Current Trends in the Diagnosis and Management of Renal Nutcracker Syndrome: A Review

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. Other common presentation is as "pelvic congestion syndrome" characterized by symptoms of dysmenorrhea, dyspareunia, post-coital ache, lower abdominal pain, dysuria, pelvic, vulvar, gluteal or thigh varices and emotional disturbances. Likewise compression of the left renal vein can cause left renal-to-gonadal vein reflux resulting in lower limb varices and varicoceles in males. Its diagnosis is based on history and physical examination, basic lab tests to exclude other causes of haematuria, cystoscopy and ureteroscopy to confirm unilateral haematuria and exclude other causes of this sinister symptom. Sequence of imaging has more or less been rationalised to USS with Doppler studies, CT or MR angiography and finally phlebography with renal vein and IVC manometery to confirm the diagnosis.

Venous compression syndromes: clinical features, imaging findings and management

“…NUTCRACKER SYNDROME Background NCS, also known as renal vein entrapment syndrome or mesoaortic compression of the left renal vein (LRV), results from compression of the LRV between the superior mesenteric artery (SMA) and the aorta [20,21]. In cases where compression is seen on imaging but there is no clinical manifestation, it is named Nutcracker phenomenon.…”

Tratamento endovascular da Sindrome de Quebra-nozes (Nutcracker)

“…Clinical manifestations include hematuria combined with other signs and symptoms, such as lumbar or pelvic pain and pelvic varicocele or varicose veins 1,2 . It most often affects women aged 20 to 40 3,4 and is one cause of chronic pelvic pain that is underdiagnosed by the medical community 5 .…”

A Rare Cause of Macroscobic Hematuria: Nutcracker Syndrome

“…Kesin tanı koymada geleneksel yöntem olan sol renal venografi invazivdir. Renkli doppler USG, kontrastlı BT, BT anjiyo, manyetik rezonans görüntüleme (MRG) ve MR anjiyo invaziv olmayan seçeneklerdir (4,(7)(8)(9) Genellikle tedavi endikasyonu olarak anemi oluşturan şiddetli hematüri, yaşam kalitesini bozan şiddetli yan ağrıları görülmekte, bu derecede ağır bulguları olmayan hastalarda ise izlem ve konservatif tedavi önerilmektedir. Özellikle çocuklarda yaşın ilerlemesi ile birlikte anotomik bozuklukta düzelme beklenir.…”

“…Tedavi yöntemleri konusunda tam bir görüş birliği olmasa da açık cerrahi ve sol renal ven transpozisyonu daha az komplike olmasının yanı sıra daha az böbrek iskemisi yaratması nedeniyle diğerlerinden üstündür. Endovasküler girişimlerin ise uzun süre antikoagülan tedavi gerektirmeleri ve uzun dönem komplikasyonlarının bilinmemesi dezavantajlarıdır (8,10). Sonuç olarak, sendromun nadir olarak tanımlanmasındaki en önemli etkenlerden biri tanısal incelemelerde akla getirilmemesi olabilir.…”