Nutcracker phenomenon secondary to superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome, compression of the duodenum due to a decreased angle between the aorta and SMA, has a wide range of clinical presentations making it difficult to diagnose. Compression of the left renal vein is known as Nutcracker syndrome. We present the case of a 26-year-old male with a delayed diagnosis of SMA syndrome and Nutcracker phenomenon due to the patient's history of chronic pancreatitis. As a result of his obstruction and aspiration pneumonia, he was diagnosed with septic shock. The patient was treated for septic shock and maintained on an enteric diet with improvement in the body mass index and complete resolution of SMA syndrome symptoms.

Correlation between "Nutcracker phenomenon" and venous hypertension of the lower extremities: Three case reports

We report three cases of left renal vein (LRV) compression resulting in deep venous insufficiency of the lower extremities, among which two patients showed clinical symptoms in both lower extremities. All patients were treated successfully with LRV stenting. The pathophysiology suggested that the secondary gonadal vein reflux owing to LRV compression drained into the iliac veins, resulting in a volume overload and venous hypertension in the iliocaval region. Computed tomography angiography was useful in diagnosing this condition, allowing the evaluation of LRV compression, identification of early opacification of the gonadal vein reflux, and exclusion of other pathologies resulting in deep venous insufficiency of the lower extremities.

Spontaneous rupture of the ovarian vein in association with nutcracker syndrome: a case report

Background

Nutcracker syndrome is a condition in which the left renal vein is pinched between the abdominal aorta and the superior mesenteric artery, resulting in an increase in renal vein pressure and certain symptoms. We report a very rare case of retroperitoneal hematoma caused by the rupture of varicose veins of the left ovary.

Case presentation

A 77-year-old Japanese woman, para 7, experienced sudden left lower abdominal pain. She had no history of trauma or treatment complications. Computed tomography revealed a left retroperitoneal hematoma, but her abdominal pain subsided quickly; thus, urgent treatment was not required. We then scheduled her for an assessment regarding the cause of her bleeding. However, 6 days after the pain onset, abdominal pain symptoms recurred, confirming hematoma regrowth. Magnetic resonance imaging and three-dimensional computed tomography revealed an abnormal vascular network from the left side of the uterus to the left adnexa. Subsequent angiography revealed that the retroperitoneal bleeding originated from rupture of the distended left ovarian vein, which caused blood reflux from the left renal vein to the left ovarian vein. Although angiography confirmed a passage between the left renal vein and inferior vena cava, computed tomography showed obvious stenosis in the left renal vein. In accordance with these findings, we diagnosed the cause of the distention and rupture of the left ovarian vein as nutcracker syndrome. She underwent embolization of the left ovarian vein as hemostasis treatment, and had a good course thereafter.

Conclusions

This is the first report of a spontaneous rupture of the left ovarian vein caused by nutcracker syndrome. Nutcracker syndrome is not yet well known to clinicians and should be considered as part of the differential diagnosis when an abnormal vascular network in the pelvis is found.

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.

Discriminating renal nutcracker syndrome from asymptomatic nutcracker phenomenon using multidetector computed tomography

PURPOSE

To retrospectively evaluate the ability of computed tomographic (CT) findings to discriminate nutcracker syndrome (NCS) from asymptomatic nutcracker phenomenon (NCP) and to investigate the diagnostic value of CT findings in diagnosis of NCS.

METHODS

From January 2014 to April 2015, 216 patients who underwent initial urographic CT were included. Initially, 216 patients were categorized as "nutcracker" or "normal," based on the following CT criteria: (1) the presence of beak sign and (2) hilar-aortomesenteric left renal vein diameter ratio >4. Patients who satisfied both of these criteria were diagnosed with nutcracker. The nutcracker was then divided into "NCS" and "asymptomatic NCP" based on the presence of characteristic symptoms. CT findings in sagittal and axial scans of corticomedullary phase were evaluated. Multivariate analysis was used to identify significant factors among 30 NCS, 51 asymptomatic NCP, and 135 normal patients. Diagnostic performance and threshold using receiver operating characteristic (ROC) curve were calculated.

RESULTS

A total of 131 males and 85 females, with mean age of 38.6 years (range 18-89 years), were included. Multivariate analysis demonstrated superior mesenteric artery (SMA)-aortic angle (p < 0.001) and visualization of a dilated collateral vein with reflux (p = 0.001) were independent factors for distinguishing NCS from asymptomatic NCP. The combination of SMA-aortic angle <25° and visualization of a dilated collateral vein with reflux provided the greatest diagnostic accuracy (area under the ROC curve, 0.841).

CONCLUSIONS

The combination of SMA-aortic angle and visualization of a dilated collateral vein with reflux in multidetector CT can be useful to differentiate NCS from asymptomatic NCP.

Transcatheter ovarian vein embolisation without renal vein stenting for pelvic venous congestion and nutcracker anatomy

The diagnosis of a nutcracker syndrome can be aggravated by overlap of a nutcracker phenomenon with other pathologies. In patients with nutcracker anatomy and predominantly pelvic congestion symptoms, ovarian vein embolization without left renal vein stenting could be considered a first line therapy.

Surgical management of nutcracker phenomenon presenting as left varicocele in adolescents: a novel approach

OBJECTIVE

To present a new approach using a shunt operation for the management of nutcracker phenomenon presenting as left varicocele in adolescent patients.

MATERIALS AND METHODS

12 adolescent patients with the nutcracker phenomenon presenting as left varicocele underwent a shunt operation consisting of anastomosis of the proximal part of the spermatic vein and inferior epigastric vein to lower the left renal vein (LRV) pressure. A simple ligation of the left spermatic vein was then used to repair the varicocele.

RESULTS

12 patients underwent surgery, and symptoms of hematuria, proteinuria, scrotum discomfort, and flank pain disappeared post surgery in all patients. Patients were followed for 24-72 months (mean 48 months). The diameters of the proximal LRV and the peak velocities in the aortomesenteric portion of the LRV were significantly decreased after surgery (p < 0.001). Left testicular volume significantly increased after surgery. One patient had recurrence of the left varicocele and one adolescent had minimal hydrocele requiring no intervention. No major complications were observed during and after surgery.

CONCLUSION

Anastomosis of the proximal part of the spermatic vein and inferior epigastric vein is an efficacious and safe surgical approach for the management of nutcracker phenomenon presenting as left varicocele in adolescents.