Ultrasonographically demonstrated nutcracker phenomenon: Alternative to angiography

Arima, Masaaki; Hosokawa, S; Ogino, Toshihiro; Ihara, Hideari; Terakawa, Tomoyoshi; Ikoma, Fumihiko

doi:10.1007/bf02550429

Cited by 27 publications

(18 citation statements)

References 6 publications

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“…99, 100 Ozkurt et al 101 found a moderate positive correlation between BMI and AMA on CT. Ultimately, positional changes are probably unreliable.…”

Section: Normal Anatomic and Physiologic Findingsmentioning

confidence: 99%

“…21,23,24 Other studies suggested half smaller numbers for normal and NCP variants, consistent with earlier reports. 65,99 Despite this reported variability, smaller AMAs have been associated with NCP compared with healthy controls; however, when the third portion of the duodenum courses between the aorta and the SMA (duodenal interposition), the LRV compression occurs even with a larger AMA. 10 The AMA is highly variable depending on the patient position during examination, with greater compression of the LRV by the SMA in an erect For personal use.…”

Section: Normal Anatomic and Physiologic Findingsmentioning

confidence: 99%

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Nutcracker Phenomenon and Nutcracker Syndrome

Kurklinsky¹,

Rooke

2010

Mayo Clinic Proceedings

454

586

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N utcracker phenomenon (NCP), also known as left renal vein entrapment,1-3 is characterized by impeded outflow from the left renal vein (LRV) into the inferior vena cava (IVC) due to extrinsic LRV compression, often accompanied by demonstrable lateral (hilar) dilatation and medial (mesoaortic) narrowing (schematic representation of NCP/ nutcracker syndrome [NCS] in Figure 1). Although the terms nutcracker syndrome and nutcracker phenomenon are sometimes used interchangeably in the literature, Shin and Lee 4 emphasize that the nutcracker anatomy is not always associated with clinical symptoms and that some of the anatomic findings suggestive of nutcracker may represent a normal variant or be accounted for by other conditions. Therefore, the term nutcracker syndrome should be reserved for patients with characteristic clinical symptoms associated with demonstrable nutcracker morphologic features. No consensus exists on what symptoms are severe enough to warrant the designation of a clinical syndrome or to what extent various findings may simply reflect different evolutionary stages of the process. Because of these uncertainties, some authors focus on the characteristic anatomic and hemodynamic findings, referring to them as NCP rather than NCS. 5Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. The nutcracker syndrome (NCS) is the clinical equivalent of nutcracker phenomenon characterized by a complex of symptoms with substantial variations. Depending on specific manifestations, NCS may be encountered by different medical specialists. Although it may be associated with substantial morbidity, the diagnosis of NCS is often difficult and is commonly delayed. Diagnostic and treatment criteria are not well established, and the natural history of NCS is not well understood. We performed an initial review of the literature through MEDLINE, searching from 1950 to date and using the keywords nutcracker syndrome, nutcracker phenomenon, and renal vein entrapment. We performed additional reviews based on the literature citations of the identified articles. We attempted to elucidate clinical relevance of these conditions and their prominent features and to summarize professional experience. Mayo Clin

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“…99, 100 Ozkurt et al 101 found a moderate positive correlation between BMI and AMA on CT. Ultimately, positional changes are probably unreliable.…”

Section: Normal Anatomic and Physiologic Findingsmentioning

confidence: 99%

Section: Normal Anatomic and Physiologic Findingsmentioning

confidence: 99%

Nutcracker Phenomenon and Nutcracker Syndrome

Kurklinsky¹,

Rooke

2010

Mayo Clinic Proceedings

454

586

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“…repeated 25 days later, showed collat erals around the left kidney and resolution of the thrombus. After 30 days of prednisolone (1 mg/kg/day), azathioprinc (150mg/day) and dipyridamole (225 mg/day) therapy, the amount of protein in 24-hour urine was 1 g.The complaints of patients in the re ported cases of nut cracker syndrome were microscopic or gross hematuria with or with out abdominal or flank pain [1][2][3][4][5], It is reported that hematuria from the left renal vein orifice, in the absence of any other detectable pathology, should raise the suspi cion of nut cracker syndrome. The diagnosis of this anatomic variation is established by demonstrating compression of the renal vein during selective renal venography [1].…”

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confidence: 99%

“…A sig nificant pressure gradient exists over the ob struction. Doppler USG, CT, MRI are noninvasive diagnostic alternatives to angiogra phy [3,5], In this case, PNS was thought to be one of the probable causes of renal vein throm bosis (RVT). Since there is no reported case of nut cracker syndrome complicated with RVT, other etiologies for RVT were also searched.…”

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confidence: 99%

A Case of Renal Vein Thrombosis with Posterior Nut Cracker Syndrome

Cakir¹,

Arınsoy²,

Sindel³

et al. 1995

Nephron

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Dear Sir, Compression of the left renal vein be tween the aorta and the superior mesenteric artery is known as 'nut cracker phenomenon' [ 1 ]. The compression is thought to be caused by a decrease in the angle of the superior mesenteric artery from the aorta or posterior renal ptosis with stretching of the left renal vein over the aorta [ 1 ]. A variant of this phe nomenon, 'posterior nut cracker syndrome' (PNS). refers to compression of the retroaortic renal vein between the aorta and spine [2]. It is associated with hematuria, ab dominal pain and varicocele formationWe present a case of renal vein thrombo sis with PNS. A 36-ycar-old man was admit ted to the emergency room with acute ab dominal pain. Physical examination re vealed left (lank tenderness. Urinalysis dem onstrated +++ protein and on microscopic evaluation 7-8 erythrocytes, 3-4 hyaline casts were observed. Daily urinary protein excretion was 3.5 g. Abdominal Doppler ul trasonography (USG) demonstrated com pression of the left renal vein between the aorta and spine (PNS), an increase in left kidney size, minimal left renal subcapsular edema, a thrombus occluding the left renal vein extending towards the lumen of the vena cava inferior ( fig. 1, 2). Abdominal CT confirmed these findings ( fig. 3). Inferior cavography was normal. Selective venography was not performed because of the risk of dis lodging the thrombus. Prothrombin time, partial thromboplastin time, ai-antitrypsin. anticardiolipin antibody, antithrombin III, protein and protein C levels were also nor mal. Renal biopsy showed features of mem branous glomerulonephritis (MGN) (fig. 4). The patient was anticoagulated with heparin followed by warfarin. Abdominal Doppler USG. repeated 25 days later, showed collat erals around the left kidney and resolution of the thrombus. After 30 days of prednisolone (1 mg/kg/day), azathioprinc (150mg/day) and dipyridamole (225 mg/day) therapy, the amount of protein in 24-hour urine was 1 g.The complaints of patients in the re ported cases of nut cracker syndrome were microscopic or gross hematuria with or with out abdominal or flank pain [1][2][3][4][5], It is reported that hematuria from the left renal vein orifice, in the absence of any other detectable pathology, should raise the suspi cion of nut cracker syndrome. The diagnosis of this anatomic variation is established by demonstrating compression of the renal vein during selective renal venography [1]. A sig nificant pressure gradient exists over the ob struction. Doppler USG, CT, MRI are noninvasive diagnostic alternatives to angiogra phy [3,5], In this case, PNS was thought to be one of the probable causes of renal vein throm bosis (RVT). Since there is no reported case of nut cracker syndrome complicated with RVT, other etiologies for RVT were also searched. Laboratory findings were consis tent with nephrotic syndrome, and renal biopsy examination demonstrated MGN. It is known that MGN accounts for approxi mately 30% of cases of nephrotic syndrome and 5-62% of them are associated with RVT [6,7]. Vari...

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“…In contrast, patients with NCS have frequently been noted to have an angle of <16 degrees. 38 Currently, 2 types of NCS are classified, anterior and posterior NCS.…”

Section: Pathogenesismentioning

confidence: 99%

Nonatherosclerotic Obstructive Vascular Diseases of the Mesenteric and Renal Arteries

Escárcega

Mathur

Franco

et al. 2014

Clinical Cardiology

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Nonatherosclerotic vascular diseases of the mesenteric and renal arteries are considered to occur less frequently than those caused by occlusive atherosclerotic disease. However, when present, they pose a significant diagnostic and therapeutic challenge. Such disorders include fibromuscular dysplasia, median arcuate ligament syndrome, the renal nutcracker syndrome, and some forms of acute and chronic mesenteric ischemia (embolic and thrombotic). This is a heterogeneous group of disorders with substantial differences in the pathogenesis and diagnostic approaches to these diseases. We provide an overview of the pathogenesis, clinical presentation, diagnosis, and current management of fibromuscular dysplasia, median arcuate ligament syndrome, and the renal nutcracker syndrome.

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Ultrasonographically demonstrated nutcracker phenomenon: Alternative to angiography

Abstract: We report on a child with nutcracker phenomenon, which is a possible cause of intermittent gross haematuria of unknown origin. Early serial ultrasound examinations can demonstrate the lesions. The merits and demerits of conventional angiographic imaging are also discussed.

Cited by 27 publications

References 6 publications

Nutcracker Phenomenon and Nutcracker Syndrome

Nutcracker Phenomenon and Nutcracker Syndrome

A Case of Renal Vein Thrombosis with Posterior Nut Cracker Syndrome

Nonatherosclerotic Obstructive Vascular Diseases of the Mesenteric and Renal Arteries

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