Nutcracker syndrome

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In medicine, the nutcracker syndrome — also known as nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein — is a compression of the left renal vein between the abdominal aorta (AA) and superior mesenteric artery (SMA).Sugimoto I, Takashi O, Ishibashi H, Takeuchi N, Nagata Y, Honda Y. Left Renal Vein Entrapment Syndrome (Nutcracker Syndrome) treated with Left Renal Vein Transposition. Jnp J Vasc Surg. 2001 10:503-507. Abstract. The popular name "nutcracker syndrome" derives from the fact that, in the sagittal view, the SMA and AA (with some imagination) appear to be a nutcracker crushing a nut (the renal vein).

Signs and symptoms

The syndrome is associated with hematuria, which can lead to anemiaOteki T, Nagase S, Hirayama A, Sugimoto H, Hirayama K, Hattori K, Koyama A. Nutcracker syndrome associated with severe anemia and mild proteinuria. Clin Nephrol. 2004 Jul;62(1):62-5. PMID 15267016., abdominal complaints or painHilgard P, Oberholzer K, Meyer zum Buschenfelde KH, Hohenfellner R, Gerken G. "nutcracker syndrome" of the renal vein (superior mesenteric artery syndrome) as the cause of gastrointestinal complaints Dtsch Med Wochenschr. 1998 Jul 31;123(31-32):936-40. PMID 9721569. (classically left flank painBarnes RW, Fleisher HL 3rd, Redman JF, Smith JW, Harshfield DL, Ferris EJ. Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): repair by a new stenting procedure. J Vasc Surg. 1988 Oct;8(4):415-21. PMID 3172376), nausea, and/or vomiting, due to compression of the duodenum which also passes between the SMA and abdominal aorta). Because the left gonad drains via the left renal vein, it can also result in left testicular pain in men or left lower quadrant pain in women.Unusual manifestations of the nutcracker syndrome include varicocele formation and varices in the lower limbs.Little AF, Lavoipierre AM. Unusual clinical manifestations of the Nutcracker Syndrome. Australasian Radiol. 2002 Jun;46(2):197-200. PMID 12060163.

Diagnosis

Nutcracker syndrome can be diagnosed with:
  • Left renal venography — considered to be the gold standard test.
  • Computed tomography (CT).
  • Abdominal ultrasonography — not definitive but has been found to be useful.Takebayashi S, Ueki T, Ikeda N, Fujikawa A. Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography. AJR Am J Roentgenol. 1999 Jan;172(1):39-43. PMID 9888735.

    • Treatment

    Treatment depends on the severity and symptoms. Treatments include:
  • Endovascular stenting.
  • Renal vein re-implantation.Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D. Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg. 2006 Jan;20(1):120-9. PMID 16374539.
  • Gonadal vein embolization.

    • Differential diagnosis

  • Renal stones
  • Genitourinary malignancy
  • Loin pain hematuria syndrome


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