Eighteen years of experience with pediatric nutcracker syndrome: the importance of the conservative approach

Miró, Ignacio; Serrano, A.; Perez-Ardavin, Javier; March, José-Antonio; Polo, Alba; Conca, María-Ángeles; Sangüesa, Cinta; Veiga, Diana; Carazo, E; Domínguez, Carlos

doi:10.1016/j.jpurol.2019.12.003

Cited by 23 publications

(20 citation statements)

References 25 publications

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“…12 Compression of the LRV resulting in NS may be demonstrated by venography, CT arteriography, Doppler ultrasonography (DUS), and magnetic resonance imaging. 13 To decrease invasiveness and expense without sacrificing accuracy, DUS is the most used method to measure diameter and peak velocity in both the hilar and aorto-mesenteric areas of the LRV. Diagnostic measurements from previous studies have suggested a hilar to aortico-mesenteric diameter ratio greater than 4.7 may be predictive of NS with 100% sensitivity and 90% specificity.…”

Section: Discussionmentioning

confidence: 99%

Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report

Waldrop¹,

Henning²

2021

Clinical Practice and Cases in Emergency Medicine

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Introduction: Abdominal pain and flank pain cause a significant proportion of emergency department (ED) visits. The diagnosis often remains unclear and is frequently associated with repeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank pain is compression of the left renal vein between the aorta and the superior mesenteric artery known as nutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameter proximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describe such a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the final diagnosis and intervention occurred. Case Report: A 16-year-old female, long-distance runner presented four times complaining of intractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visit urinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomography revealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred to vascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements and eliminated symptoms. Conclusion: Emergency physicians must maintain a large list of possible diagnoses during the evaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndrome may mimic other causes of abdominal and flank pain such as renal colic and requires appropriate referral.

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Section: Discussionmentioning

confidence: 99%

Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report

Waldrop¹,

Henning²

2021

Clinical Practice and Cases in Emergency Medicine

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“…This is particularly important for pediatric and minimally symptomatic patients, with invasive approaches reserved for those with severe or progressive symptoms. 7 To date, there are no society consensus guidelines to inform management of NCS, and the existing literature is largely limited to small retrospective studies and case reports.…”

Section: Treatmentmentioning

confidence: 99%

Nutcracker Syndrome: A Review of the Current Literature

DeRieux

Obed

Casey

2022

MRAJ

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Nutcracker Syndrome is a rare condition secondary to either compression of the left renal vein in its normal anatomic position by the superior mesenteric artery and aorta, or rarely, when the left renal vein is in a retroaortic position, compressed between the aorta and the spine. Left renal vein compression varies widely in presentation and severity, ranging from asymptomatic imaging findings, to chronic pelvic or flank pain. While left renal vein transposition remains the most common management modality, there is growing acceptance for other surgical interventions as well as endovascular treatments–particularly stenting. However, there remains a scarcity of evidence for these less invasive techniques. We conduct a review of the recent literature and discuss the diagnosis and current management strategies for nutcracker syndrome. We also revisit a unique case of nutcracker syndrome in a female patient with a history of chronic pelvic pain and venous congestion wherein transposition of the left renal vein resulted in complete resolution of her symptoms.

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“…It is well- established that the majority of pediatric patients with NCS will have spontaneous resolution, an effect possibly related to increased retroperitoneal and/or mesenteric adipose during growth and the accumulation of fibrous tissue at the SMA origin. The most widely accepted therapy for the pediatric population is angiotensin converting enzyme inhibitors (ACEIs) to minimize orthostatic proteinuria and treat concomitant hypertension, with or without aspirin, to maximize renal perfusion (3,44,45).…”

Section: Conservative Managementmentioning

confidence: 99%

Nutcracker syndrome: diagnosis and therapy

Kolber¹,

Cui²,

Chen³

et al. 2021

Cardiovasc Diagn Ther

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Nutcracker syndrome (NCS) is an extrinsic compression of the left renal vein (LRV) by the superior mesenteric artery (SMA) anteriorly and aorta posteriorly resulting in renal vascular congestion manifesting as hematuria, proteinuria, orthostatic hypotension, pain, or even renal dysfunction. Longstanding venous compression can encourage collateral drainage pathways through gonadal and pelvic veins, which may explain reported symptom and syndrome overlap with pelvic congestion syndrome. Diagnosis can be challenging and variable, frequently involving a combination of ultrasound Doppler, cross-sectional, and invasive imaging. Often, intravascular pressure measurements are required to prove a renocaval pressure gradient to aid in a definitive diagnosis. Conservative management is appropriate, especially in children, who tend to outgrow the disorder. In the interim, medical management with angiotensin converting enzyme inhibitors (ACEIs) is a useful therapy to manage orthostatic hypotension in the pediatric population.In adults, invasive therapies are more frequently pursued. These are aimed at relieving the extrinsic compression on the LRV. The standard of care is renal vein transposition, with renal autotransplantation reserved for recalcitrant cases. Endovascular stenting is a less invasive option. Laparoscopic placement of an exovascular stent is a newer therapy intended to minimize trauma to the LRV. In this review, we will discuss the clinical manifestations, diagnostic criterion, imaging features, and conservative and surgical therapies for this condition.

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Eighteen years of experience with pediatric nutcracker syndrome: the importance of the conservative approach

Cited by 23 publications

References 25 publications

Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report

Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report

Nutcracker Syndrome: A Review of the Current Literature

Nutcracker syndrome: diagnosis and therapy

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