LRV entrapment in different types of renal diseases were then analyzed. Propensity score matching analysis was used to adjust for age, gender, and body mass index. Immunostaining of Gd-IgA1 with KM55 was performed in paraffin-embedded sections of renal biopsy specimens.

Results

LRV entrapment was diagnosed in 47 patients (6%) with several kinds of renal diseases in our cohort. A total of 32 (68%) LRV entrapments were combined with expanded IgAN (idiopathic IgAN and HSPN). The prevalence of LRV entrapment in expanded IgAN was significantly higher than that in non-expanded IgAN (17 vs. 2%, p < 0.001), even after adjustment for age, gender, and body mass index by propensity score matching analysis (13 vs. 2%, p < 0.001). Removing expanded IgAN and LN, glomerular incidental IgA deposition was observed to be significantly more common in patients with LRV entrapment compared with patients without it (43 vs. 9%, p < 0.001). Furthermore, in glomerular diseases with incidental IgA deposits, significantly much larger proportion of patients with LRV entrapment were positive for glomerular Gd-IgA1 in contrast to patients without LRV entrapment (5/5 vs. 5/17, p = 0.01).

Conclusions

LRV entrapment coexisted with several kinds of renal diseases, with a significantly higher prevalence in patients with idiopathic IgAN and HSPN. In patients of LN and IgAN-unrelated disease with LRV entrapment, glomerular IgA and Gd-IgA1 deposition was more common compared with patients without LRV entrapment.

Interventional Management of a Rare Combination of Nutcracker and Wilkie Syndromes

Nutcracker and Wilkie syndromes are rare mesoaortic compression entities, and their association is even less common. Data on interventional treatment of these pathologies are still scarce, but results from limited case series are encouraging. We report the case of a previously healthy 45-year-old woman diagnosed with nutcracker and Wilkie syndromes who presented with macroscopic hematuria, intermittent pain in the left flank and hypogastric region, postprandial nausea, and unexplained significant weight loss. A successful endovascular approach with stent implantation in the left renal vein was performed, but the stent migrated toward the left kidney, and this acute complication was managed through an interventional strategy as well. At the three-month follow-up, the patient described a marked improvement in all symptoms, except for the macroscopic hematuria. As it was our strong belief that the approach was efficient, we further investigated the “hematuria”, which eventually led to the diagnosis of endometrial carcinoma. A hysterectomy and bilateral adnexectomy were planned, and chemoradiotherapy was initiated with the goal of preoperative tumor reduction. To our knowledge, this is the first reported case in which both Wilkie and nutcracker syndromes were effectively treated by stent implantation in the left renal vein, complicated with very early stent migration due to inadequate apposition to the less compliant venous lumen. The treatment of the duodenal compression was indirectly included in the stenting of the left renal vein, as reclaiming the venous lumen widened the aortomesenteric angle. The aim of this review is to discuss our center’s transcatheter experience with these rare disorders and explore the literature in order to establish the benefits and limitations of such an approach.

Bibliometric and visual analysis of research on nutcracker syndrome from 1974 to 2021: A systematic review

BACKGROUND

At present, researchers have obtained fruitful results in the study of nutcracker syndrome (NCS), but there is still a lack of systematic research on the overall status of this disease. This article aims to describe the past and current status of research into NCS, and predict future research trends and popular research topics.

METHODS

Using bibliometric and visualization methods, 552 articles related to NCS collected from the Scopus database from 1974 to 2021 were analyzed from multiple perspectives.

RESULTS

Overall, the amount of literature related to NCS is on the rise every year, and the number of citations is the turning point in 2006. The United States has the largest number of publications and has the most extensive cooperation with other countries. The main contents of the co-authored study focused on the symptoms, surgical procedures, and concomitant diseases of NCS. Keywords such as peak velocity, ultrasonography, orthostatic proteinuria, etc appeared earlier, whereas diagnosis, chronic pelvic pain, endovascular stents, etc appeared later.

CONCLUSIONS

The literature utilization rate of NCS is relatively insufficient. The pathogenesis and pathological mechanisms need to be further studied, and the diagnostic criteria and surgical methods will continue to be favored by clinicians.

Pelvic Congestion Syndrome: A Missed Opportunity

Background/Aims  Chronic pelvic pain (CPP) is pelvic pain for greater than 6 months with many potential causes one being pelvic congestion syndrome (PCS). PCS is diagnosed by clinical symptoms, exclusion of other etiologies, and imaging. Given the complex nature and diagnosis of CPP, we examined ordering and referral patterns in our local population to understand how the imaging findings of PCS correlate with patient symptoms and referral and treatment. Materials and Methods  After IRB approval, we searched all 18 to 70-year-old females with CT of the pelvis between March 2015 and March 2018 with the terms "pelvic" plus "congestion," "varices," or "vein dilation" in the dictation. Via electronic medical record and image review we collected data regarding demographics, clinical presentation, symptoms, imaging findings, ordering provider, and any follow-up/referrals or interventions regarding PCS. Results  A total of 96 patients were included of the 197 studies, with an average age of 47 years and average body mass index of 19.3 ( n  = 93) at the time of imaging. The reason for imaging was often acute abdominal or flank pain ( n  = 22) with 38% of cases ordered from the emergency room. Only 72 patients had documentation of clinical evaluation for symptoms of PCS. Notably, only 20 were referred for their symptoms, and only two patients were referred to IR. Both patients underwent successful endovascular intervention. Conclusion  CPP is a common cause of morbidity with PCS representing an underdiagnosed cause. We demonstrate that while imaging findings may be incidental, we are failing to capture and triage patients with clinical symptoms of PCS. Radiologists can play a key role in the care of these patients.

Coexisting nutcracker phenomenon and superior mesenteric artery syndrome in a patient with IgA nephropathy: A case report

RATIONALE

Nutcracker and superior mesenteric artery (SMA) syndrome share the same pathogenesis, but the simultaneous occurrence of both diseases is quite rare. A combination of the nutcracker syndrome and IgA nephropathy has previously been reported. Herein, we report what we believe is the first case of coexisting nutcracker and SMA syndrome in a patient with IgA nephropathy.

PATIENT CONCERNS

A 15-year-old Chinese boy who was diagnosed with IgA nephropathy at 8 years of age presented with gross hematuria, fatigue, anorexia, nausea, and recurrent abdominal distension for 1 week without any obvious evidence of preceding infection. Laboratory data showed macroscopic hematuria, heavy proteinuria, and relatively normal renal function. Doppler ultrasonography and upper gastrointestinal gastrografin study were performed, respectively. Since his renal function deteriorated after admission, repeated renal biopsy was performed.

DIAGNOSES

IgA nephropathy with nutcracker phenomenon and SMA syndrome.

INTERVENTION

Immunosuppressive therapy combined with conservative therapy for superior mesenteric artery syndrome.

OUTCOMES

One month later, his abdomen symptoms such as anorexia and abdominal distension eased a lot with body weight increase of about 3 kg. After 6 months of follow-up, his body weight increased to 57 kg, serum creatinine decreased to 63 μmol/L, and urine microscopy showed 75.5 RBC/high-power field with 0.3 g urine protein per day.

LESSONS

Although the association between vascular compression and IgA nephropathy (IgAN) has not been elucidated yet, combination of nutcracker syndrome and SMA syndrome should be considered in patients with IgAN. The combination may increase the complexity of the disease, and renal biopsy should not be hesitated for differential diagnosis.

Splenic vein enlargement, a rare cause of nutcracker syndrome

Abnormal enlargement of the splenic vein is one of the etiologies of nutcracker syndrome that should be considered when examining the causes of this syndrome. Because knowing rare etiologies can help correct diagnose and reduce mortality.

Nutcracker Phenomenon with Menorrhagia in a Woman with Marfan Syndrome

Nutcracker phenomenon (NCP) refers to left renal vein compression at the superior mesenteric artery origin involving hematuria and dysuria due to the compression of the renal venous return and pelvic congestion syndrome caused by the compression of the gonadal venous return. A leptosomatic woman (body mass index, 19 kg/m²) presented with NCP and Marfan syndrome accompanied by severe menorrhagia. Vascular ultrasonography revealed reversed flow in the left ovarian vein. Preoperative computed tomography revealed a sharp aortomesenteric angle and short aortomesenteric distance. After controlling her menstrual period via oral contraception, she underwent valve-sparing surgery for aortic root dilation, which spontaneously subsided the menorrhagia.

Female pelvic congestion syndrome: how can CT and MRI help in the management decision?

OBJECTIVE

Diagnosis of female pelvic congestion syndrome (PCS) is challenging. Although invasive venography is the gold-standard for diagnosis, however, CT and MRI are important in the assessment. In this study, we tried to highlight the role of CT and MRI as non-invasive tools in the diagnosis and management of PCS.

METHODS AND MATERIAL

This was a retrospective study of 50 patients confirmed clinically to have PCS. These patients had already done CT and MRI before venography or surgery.

RESULTS

The mean age of the patients was 48 years ± 12 years SD. Vaginal discharge and pelvic heaviness were the commonest symptoms (46 and 42% respectively). The commonest risk factor was multiparity (56%) followed by the RVF uterus (26%). No significant difference was found between CT, MRI, and venography as regarding the diameter of the ovarian vein, diameter, and the number of the varicose veins. The sensitivity of CT and MRI was 94.8 and 96%. CT and MRI discovered five cases with local pelvic obstructing cause,14 cases with evidence of vascular compression syndrome, and the rest 31 cases diagnosed to have primary non-obstructing PCS which was effective in decision-making with the surgery indicated in the first group while stenting of the vascular obstruction followed by bilateral ovarian veins coiling was the better option for the second group and only bilateral coiling was needed for the last group.

CONCLUSION

CT and MRI play important roles in the diagnosis and even management decision in cases of PCS.

ADVANCES IN KNOWLEDGE:

Identification of the importance of diagnostic radiology before management decisions of cases with PCS.

Variceal Veins Embolization and Left Renal Vein Stenting in a Patient with Combined Nutcracker and May–Thurner Syndrome

Nutcracker syndrome is defined as a compression of left renal vein leading to symptomatic hematuria and flank pain. There are very few reports about its association with May–Thurner syndrome that is related to compression of left iliac vein causing severe leg edema. We are reporting a rare case of a patient having both conditions successfully treated with sequential percutaneous interventions. This case and treatment options are discussed in detail.

From Nutcracker Phenomenon to Nutcracker Syndrome: A Pictorial Review

Left renal vein (LRV) entrapment, also known as nutcracker phenomenon if it is asymptomatic, is characterized by abnormality of outflow from the LRV into the inferior vena cava (IVC) due to extrinsic LRV compression, often accompanied by demonstrable lateral (hilar) dilatation and medial (mesoaortic) stenosis. Nutcracker syndrome, on the other hand, includes a well-defined set of symptoms, and the severity of these clinical manifestations is related to the severity of anatomic and hemodynamic findings. With the aim of providing practical guidance for nephrologists and radiologists, we performed a review of the literature through the PubMed database, and we commented on the definition, the main clinical features, and imaging pattern of this syndrome; we also researched the main therapeutic approaches validated in the literature. Finally, from the electronic database of our institute, we have selected some characteristic cases and we have commented on the imaging pattern of this disease.

[Immediate and remote results of endovascular embolization of ovarian veins]

Presented in the article is a prospective study of endovascular embolization of ovarian veins in female patients suffering from primary pelvic varicose veins, with the assessment of the immediate and remote results, as well as a 1-year follow up.

AIM

The aim of our investigation was a comprehensive clinical and instrumental assessment of efficacy of endovascular embolization in women with pelvic varicose veins.

PATIENTS AND METHODS

Our single-centre study included a total of 29 female patients presenting with pelvic varicose veins and undergoing embolization of ovarian veins using microcoils, in 5 cases the procedure was supplemented with injecting a foam sclerosant.

RESULTS

The technical success of endovascular occlusion of ovarian veins amounted to 100%. Two women immediately after the operation were subjected to a redo intervention: in one case - resection of the ovarian vein and in the second case - repositioning of the microcoils. In the remote period, one patient due to recurrent relapses underwent repeat embolization followed by retroperitoneal resection of the ovarian vein. The findings of the clinical methods of examination demonstrated a decrease in the intensity of manifestations of pelvic varicose veins according to the pelvic venous clinical severity score and visual analogue scale, as well as improvement of the women's quality of life.

CONCLUSION

Endovascular occlusion of ovarian veins is a highly effective, minimally invasive, and safe method of treatment of female patients with incompetent ovarian veins. Endovascular treatment may be regarded as a method of choice in management of the primary form of pelvic varicose veins.

Role of imaging in visceral vascular emergencies

Differential diagnosis in non-traumatic acute abdomen is broad and unrelated diseases may simulate each other from a clinical perspective. Despite the fact that they are not as common, acute abdominal pain due to diseases related to visceral vessels may be life-threating if not detected and treated promptly. Thrombosis, dissection, and aneurysm in the abdominal visceral arteries or thrombosis in visceral veins may cause acute abdominal pain. Imaging with appropriate protocoling plays a fundamental role in both early diagnosis and determination of the treatment approach in these cases where early treatment can be life-saving. Computed tomography (CT) appears to be the most effective modality for the diagnosis as it provides high detail images in a very short time. Patient cooperation is also a less concern as compared to magnetic resonance imaging (MRI). As the imaging findings may sometimes be really subtle, diagnosis may be difficult especially to inexperienced imagers. Correct protocoling is also very critical to detect arterial abnormalities as visceral arterial abnormalities may not be detectable in portal phase only abdominal CT scans. In this article, we aimed to increase awareness among imaging specialists to these not very common causes of acute abdomen.

Gonadal vein transposition is a safe and effective treatment of nutcracker syndrome

BACKGROUND

Nutcracker syndrome (NCS) is a pelvic venous disorder that results from outflow obstruction of the left renal vein, most often due to a decreased aortomesenteric angle, leading to gonadal vein reflux, pain, and varices. Although a number of open and minimally invasive procedures to treat NCS have been described, the optimal management of this condition remains uncertain. To the best of our knowledge, we have presented the largest case series to date using gonadal vein transposition (GVT) to treat NCS.

METHODS

Patients considered for intervention to treat NCS underwent a rigorous and standardized workup, including axial imaging studies, catheter-based diagnostic procedures, and urinalysis. GVT has been the institutional first-line treatment of NCS for appropriate patients. With institutional review board approval, a retrospective review of patients who had undergone GVT for NCS was conducted.

RESULTS

From 2014 to 2019, 18 GVTs had been performed. Of the 18 patients, none had died or required reintervention, although 2 had required readmission. During a median follow-up of 178 days, complete symptom relief was achieved in 11 patients (61.1%), with 4 patients (22.2%) reporting partial symptom relief and 2 (11.1%) reporting transient symptom relief.

CONCLUSIONS

GVT is a safe and effective procedure to treat NCS in appropriately selected patients with outcomes that compare favorably with those of other described procedures. Appropriate patient selection for this procedure is critical and requires a rigorous and standardized approach to diagnosis and management.

Combined Superior Mesenteric Artery Syndrome and Nutcracker Syndrome in a Young Patient: A Case Report and Review of the Literature

Patient: Male, 18-year-old

Final Diagnosis: Superior mesenteric artery syndrome

Symptoms: Abdominal pain

Medication:—

Clinical Procedure: —

Specialty: Surgery

3D-Printed PEEK Extravascular Stent in the Treatment of Nutcracker Syndrome: Imaging Evaluation and Short-Term Clinical Outcome

Minimally invasive options are safe and reliable alternatives for the treatment of nutcracker syndrome (NCS). After continued efforts, our team successfully devised a new and effective therapeutic method: 3D-printed extravascular stenting of the left renal vein. From December 2017 to May 2019, 28 patients (25 men and 3 women) from different parts of China between 18 and 37 years old (mean, 23.6 years) diagnosed with NCS were admitted for laparoscopic 3D-printed extravascular stenting treatment. The post-operative follow-up duration was 6-24 months (median, 16.3 months). Technical success of the operation was achieved in all patients. After treatment, the NCS symptoms all patients resolved or improved during the follow-up period, without relapse. Most symptoms, including macro-/microhematuria, proteinuria, and flank/abdominal pain, tended to resolve within 3-6 months after the surgery; other symptoms, such as left-sided varicocele, also showed varying degrees of improvement at different times post-operatively. Perioperative complications were noted in two patients, including transient and mild lymphatic leakage, without any adverse effects. All extravascular stents were visualized on computed tomography and Doppler ultrasound scans, and no migration or any side effects occurred during the entire follow-up period. Compared to endovascular stenting or polytetrafluoroethylene artificial vessel procedures, 3D-printed polyetheretherketone extravascular stenting has more advantages in terms of stent design and rigidity and approach rationality while successfully preventing stent migration and thrombosis. Therefore, this method may serve as an accurate and effective treatment for NCS patients.

Doppler US and CT Diagnosis of Nutcracker Syndrome

Nutcracker syndrome (NCS) is a syndrome caused by compression of the left renal vein (LRV), between the abdominal aorta and the superior mesenteric artery, resulting in hypertension of the LRV and hematuria. Doppler ultrasonography (US) has been commonly used for the diagnosis of NCS. However, several technical issues, such as Doppler angle and sample volume, need to be considered to obtain satisfactory results. In addition, morphologic changes of the LRV and a jetting phenomenon across the aortomesenteric portion of the LRV on contrast-enhanced computed tomography (CECT) are diagnostic clues of NCS. With proper Doppler US and CECT, NCS can be diagnosed noninvasively.

Serial ganglion impar blocks in a patient with nutcracker syndrome refractory to left renal vein transposition: a case report

Background

Nutcracker syndrome is a rare disorder caused by compression of the left renal vein, usually between the aorta and the superior mesenteric artery. It typically presents with left-sided abdominal pain and hematuria. Left renal vein transposition is the most commonly employed surgical technique to alleviate the compression.

Case presentation

A 22-year-old Caucasian man with a known diagnosis of nutcracker syndrome had undergone left renal vein transposition 1 year before presentation without any subsequent pain relief. In addition, his surgery was complicated by massive blood loss and a 1-week-long stay in an intensive care unit (ICU); as such, he was not amenable to further surgical intervention or stenting to treat his underlying pathology. His symptoms included constant sharp left-sided flank, perineal, and testicular pain. A series of ganglion impar blocks were performed every 3–4 months over the course of 5 years with substantial pain relief achieved.

Conclusions

Our case report highlights a treatment option that has not yet been described for patients with pain secondary to nutcracker syndrome refractory to surgical intervention.

Microsurgical gonadal-inferior epigastric vein anastomosis to treat the nutcracker phenomenon with left gonadal vein varices with reflux

OBJECTIVE

To evaluate the effectiveness and safety of microsurgical gonadal-inferior epigastric vein anastomosis for the treatment of the nutcracker phenomenon (NCP) associated with left gonadal vein varices with reflux.

METHODS

Thirty-five patients with NCP associated with left gonadal vein varices with reflux diagnosed in our hospital from June 2016 to June 2018 were included. All patients underwent a shunt operation consisting of microsurgical gonadal-inferior epigastric vein anastomosis, and the patients were followed up for 1 year.

RESULTS

All patients were successfully operated on, with an average operation time of 96.5 ± 12.3 min. After a 1-year follow-up, the symptom of gross hematuria disappeared in 3 patients (including 1 woman). For the other 32 patients, the sperm concentration (27.43 ± 8.68 × 10⁶/ml) and motility (33.06 ± 4.27%) postoperatively were significantly higher than that preoperatively (16.21 ± 6.43 × 10⁶/ml and 23.48 ± 4.43%, respectively) (P < 0.05); among these patients, 2 had natural pregnancies with their spouses. The peak velocity (PV) at the aortomesenteric portion of the left renal vein (LRV) and the PV ratio between the aortomesenteric and hilar portion of the LRV significantly decreased after surgery (117.9 ± 30.4 cm/s vs 76.6 ± 18.5 cm/s; 7.3 ± 0.7 vs 4.1 ± 0.4). Two patients had complications of mild hydroceles requiring no intervention, and no major complications were observed during and after surgery.

CONCLUSION

Our results suggest that the microsurgical gonadal-inferior epigastric vein anastomosis is both effective and safe to treat patients with gonadal varicose veins caused by the nutcracker phenomenon.

Localized solitary left renal vein thrombus complicating nutcracker syndrome: a case report and review of the literature

Nutcracker syndrome (NCS) refers to compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery (SMA). The clinical presentation of NCS includes hematuria, abdominal and left flank pain, gonadal varices, and varicocele formation. Theoretically, thrombosis can occur in the LRV in patients with NCS. However, an isolated solitary left renal vein thrombus (LRVT) complicating NCS is rare. In addition, the clinical features of an LRVT complicating NCS remain unclear. We describe a 43-year-old woman presenting with an asymptomatic LRVT complicating NCS. She was referred to our hospital for investigation of dysfunctional uterine bleeding, and detailed examination revealed endometrial cancer. Computed tomography angiography (CTA) and Doppler ultrasonography revealed compression of the LRV between the aorta and the SMA, as well as an LRVT. CTA performed 4 months after the administration of an anticoagulant showed complete disappearance of the LRVT. We have also included a review of published reports describing LRVT complicating NCS and discussed the clinical features of such a presentation.

Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome

Pelvic venous congestion syndrome (PVCS) is a challenging and complex cause of chronic pelvic pain in female patients. PVCS due to incompetent vein valves is the combination of gonadal vein reflux and pelvic venous engorgement in patients with chronic pelvic pain without other causes. However, pelvic venous engorgement and gonadal vein reflux can be seen in patients without pelvic pain, which makes obtaining a detailed history and physical examination important for workup and diagnosis. The underlying cause of PVCS may be incompetent gonadal vein valves or structural causes such as left renal vein compression with an incompetent gonadal vein valve (nutcracker syndrome) or iliac vein compression (May-Thurner configuration) with reflux into the ipsilateral internal iliac vein. Venography is considered the criterion standard for imaging diagnosis; however, more recently, US and MRI have been shown to provide adequate accuracy for diagnosis. Noninvasive imaging studies aid in the diagnosis of PVCS and also aid in pretreatment planning. When PVCS is caused by incompetent gonadal vein valves, treatment typically is performed by means of embolization via a minimally invasive catheter with excellent technical and clinical success rates. When PVCS is caused by venous obstruction, the obstruction must be treated first before gonadal vein embolization and sclerotherapy are considered. ^©RSNA, 2019 Online supplemental material is available for this article.

A minimally invasive alternative for the treatment of nutcracker syndrome using individualized three-dimensional printed extravascular titanium stents

BACKGROUND

This study was designed to evaluate the clinical and radiographic outcomes of patients with nutcracker syndrome (NCS) who were treated with three-dimensional printing (3DP) extravascular titanium stents (EVTSs). The 3DP EVTS was expected to release the hypertension of the left renal vein (LRV) produced by its compression between the superior mesenteric artery (SMA) and the aorta without causing any complications.

METHOD

The pre-operative kidney model of each patient was printed out to enable surgical planning. After that, the EVTS was designed based on the LRV's primitive physiologic structure using computer-aided design software, and each stent was printed out with a precision setting of 20 μm. Seventeen patients who had been suffering from NCS underwent laparoscopic 3DP EVTS placement. The surgical procedure was designed for the placement of EVTS, taking great care in positioning and fixing the stent. Surgical data, which included patient demographic characteristics as well as pre- and post-operative test results, were collected and analyzed.

RESULTS

The mean duration of surgery was 75 ± 9 min, and the mean blood loss was 20 ± 5 mL. Computed tomography examinations revealed that the pre- and post-operative angle between the SMA and the aorta ranged from 18.7° ± 4.3° to 48.0° ± 8.8° (P < 0.05); in patients with left varicocele, the mean diameter of the left spermatic vein ranged from 3.7 ± 0.5 to 1.3 ± 0.2 mm (P < 0.05). Moreover, Doppler ultrasound examinations showed that the peak velocity of blood flow at the hilar area ranged from 12.4 ± 3.3 to 18.5 ± 3.4 cm/s (P < 0.05). No side effects were observed in the 24 to 42 months following surgery.

CONCLUSION

The findings after 2 years of follow-up suggest that the 3DP EVTS is a safe and effective minimally invasive alternative for the treatment of NCS.

Nutcracker Syndrome-An Unusual Case of Chronic Left Upper Abdominal Pain: A Case Report

A 38-year-old woman presented with a chief complaint of sharp, achy left upper abdominal pain with radiation to the left flank. This pain started approximately one-and-a-half years before she consulted with a pain specialist. Although an extensive workup was completed, no organic cause was established as the cause of her pain. After undergoing successful fluoroscopically guided celiac plexus blocks, an abdominal magnetic resonance imaging scan was obtained that revealed nutcracker phenomenon. The patient was evaluated by an urologist and underwent renal autotransplantation. The patient subsequently had complete relief of her pain.

Co-occurring superior mesenteric artery syndrome and nutcracker syndrome requiring Roux-en-Y duodenojejunostomy and left renal vein transposition: a case report and review of the literature

BACKGROUND

The duodenum and the left renal vein occupy the vascular angle made by the superior mesenteric artery and the aorta. When the angle becomes too acute, compression of either structure can occur. Each type of compression is associated with specific clinical symptoms that constitute a rare disorder. If clinical symptoms are mild, conservative treatment is implemented. However, surgery is often the only solution that can improve quality of life and/or avoid life-threatening complications. This report describes a case of a patient with both types of aortomesenteric compression that required two separate surgeries to alleviate all symptoms.

CASE PRESENTATION

A 20-year-old white woman presented to the Emergency Room complaining of sudden onset severe left flank and lower left quadrant abdominal pain, nausea, and vomiting. A clinical work-up revealed elevated white blood cells and hematuria. She was discharged with a diagnosis of urinary tract infection. Symptoms continued to worsen over the subsequent 2 months. Repeated and extensive clinical work-ups failed to suggest evidence of serious pathology. Ultimately, an endoscopy revealed obstruction of her duodenum, and barium swallow identified compression by the superior mesenteric artery, leading to the diagnosis of superior mesenteric artery syndrome. She underwent a Roux-en-Y duodenojejunostomy. Six weeks later she continued to have severe left-sided pain and intermittent hematuria. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. A diagnosis of nutcracker syndrome was made and a left renal vein transposition was performed. Significant improvement was seen after 8 weeks.

CONCLUSIONS

The disorders associated with aortomesenteric compression can lead to serious symptoms and sometimes death. Diagnosis is challenging not only because of the lack of awareness of these rare disorders, but also because they are associated with symptoms that are similar to those seen in less serious diseases. Guidance for health care professionals with respect to relevant radiological and clinical markers needs to be reconsidered in order to clarify the etiology of the diseases and create better diagnostic protocols.

Nutcracker syndrome: A proposed ultrasound protocol

BACKGROUND

Nutcracker phenomenon (NCP) describes the compression of the left renal vein between the aorta and the superior mesenteric artery. Nutcracker Syndrome (NCS) refers to the clinical manifestations of NCP.

AIMS

This paper aims to provide education and ultrasound protocol for Clinicians and Sonographers who encounter patients with the symptoms of NCS during their course of practice.

METHODS

The following report examines two case studies where a diagnosis of NCP was made from clinical history and ultrasound findings. Based on these case studies, we would like to propose an appropriate ultrasound scanning protocol for patients presenting with symptoms of gonadal vein incompetence.

RESULTS

The above case studies highlight the need for further assessment with ultrasound to help diagnose cases of NCP.

CONCLUSION

The proposed ultrasound techniques are a valid protocol extension to the ultrasound examination to help diagnose NCP.

Nutcracker syndrome in adolescent with perineal pain

Nutcracker phenomenon is the descriptor for a patient's anatomy whenever the left renal vein becomes compressed between the abdominal aorta and the superior mesenteric artery. Nutcracker syndrome is the terminology used when the nutcracker phenomenon is accompanied by symptoms including pain (abdominal, flank, pelvic), hematuria, and orthostatic proteinuria. Diagnosis can be made with Doppler ultrasound, venography, computed tomography, or magnetic resonance imaging. This case demonstrates some of the typical findings of nutcracker syndrome. The limited clinical features and interesting imaging findings, in addition to the young age of the patient, make this a notable case.

Incidental Anatomic Finding of Celiacomesenteric Trunk Associated with 'Nutcracker Phenomenon,' or Compression of the Left Renal Vein

Patient: Female, 91

Final Diagnosis: Nutcracker syndrome • celiacomesenteric trunk

Symptoms: Dyspepsia • dysphagia

Medication: —

Clinical Procedure: —

Specialty: Surgery

[Nephrotic syndrome and microhematuria in a patient with nutcracker syndrome: Report of a case and review of the literature]

We report about a 43-year-old woman with polyvalent drug addiction (i.e. alcohol, nicotine, methadone maintenance program with parallel consumption of heroin) who presented to the emergency department with peripheral edema, generalized weakness, and arthralgia. Laboratory findings revealed, among others, proteinuria, hyperlipoproteinemia and hypoproteinemia defining nephrotic syndrome. Computed tomography of the abdomen and iliocavography further revealed compression of left renal vein between aorta and superior mesenteric artery with distention of left ovarian vein as a possible cause of nephrotic syndrome (i. e. nutcracker syndrome). After excluding other possible causes of nephrotic syndrome, we decided against an interventional procedure due to poor compliance of the patient and potential risk of secondary stent dislocation. Instead, we opted for a surgical approach (i. e. veno-venous bypass, meaning transposition of left vena ovarica on vena cava inferior). The operative and postoperative course was uneventful. Postoperatively, proteinuria, microhematuria, arthralgia and edema receded.

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.

Management of left renal vein compression in patients presenting left gonadal vein reflux

Background

Compression of left renal vein is an atypical cause of reflux in pelvic veins resulting in pelvic varices that in turn causes frequently lower limb varices in many cases.

Methods

A monocentric study was undertaken to report the treatment and five-year follow up of patients presenting left renal vein compression. Embolization of refluxive gonadal/pelvic veins was performed generally as the initial procedure. Left renal vein stenting was performed in patients presenting haematuria, severe lumbar pain or persistent pelvic/lower limb varices after embolization.

Results

From 462 cases of left renal vein compression, 40 were treated by stenting as first procedure. Four hundred twenty-two were treated by gonadal/pelvic vein embolization and only 15 needed complementary stenting. After follow-up, all cases with haematuria had improved and lumbar pain was eliminated in 81.5%. Patients with recurrent or persistant varices were all improved.

Conclusion

Left renal vein stenting should be considered an effective and safe procedure, with demonstrated durable efficacy and safety and no evidence of restenosis.

Venous Compression Syndromes

Venous compression syndromes occur due to extrinsic compression causing complications of venous hypertension or venous thrombosis. This review focuses on 4 venous compression syndromes involving the left common iliac vein, subclavian vein, left renal vein, and popliteal vein. Clinical presentation, diagnostic methods, and management options are reviewed. When properly diagnosed and treated, long-term consequences can be avoided.

Surgically Treated Pelvic Pain Caused by Nutcracker Syndrome and Worsened by Cockett Syndrome in a Child

Nutcracker syndrome is rarely seen in the young. Most of the symptoms regress during follow-up. Rarely surgical intervention is necessary. This case presentation is unique for being the first case of nutcracker syndrome and coexistent Cockett syndrome that is treated with surgical intervention.

Venous Compression Syndromes: a Review

OPINION STATEMENT

Venous compression syndromes present a diagnostic and therapeutic challenge as the clinical presentation can be vague, diagnostic criteria are often not present, and high quality standardization of when and how to treat is not available in part due to the limited number of cases reported and also due to the limited literature available. Significant venous compression should be considered when clinical symptoms correlate to location of compression and there is evidence of hemodynamic changes including venous hypertension, collateral/variceal formation, and/or thrombus formation. In general, treatment of venous compression should address the etiology of the compression as opposed to just treating symptoms associated with it such as significant varices or anticoagulation for thrombus to avoid recurrence of symptoms.

[Macroscopic hematuria secondary to nutcracker syndrome and successful endovascular treatment]

BACKGROUND

Nutcracker syndrome is a rare entity, and in the majority of cases is the result of extrinsic compression of the left renal vein between the superior mesenteric artery and the aorta, associated with functional stenosis.

OBJECTIVE

To present the case of a 19-year-old female with no significant medical history with confirmed diagnosed of nutcracker syndrome treated successfully by endovascular means.

CLINICAL CASE

She was referred to the Vascular Surgery Department with a 6-month history of macroscopic haematuria, after other aetiologies were ruled out. Abdominal computed tomography angiography revealed compression of the left renal vein; the patient underwent endovascular treatment, and a 12×16 mm balloon expandable stent was placed with immediate angiographic improvement, decreased pressure gradients and progressive resolution of haematuria. At one year, she remains symptom-free.

CONCLUSION

Nutcracker syndrome is uncommon, and a high index of suspicion is needed. Macroscopic haematuria is not always present, and in our case stent placement demonstrated effectiveness in the resolution of symptoms at 12 months' follow--up. We also present a brief review of the literature.

Management of uncommon disorders in pregnancy: Von Hippel-Lindau disease, Gitelman syndrome, and Nutcracker syndrome

Uncommon renal disorders in pregnancy can be challenging to manage given limited evidence in the literature to guide management. We present a series of three uncommon renal disorders in pregnancy: Von Hippel-Lindau disease, Gitelman syndrome, and Nutcracker syndrome. Previously published case reports with differing outcomes offer some guidance to the management of these disorders in pregnancy. In this case series, we address the management of these syndromes during pregnancy and discuss the maternal and fetal outcomes. All three of our patients had good maternal and fetal outcomes, which will contribute to current data on maternal and fetal outcomes in these rare diseases, which is limited.

Nutcracker syndrome: A rare cause of left flank pain that can also manifest as unexplained pelvic pain

Nutcracker syndrome (NCS) is symptomatic unilateral renal venous hypertension due to compression of the left renal vein between the superior mesenteric artery and aorta (anterior NCS) or between the aorta and spine (posterior NCS). The left ovarian or spermatic vein empties into the left renal vein and is an additional site of venostasis in about half the cases of NCS. The presenting symptom of NCS in about half the cases is atypical left flank pain suggesting a disorder of the lower ribs or thoracolumbar spinal junction, particularly as the pain worsens with standing and increased lumbar lordosis. NCS may be suggested by any combination of the following manifestations: hematuria, which is often only microscopic; orthostatic proteinuria; varicocele and infertility; dyspareunia and other gynecological symptoms; varicose veins in the pelvis, buttocks, or upper thighs; orthostatic hypotension and fatigue; and abdominal pain. Narrowing of the left renal vein on imaging studies is required but far from sufficient to establish the diagnosis. Several converging clinical findings and a marked pressure gradient between the left renal vein and inferior vena cava must be present also. Urological procedures and vascular surgery are being superseded by endovascular stenting with or without simultaneous treatment of the acquired gonadal vein insufficiency by embolization.