Intravenous Stent Placement for Treatment of the Nutcracker Syndrome

Abstract

The nutcracker syndrome was first reported in 1972 by de Schepper.1 It is a rare cause of hematuria. We placed a stent in the left renal vein to treat a recent case of the nutcracker syndrome. CASE REPORT A 37-year-old man presented with intermittent gross hematuria 4 years in duration. Physical examination revealed no abnormal findings. Laboratory tests were within normal range except for microscopic hematuria. Ultrasonography of the urinary tract and excretory urography were normal. Cystoscopy showed gross bleeding from the left ureteral orifice. Angiographic computerized tomography (CT) of the abdomen demonstrated that the left renal vein was compressed between the abdominal aorta and superior mesenteric artery (SMA), and had become stenosed. The distal portion of the left renal vein was dilated (fig. 1, A). Sagittal magnetic resonance angiography revealed that the angle between the abdominal aorta and SMA was only 21 degrees (normal 90) and the left renal vein exhibited oblate form due to compression (fig. 1, B). Left renal venography showed obstruction of left renal venous outflow, and intrarenal and perihilar varices (fig. 2, A). On the basis of these findings, we diagnosed the nutcracker syndrome. We used a venous endoprosthetic stent (Wallstent, Boston Scientific Corp., Natick, Massachusetts) for treatment. The stent was composed of thin stainless steel wire, which was bent into a cylindrical mesh structure. It was placed into the left renal vein via the left transfemoral vein. After stent placement left renal venography demonstrated that blood outflow was unobstructed (fig. 2, B). The patient received antiplatelet therapy postoperatively. Six days later the hematuria resolved. The patient has been free of hematuria for more than 3 months.