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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 1  |  Page : 45-46

Entrapment of left renal vein between the aorta and superior mesenteric artery and nutcracker syndrome


1 Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Obstetrics and Gynecology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Web Publication21-May-2019

Correspondence Address:
Dr. Mohd Ilyas
Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_106_17

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  Abstract 


We report the classic imaging features of nutcracker syndrome on computed tomography. The term nutcracker is used for the position of the left renal vein (LRV) between aorta and superior mesenteric artery. It is called as syndrome only when there occurs compression of the LRV between these structures due to decreased aortomesenteric angle.

Keywords: Left renal vein, mesoaortic angle, nutcracker syndrome


How to cite this article:
Ahmad Z, Ilyas M, Khan I, Mohammad G, Wani AA. Entrapment of left renal vein between the aorta and superior mesenteric artery and nutcracker syndrome. J Datta Meghe Inst Med Sci Univ 2019;14:45-6

How to cite this URL:
Ahmad Z, Ilyas M, Khan I, Mohammad G, Wani AA. Entrapment of left renal vein between the aorta and superior mesenteric artery and nutcracker syndrome. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2019 Dec 9];14:45-6. Available from: http://www.journaldmims.com/text.asp?2019/14/1/45/258655




  Introduction Top


Nutcracker syndrome is a rare disorder characterized by increased venous pressure in left renal vein (LRV) secondary to inferior vena cava (IVC) obstruction or secondary to change in angulation of origin of superior mesenteric artery (SMA). It was first described by El-Sadr and Mina in 1950, but the term “nutcracker syndrome” was first used by de Schepper in 1972.


  Case Report Top


A 35-year-old married female presented to the outpatient clinic with the complaints of dull-aching left flank pain and irregular menstrual history with two episodes of hematuria for the past 1 year. She had no history of fever. The general physical examination was unremarkable. Her blood pressure was 120/80 mmHg, and respiratory rate was 14 breaths/min with a temperature of 98.7°F. The respiratory and cardiovascular examination was normal. On clinical examination, the abdomen was nontender and nondistended with no palpable lump. The laboratory results including hemogram, coagulation profile, and triple serology were negative.

Ultrasonography of the abdomen was inconclusive due to poor sonographic window because of gut gases. The computed tomography (CT) examination of the abdomen was performed using Somatom Sensation-64 (Siemens Healthcare, Germany).

The CT findings revealed decreased aortomesenteric angle and stenosis of LRV due to acute angulation of origin of SMA and grossly dilated left gonadal vein [Figure 1] and [Figure 2]. There was no mass lesion seen. IVC was normal in caliber. The CT findings were consistent with the features of nutcracker syndrome. The patient was referred to the vascular surgery department for the renal vein bypass surgery.
Figure 1: Axial computed tomography image showing the compressed left renal vein (white arrow) between the aorta (white dot) and the superior mesenteric artery (black arrow)

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Figure 2: (a) Sagittal computed tomography reformatted image showing the decreased mesoaortic angle and compressed left renal vein (straight black arrow) between the superior mesenteric artery (oblique black arrow) and aorta (lack dot). (b) Sagittal computed tomography image showing the dilated left gonadal vein (white arrow) and pelvic collaterals (black arrow)

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  Discussion Top


The term “nutcracker” was described by Grant in 1973 for the position of the LRV between the aorta and SMA as being akin to that of a nut between the jaws of a nutcracker. This phenomenon is not always associated with symptoms. When associated with symptoms, it is called as “nutcracker syndrome.”

It is of two types, anterior and posterior. The most common is the anterior and left sided while the posterior and right sided are very rare.

The clinical presentation ranges from asymptomatic to symptoms such as left flank pain, hematuria (due to rupture of fragile veins in the collecting system), left-sided varicocele in males, and pelvic congestion syndrome due to left-sided vulvar or pelvic varices in females.[1]

Multidetector CT (MDCT) in the venous phase is used for its diagnosis after injection of contrast agent. The MDCT findings include decreased mesoaortic angle with focal midline compression of the LRV between the aorta and SMA [Figure 1]. The hemodynamic consequences result in prestenotic dilatation, dilated gonadal vein, and periureteric collaterals [Figure 2]. The definitive diagnostic test is retrograde venography.[2]

The management of the nutcracker syndrome depends on the clinical severity of the symptoms and presentation. Mild symptoms such as tolerable flank pain can be managed conservatively while symptoms such as gross hematuria, anemia, persistent pain, or altered renal function tests warrant surgical intervention.[3] The treatment options include nephropexy, intravascular and extravascular stent implantation, transposition of the LRV or SMA, gonadocaval bypass, renal autotransplantation, and nephrectomy.[4]


  Conclusion Top


The nutcracker syndrome is a rare disorder in which the early diagnosis forms the key to appropriate management. The CT forms the most sensitive investigation for the accurate diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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;20:120-9.  Back to cited text no. 1
    
2.
Lamba R, Tanner DT, Sekhon S, McGahan JP, Corwin MT, Lall CG, et al. Multidetector CT of vascular compression syndromes in the abdomen and pelvis. Radiographics 2014;34:93-115.  Back to cited text no. 2
    
3.
Shin JI, Baek SY, Lee JS, Kim MJ. Follow-up and treatment of nutcracker syndrome. Ann Vasc Surg 2007;21:402.  Back to cited text no. 3
    
4.
Gulleroglu K, Gulleroglu B, Baskin E. Nutcracker syndrome. World J Nephrol 2014;3:277-81.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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Discussion
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