Compression Of Left Renal Vein Research Articles

A new notable compression source of left renal vein entrapment: right renal artery

PurposeTo estimate the incidences of left renal vein (LRV) entrapment by right renal artery (RRA), a phenomenon primarily reported as case reports.MethodsThe cross-sectional study consecutively screened renal vessel CT data of 38 (Renal) patients with nephropathy and 305 (Non-renal) patients with peripheral arterial diseases in a teaching hospital in northeast China between November 2018 and March 2023. The LRV compression by adjacent anatomical structures, including but not limited to RRA and multiple compression-related parameters, were investigated through multiplanar analysis of the CT data.ResultsThe overall LRV entrapment rates by adjacent structures were 41.93% (12/31) and 24.00% (6/25), the rates of RRA-sourced LRV compression 22.58% (7/31) and 20.00% (5/25), and the rates of compression by superior mesenteric artery (SMA) 16.13% (5/31) and 4.00% (1/25) in the Renal and Non-renal groups, respectively, with no significance. The venous segments distal to the RRA-compressed site had a significantly larger transectional lumen area than those of the non-compressed veins in both groups (3.09 ± 1.29 vs. 1.82 ± 0.23, p < 0.001 and 4.30 ± 2.65 vs. 2.12 ± 0.55, p = 0.006; maximum-to-minimum area ratios in Renal and Non-renal groups, respectively). Nearly 80% of RRAs were found arising anteriorly rightwards instead of passing straight to the right.ConclusionRRA-sourced LRV compression was not rare, and its incidence was higher than that of the compression by SMA in both patient cohorts. RRA could be a more common compression source than SMA concerning LRV entrapment. Further investigations involving different populations, including healthy individuals, are needed.

#400 A new notable compression source of left renal vein entrapment: the Right Renal Artery

Abstract Background and Aims Clinically, left renal vein (LRV) entrapment is almost equivalent to the nutcracker phenomenon (NCP). However, there is still much uncertainty and debate about the prevalence of NCP and its diagnostic criteria. As a particular type of LRV entrapment, the LRV compression by the right renal artery (RRA) was primarily reported as case reports. The study was designed to investigate the RRA-sourced LRV compression in two selected patient cohorts. Method The cross-sectional study consecutively selected 38 hospitalized kidney patients diagnosed with membranous nephropathy (Renal group) and 305 peripheral vascular inpatients or outpatients (Non-renal group) in the Second Affiliated Hospital of Harbin Medical University in China from November 2018 to March 2023. The patients with computed tomography (CT) of renal veins or abdominal aorta were included in both groups if axial CT imaging could visualize the renal vessels and was with regular and adequate layer thinness to perform multiplanar reconstruction analysis. Any potential situations that might cause positional or course changes in proximal RRA or LRV due to pathological reasons were excluded from the study. The CT data of LRV compression by different anatomical sources, including but not limited to RRA, was analyzed. Results With other anatomical compression sources excluded, there were 22.58% (7/31) and 20.00% (5/25) LRVs compressed by the RRAs in the Renal and Non-renal groups, respectively, with no significant difference (p = 1.0). The distal segments of the LRVs compressed by RRAs have a significantly larger lumen area than those of non-compressed veins (p &amp;lt; 0.01 in both groups). The overall incidence of NCP was calculated as 10.71% (6/56). Complex compressions, namely those LRV compressions by another adjacent structure besides RRA, coincided in 7.14% of the total cases (4/56). Conclusion Our study showed that it was not rare for the proximal RRA to compress the end of LRV. The detected incidence of RRA-sourced LRV compression was twice that of the entrapment related to the superior mesenteric artery, the mainstay of NCP. Though this finding came from two relatively small subject populations, it challenged the present connotation of LRV entrapment. Further repetitive studies are needed to test if such a phenomenon prevails in different populations, including healthy individuals. Legends for all figures: Green thick arrows, RRA; green arrowheads, superior mesenteric artery (SMA); red-edged white arrows, left renal artery (LRA); white short-shafted arrows, LRV; white long-shafted arrows, inferior vena cava (IVC); transparent or white arrowheads, compressed sites.

Surgical treatment of Nutcracker Syndrome

The objective of this paper is to report early and mid-term outcomes of the surgical treatment Nutcracker Syndrome (NCS) in a single-center prospective study. Between January 2019 and September 2023, five patients with symptomatic NCS were treated at our center using left renal vein caudal transposition on the inferior vena cava, conducted through a midline incision of approximately 12 cm and a transperitoneal technique. Patient characteristics, presentation, length of hospital stay, and complications were analyzed. All diagnoses were established after clinical evaluation, ultrasound scanning, and radiological investigations, which confirmed left renal vein compression between the aorta and the Superior Mesenteric Artery (SMA). The average operating time was 159 minutes, with an average blood loss of 205 mL. There was no need for blood transfusions. Intensive care stay was not required and there were no early complications. The mean length of stay was 3.5 days. At a mean follow-up of 18.8 months, one patient reported persistent hematuria, and therefore underwent a secondary procedure, which incorporated patch venoplasty using the great saphenous vein. In our experience, left renal vein transposition appears to be a safe and effective procedure for the surgical management of severe NCS.

Hemodynamic Consequences of Pre-and Retroaortic Left Renal Vein Compression (“Nutcracker Syndrome”) Causing a Surprising Variety of Symptoms and Complaints, Especially in Patients Affected by Hypermobility Spectrum Disorders

Hemodynamic Consequences of Pre-and Retroaortic Left Renal Vein Compression (“Nutcracker Syndrome”) Causing a Surprising Variety of Symptoms and Complaints, Especially in Patients Affected by Hypermobility Spectrum Disorders

Effect of left renal vein compression stenosis on functional status of left kidney in patients with pelvic venous disorders

Effect of left renal vein compression stenosis on functional status of left kidney in patients with pelvic venous disorders

Patient reported outcome measures (PROMS) and patient reported experience measures (PREMS): Measuring outcomes in pelvic venous disorders

Pelvic venous disorders (PeVD) present with a range of heterogenous symptoms that arise from altered venous hemodynamics in the pelvis. Many of these symptoms lead to mental health and quality of life issues and are not limited to the pelvic region. The nutcracker phenomenon causing left renal vein compression and left ovarian venous hypertension as well as the compression of the left common iliac vein by the overlying right common iliac artery are often stated as the common underlying pathologies. As a result, there has been a sudden increase in the number of ovarian vein coil embolizations and iliac vein stents placed. In truth however, the altered venous hemodynamics in PeVD is more complex. There appears to be little correlation between the symptoms patients experience and the obvious image detected anatomical lesions being treated. In addition, these anatomical lesions are very commonly seen in asymptomatic and especially muti-parous women as well. To compare outcomes of these and other more extensive procedures being performed for these commonly seen anatomical changes in the pelvic veins, objective assessments of the outcomes as seen from the symptom relief they bring to patients treated is essential. Validated Patient-reported outcome measures (PROMS) can be an important tool to compare outcomes across interventions for PeVD. However, as the impact of similar symptoms on different patients’ quality of life (QoL) can vary, developing a validated PROM that can be used to compare procedural outcomes in PeVD is a challenge. On the other hand, complications and procedural success as reported by physician do not assess the effect on a patient’s QoL. This paper provides a narrative review of PROMs, patient reported experience measures (PREMs) and individualized-PROMs. It also suggests a process for how a validated PROM for comparing procedural outcomes in PeVD may be developed. This could provide a framework that incorporates the recently adopted Symptoms-Varices-Pathophysiology (SVP) classification of pelvic venous disorders into the PROM development process to ensure that a like-for-like comparison is made between procedures being performed on a very heterogenous, but long-suffering group of patients.

Nutcracker syndrome in pediatrics: initial findings and long-term follow-up results.

Nutcracker syndrome (NCS) describes a set of symptoms and signs resulting from compression of the left renal vein (LRV). There is a lack of knowledge about its natural course, diagnosis, and management, especially in children. Herein, we present our single-center experience with a large number of patients who have long-term follow-up results. All patients with NCS diagnosed between January 2011 and March 2021 were included and their data were obtained retrospectively. A total of 123 NCS patients (85 females) were included. The median age at the time of diagnosis was 12 (IQR 10-14) years, and BMI percentiles were below 5% in 38% of the cases. At the time of diagnosis, two-thirds of the patients were asymptomatic. The most common laboratory finding was nephritic proteinuria (98%), followed by microscopic hematuria (16%). Signs of LRV compression were significantly more evident in upright position Doppler ultrasonography (DUS) examination. All patients have been followed conservatively; hematuria and/or proteinuria resolved in 43 of the 108 patients (40%) within 35.8 ± 25.8months of follow-up. Control DUS was performed in 52 patients after a mean period of 39.1 ± 21.3months. The median peak velocity and diameter ratios of the LRV in the upright position were found to be decreased significantly when compared to the initial assessment (p < 0.05). Normal DUS findings were noted in 13 patients at the final evaluation. In unexplained proteinuria and/or hematuria, NCS should be considered, especially in asthenic adolescents. Our results support conservative management in children as the first-line treatment approach.

Effect of left renal vein compression stenosis on functional status of left kidney in patients with pelvic venous disorders

ObjectiveWe evaluated the effect of left renal vein (LRV) compression stenosis on the functional state of the left kidney in patients with pelvic venous disorders (PeVDs). MethodsWe examined 162 female patients with PeVD and diagnosed LVR compression stenosis using duplex ultrasound (DUS) in 40. Patients with clinical manifestations of PeVD (n = 26) had symptoms and signs of pelvic venous congestion but without pain in the left flank of the abdomen, typical for nutcracker syndrome (NS). The remaining patients were asymptomatic (n = 14). The parameters measured with DUS included the angle of the superior mesenteric artery (SMA) with the aorta, the LRV diameter (Dhilum/Dstenosis) ratio, and LRV velocity (Vstenosis/Vhilum) ratio. All the patients underwent laboratory testing (complete blood count, urinalysis, and biochemical blood testing) and dynamic renal scintigraphy to assess the secretory and evacuation functions of the renal tubular system. ResultsThe laboratory tests revealed no abnormalities, including no hematuria or proteinuria, in either group. The Dhilum/Dstenosis and Vstenosis/Vhilum ratios varied from 2.8 to 5.2 and from 2.9 to 8.3, respectively, and did not differ between the symptomatic and asymptomatic patients. All 40 patients with LRV compression stenosis were diagnosed with left gonadal vein reflux with a mean duration of 4.7 ± 0.6 seconds and 2.2 ± 0.6 seconds in the symptomatic and asymptomatic patients, respectively (P = .005). Eight patients had signs of NS on DUS, including five in the symptomatic group (SMA angle, 34.8° ± 2.7°; Dhilum/Dstenosis ratio, 5.2 ± 0.2; and Vstenosis/Vhilum ratio, 5.7 ± 0.4) and three in the asymptomatic group (SMA angle, 35° ± 2.8°; Dhilum/Dstenosis ratio, 5; and Vstenosis/Vhilum ratio, 5 ± 0.5). The groups did not differ significantly in the DUS parameters. Scintigraphy did not reveal any cases of secretory or evacuation dysfunction of the left kidney, including in the patients with DUS signs of NS. The maximum uptake time, elimination half-life, and effective renal plasma flow were within the normal ranges. ConclusionsLRV compression stenosis without hematuria has no significant effects on the functional state of the left kidney, irrespective of the disease severity. In patients with PeVDs, dynamic renal scintigraphy provides an objective assessment of left kidney function.

Use of tubularized bovine pericardium in left renal vein transposition for nutcracker syndrome

Nutcracker syndrome is an extrinsic compression of the left renal vein by the superior mesenteric artery anteriorly and aorta posteriorly, resulting in hallmark manifestations of hematuria, proteinuria, and flank and/or pelvic pain. This report illustrates the case of a patient with a history of left flank pain and intermittent gross hematuria every 2 weeks. The patient denies any pelvic pain or gastrointestinal or lower extremity symptoms. Urinalysis revealed red blood cells, but no infection was noted. The cystoscopy findings were normal. Computed tomography urography showed left renal vein and duodenal compression between the aorta and superior mesenteric artery with a narrow aortic–superior mesenteric artery angle. The patient underwent left renal vein transposition to the distal inferior vena cava via a transabdominal approach. The left renal vein was transected at the inferior vena cava; however, the length was too short to create a tension-free anastomosis. Thus, a bovine pericardium sheet was tubularized and used as an interposition graft. The patient recovered well and is symptom-free. Left renal vein transposition is a well-described surgical technique in the treatment of nutcracker syndrome. The use of a vein or prosthetic graft has been described. This case demonstrates the use of an alternate conduit for reconstruction.

Surgical Treatment of Symptomatic Left Renal Vein Compression Results in Significant Improvement in Postoperative Quality of Life

Surgical Treatment of Symptomatic Left Renal Vein Compression Results in Significant Improvement in Postoperative Quality of Life

RETROAORTIC LEFT RENAL VEIN OR POSTERIOR NUTCRACKER SYNDROME: A RARE ANOMALY

The term "Retroaortic Left Renal Vein" refers to a left renal vein that passes behind the abdominal aorta, and this anomaly is a rather unusual occurrence. It has been suggested that retroaortic left renal vein may cause symptoms such as haematuria and abdominal or ank pain. Urological symptoms are likely due to increased pressure in the left renal vein secondary to the posterior nutcracker phenomenon. We describe a highly uncommon case of a 35 year old woman who was admitted via the emergency department due to left sided ank pain for several days. A thorough examination with Contrast-enhanced CT revealed left renal vein compressed in between abdominal aorta and anterior margin of L1 lumbar vertebral body causing severe compression and mild proximal dilatation of left renal vein, with multiple venous collaterals majorly draining into the hemiazygos vein and the rest in inferior vena cava. The left gonadal vein appeared dilatated. These features were suggestive of posterior nutcracker syndrome

Presence of left renal vein stenosis in the development of hypertensive disorders of pregnancy

Prior research suggests placental mechanisms as a pathophysiologic explanation for hypertensive disorders of pregnancy, but little research exists on the role of renal venous compression by the gravid uterus. Prior work has suggested radiologic evidence of significant left renal vein (LRV) compression in the gravid patient, particularly in supine position. Our study aims to assess the degree of LRV stenosis stratified by maternal position and its association with development of hypertensive disorders.

LBSAT63 Cushing Syndrome As A Presentation Of Adrenocortical Carcinoma.Case Report

Abstract Introduction adrenocortical carcinoma is a rare endocrine malignancy (1) Case: 44 year old afro American female with no past medical history. No regular medications. Amenorrhea for 2 years. smokes cigarettes. Irrelevant family history. She presented with itchiness after cat scratch and was found to have hypertension urgency 229/123. Review of systems was positive for weight gain and easy bruises. Physical examination alert and oriented with body mass index of 31 kg/m2 heart rate 75 beats per minute normal heart sounds and clear lungs with scratch marks on left hand. bilateral lower extremities pitting edema, supraclavicular fat pad and violet abdominal striae. No facial plethora or hirsutism or lymphadenopathy or acne. Laboratory work up was remarkable for hypokalemia and metabolic alkalosis. High plasma morning cortisol level 53.6ug/dl normal between 6.2 and 29, 24hour urine cortisol and DHEAS and low ACTH FSH and LH. Estradiol 261pg/ml 17hydroxyprogesterone 49ng/dl and prolactin 31.7ng/ml. HBA1C 6.7. Normal renin aldosterone TSH and plasma and 24hour metanephrine and normetanephrine. Normal creatinine liver function and complete blood count. CT abdomen and pelvis with contrast showed large lobular heterogeneously enhancing mass in the left adrenal gland of 9. 0×10.1×10.1cm with left kidney posterior displacement and left renal vein compression. The pancreatic tail and splenic vein were draped over the mass. The right adrenal gland and other abdominal organs were unremarkable. DEXA scan showed osteopenia. CT chest showed 5mm right lower lobe nodule and compression fracture in the 7th thoracic vertebrae. Echocardiogram showed dilated left ventricle dimension with reduced ejection fraction 45%. The diagnosis was made for ACTH independent Cushing syndrome with adrenal mass. She underwent open left adrenalectomy distal pancreatectomy splenectomy and left nephrectomy in another institution. Histopathology showed 12×7.5×7 cm stage III adrenal cortical malignancy T3N0M0. Extensive necrosis and capsular invasion but negative surgical margins. Possibility of lung metastasis. Postoperative cortisol level 6. 02ug/dl. She was kept on postoperative slow tapering hydrocortisone with plan of chemotherapy and Mitotane. Conclusion adrenocortical carcinoma has a poor prognosis. It usually metastasizes to distant organs at time of diagnosis and rarely presents as Cushing syndrome. Surgical resection is the main management of localized tumors with controlling the effects of secreted hormones. Adjuvant therapies are chemotherapy radiotherapy and Mitotane according to the tumor stage and size. Mitotane is adrenal cytotoxic agent showed increase survival of advanced stages(1).

Gonadal Vein Collar To Facilitate Tension-Free Left Renal Vein Transposition

Nutcracker syndrome (NCS) causing symptomatic left renal vein (LRV) compression between the superior mesenteric artery and abdominal aorta is managed by LRV transposition, gonadal vein transposition, or occasionally LRV stenting. To make the surgical intervention less invasive, robotic or laparoscopically assisted techniques have also been described. As venous transposition to a more distally positioned confluence implies the need for additional length to obtain a tension free anastomosis, this sometimes necessitates the use of a vein cuff, often from the great saphenous vein (GSV), in addition to the inferior vena cava (IVC) cuff that is taken at the time of disconnecting the LRV.

Nutcracker phenomenon with a daily persistent headache as the primary symptom: Case series and a proposed pathogenesis model based on a novel MRI technique to evaluate for spinal epidural venous congestion

ObjectiveTo determine if a specific population of patients with a daily persistent headache from onset have underlying nutcracker physiology and to propose a pathogenesis model for their headaches utilizing a novel MRI protocol. BackgroundA single case report of a daily persistent headache associated with nutcracker syndrome was recently published. As the left renal vein has a connection to the spinal lumbar veins and secondarily to the spinal epidural venous plexus, one could hypothesize that renal vein compression could lead to persistent headache by altering spinal and cerebral venous pressure with secondary alterations in CSF pressure. The authors have published on a series of patients with a unique subtype of daily persistent headache from onset that appears to be caused by an abnormal reset of CSF pressure to an elevated state. The goal of the present study was to look for the presence of nutcracker physiology in this unique patient subgroup and to propose a pathogenesis model utilizing a novel MRI protocol to evaluate for retrograde lumbar vein flow and regional spinal epidural venous plexus congestion. Materials and methodsCase series of patients with a daily persistent headache from onset, head pressure, and whose headaches worsened in the Trendelenburg position. Patients were imaged with a 3 T MRI in the supine position from the lower diaphragm to the top of the pelvis with a dynamic angiogram centered over the left L2 lumbar vein. Results12 patients were studied of which 8 were positive for left renal vein compression, lumbar vein dilation and early spinal epidural venous plexus enhancement. All were women. Mean age of headache onset was 39 years. Six of the 8 patients had a lumbar puncture, and all had a normal opening pressure. All improved with CSF volume removal although pain resolution lasted from hours to 6 months. The patient's headaches were marked by holocranial pressure and the majority displayed migrainous associated symptoms although none had a prior headache history. They did not complain of typical symptoms or signs of nutcracker syndrome. ConclusionWe suggest that patients with a daily persistent headache from onset who worsen in the Trendelenburg position may have underlying nutcracker physiology. From our imaging findings, it can be hypothesized that left renal vein compression leads to retrograde flow through the valveless lumbar vein which then leads to spinal epidural venous congestion and subsequently causes congestion of the cerebral venous system leading to an elevation of CSF pressure and to a daily headache. What appears to be unique about these patients is that a daily headache is their only manifestation of nutcracker physiology.

Nutcracker Syndrome: A Review of the Current Literature

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.

TREATMENT OF AORTA MESENTERIC COMPRESSION: CURRENT PROBLEMS AND PROSPECTS

Left renal vein compression between the aorta and the superior mesenteric artery at an acute angle of the origin of the latter (“the nutcracker syndrome”) often leads to phlebohypertension in the left renal vein causing a combination of structural and functional changes in the kidneys and pelvic organs, different clinical manifestations such as left-sided varicocele, hematuria, pelvic venous congestion syndrome, the development of renal failure.&#x0D; The objective of the research: to determine indications for surgical and conservative treatment of aorta mesenteric compression.&#x0D; Materials and methods. The study included 210 patients (142 men and 68 women) with suspected “nutcracker syndrome” who were referred to vascular surgeons for a consultation by urologists and gynecologists during the period from 1999 to 2020, mainly from the western regions of Ukraine (about 11 million population). The age of the patients ranged from 12 to 52. All patients were interviewed for specific complaints: pain in the left lumbar region and left half of abdomen, inability to eat large amounts of food, hematuria, proteinuria, hemospermia, erectile dysfunction, left sided varicocele in men, and left sided pudendal varicosity and dysmenorrhea in women. All referred patients with suspected “nutcracker syndrome” underwent color Doppler ultrasound to determine the presence of pathological reflux in the left renal and gonadal veins by measuring peak systolic velocities in order to confirm or exclude that pathology. The patients with confirmed left renal vein stenosis underwent CT angiography.&#x0D; Results. According to color Doppler ultrasound, different degree of aorta mesenteric compression was confirmed in 138 (65.7%) patients (83 men and 55 women), critical left renal vein stenosis was observed in 35 of them. Two patients were diagnosed with the retroaortic left renal vein (“posterior nutcracker”).&#x0D; According to observations, clinical manifestations of AMC syndrome severe forms occurred in case of an increase in the diameter of the distal part of the LRV compared to its proximal segment by 3-6 times as well as in case of an increase in peak systolic velocity in the stenosed proximal segment by 6-14 times (by 8.7 times on average) compared to the left renal vein distal segment.&#x0D; Conclusions. Color Doppler ultrasound with determination of peak systolic velocities and diameters of the left renal and gonadal veins, pathological reflux in them must be the obligatory diagnostic stage in the patients with suspected AMC. The choice of treatment approach should be made taking into account clinical and laboratory indices, as well as the assessment of AMC severity according to instrumental data (ultrasound, CT angiography, MRA, etc.). The severity of pathomorphological changes in the pelvic organs and their consequences proves the need to eliminate phlebohypertension in the left renal and gonadal veins. LRV transposition proves its effectiveness in the remote postoperative period.

Left Renal Vein Compression: A Cause for Right-Sided Flank and Leg Pain

Left renal vein (LRV) compression resulting in signs and symptoms is commonly known as nutcracker syndrome. In nutcracker syndrome, LRV compression can result in venous tributary engorgement and symptoms such as loin pain, hematuria, and back pain. Most often, the symptoms will occur on the left side. We have described a series of patients who presented with hematuria and right flank and back pain. We performed a case series and literature review. Patient 1 was a 28-year-old woman who had initially been evaluated for concern for LRV compression. She had complaints of intermittent hematuria and right flank pain. Venography was performed, and selective venography of the renolumbar vein confirmed cross-filling across the lumbar spine to the right side. This confirmed filling across the patient's back and elicited her right flank pain. She underwent successful LRV transposition with ligation of the tributary veins, which resulted in resolution of her hematuria and right flank pain at 18 months of follow-up. Patient 2 was 39-year-old woman with microscopic hematuria, significant proteinuria, and bilateral back and flank pain, with LRV compression identified on computed tomography venography. Conventional venography with intravascular ultrasound was performed, which identified a retroaortic venous collateral vessel draining into the inferior vena cava. When this venous tributary was selected, and venography was performed, the patient experienced right-sided back pain. The nephrology workup revealed no intrinsic renal dysfunction. Thus, the patient was offered and underwent successful LRV transposition, with complete resolution of her symptoms at 12 months of follow-up. Patient 3 was a 22-year-old woman with significant right leg pain and bilateral pelvic pain and intermittent hematuria. The patient underwent venography with intravascular ultrasound that confirmed LRV compression. Significant reflux was noted in the left ovarian vein, which drained across the pelvis to the right internal iliac vein. Her left ovarian vein was dilated to 8 mm, and left ovarian vein transposition was performed. At 14 months of follow-up, the patient was doing well, with resolution of her hematuria, pelvic pain, and right leg pain. Right-sided pain is an atypical symptom that can result from LRV compression. These three cases exemplify that venous drainage pathways can vary with LRV compression and can manifest with a variety of symptoms. Clinical suspicion for LRV entrapment syndrome should include atypical presentations.

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

IntroductionAbdominal 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 ReportA 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.ConclusionEmergency 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.

Value of magnetic resonance imaging indices of left renal vein entrapment in the diagnosis of nutcracker syndrome in children.

BackgroundNutcracker syndrome (NCS) is also known as left renal vein (LRV) compression syndrome. Magnetic resonance imaging (MRI) can better depict the anatomical structure of soft tissues in the area of compression. Diagnosis of NCS using MRI in adults is not uncommon. However, there are few studies on the diagnosis of NCS using MRI in children. Therefore, we conducted this study to evaluate the clinical value of the MRI indices of the LRV in the diagnosis of NCS in children.MethodsThis study was a single-center retrospective analysis. One hundred seventy-four patients with suspected NCS were enrolled from January 2017 to July 2020. The inclusion criteria for suspected NCS were mainly based on clinical symptoms or signs, laboratory examinations and imaging reports. Other diseases that may cause hematuria and/or proteinuria were excluded. We grouped the patients based on the diagnostic criteria for NCS into a nutcracker group and a control group. The receiver operating characteristic (ROC) curve was constructed for evaluating the value of MRI indices in the diagnosis of NCS.ResultsThe majority of NCS patients presented with orthostatic proteinuria (OP) (67.2%), followed by hematuria (55.2%), abdominal pain (19.0%), and left flank pain (15.5%). The areas under the curve (AUCs) for the superior mesenteric artery (SMA) angle, beak sign, and compression ratio (CR) in the diagnosis of NCS were 0.870, 0.895, and 0.878, respectively, and the best cutoff values of the SMA angle and CR were 36.8 and 3.99, respectively. The specificities of SMA angle <36.8°, beak sign, CR >3.99, SMA angle <36.8° and beak sign, SMA angle <36.8° and CR >3.99, and beak sign and CR >3.99 were 82.5%, 93.8%, 93.8%, 97.9%, 95.9% and 97.9%, respectively.ConclusionsChildren with SMA angles less than 36.8°, beak signs and CR greater than 3.99 should be highly suspected of having NCS. Among these parameters, “beak sign” showed the highest diagnostic accuracy by MRI, and the combination of any two of the above parameters achieved a higher specificity than the single parameters.