Nutcracker syndrome is a very common condition that is present in almost 50% of women with other forms of pelvic vein disease, such as may thurner syndrome mts and pelvic congestion. An example of this is the nutcracker syndrome, in which the left renal vein is compressed between the aorta and the superior mesenteric artery. Nutcracker syndrome complicated by left renal vein thrombosis. The mild nutcracker syndrome can be witnessed in children during the changes their body undergoes due to growth. This is because both mts and pcs are anatomic variants in the structure of abdominal veins that predispose the patient to all three issues. Imaging techniques found a large kidney with nutcracker syndrome. Although uncommon, it is an important diagnosis due to the important morbidity associated with it, including the risk of chronic kidney disease from longterm left renal vein lrv hypertension and the risk of lrv thrombosis. Nutcracker syndrome is a vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric artery sma and aorta, although other variations can exist 1 this can lead to renal venous hypertension, resulting in rupture of thinwalled veins into the collecting system with resultant hematuria. However, obstruction of the gonadal outflow may produce similar symptoms. Maythurner syndrome, also known as iliac vein compression syndrome or cocketts syndrome, affects two blood vessels that go to your legs.
Nutcracker syndrome ncs or left renal vein lrv entrapment is rare and may be caused by compression of the vein between the aorta and the superior mesenteric artery sma. A totally laparoscopic transposition of the left renal vein was performed. Nutcracker phenomenon ncp, also known as left renal vein entrapment, 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 ncpnutcracker syndrome ncs in figure 1. Vulvovaginal varicosities and pelvic congestion syndrome. Multidetector ct of vascular compression syndromes in the. In addition, venous outflow obstruction from anatomic variants, such as compression of the left renal vein by the superior mesenteric artery nutcracker syndrome may result in engorgement of the left ovarian vein. It could make you more likely to have a dvt deep vein. Management of renal nutcracker syndrome by retroperitoneal. Mesoaortic compression of the left renal vein nutcracker syndrome produces both obstruction and reflux, resulting in symptoms of pelvic congestion. When symptomatic, such compressions can result in a variety of uncommon syndromes in the abdomen and pelvis, including median arcuate ligament syndrome mals, maythurner syndrome, nutcracker syndrome, superior mesenteric artery sma syndrome, upj obstruction, ovarian vein syndrome ovs, and other forms of ureteral compression. The case describes an underreported disorder, nutcracker syndrome ncs, which presents with nonspecific symptoms and predisposes patients to developing renal vein thrombosis. This syndrome results most commonly from the compression of the left renal vein between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist.
Ovarian vein embolization for the treatment of pelvic congestion syndrome. Compression of the subclavian vein at the thoracic outlet which leads to subclavian vein thrombosis is called what. In most cases, compression of the left renal vein is between the abdominal aorta the main artery in the abdomen and the superior mesenteric artery, which brings blood. A 40yearold woman with a solitary left kidney suffered from left lumbar pain and hematuria. Hematuria, pelvic or back pain and left varicocele are the most commonly symptoms. We present a patient whose complaint of flank pain led to the diagnosis of a renal vein thrombosis. Posterior nutcracker syndrome pncs is the entrapment of the left renal vein between the aorta and the vertebral column.
Nutcracker syndrome is a rare vein compression disorder. The name derives from the fact that, in the sagittal plane andor transverse plane, the sma and aa with some imagination appear to be a nutcracker crushing a nut the renal vein. Diseases associated with the renal vein include renal vein thrombosis rvt and nutcracker syndrome renal vein entrapment syndrome. Although uncommon, it is still an important diagnosis due to the high. The right ovarian vein opens into the inferior vena cava and the left ovarian vein into the renal vein. Nutcracker syndrome ncs is a rare entity defined by the symptomatic hypertension of the left renal vein lrv compressed in the majority of cases between the superior mesenteric artery and the aorta.
Case report nutcracker syndrome complicated by left renal. Laparoscopic transposition of the left renal vein into the. Nutcracker syndrome ncs describes left renal vein compression between the superior mesenteric artery and the aorta. Nutcracker syndrome is the result of extrinsic compression of what. Nutcracker syndrome accompanying pelvic congestion. In this case, abdominal computed tomography angiography was helpful in diagnosing the nutcracker syndrome. More rarely, an ovarian varicocele may develop as a result of backpressure from the inferior vena cava or left renal vein. Ovarian vein syndrome relation of arteries and veins to ureters, view from the back in medicine, ovarian vein syndrome is a rare possibly not uncommon, certainly underdiagnosed condition in which a dilated ovarian vein compresses the ureter the tube that brings the urine from the kidney to the bladder. Nutcracker syndrome wikimili, the free encyclopedia. The left kidney vein has to cross over the left sided aorta to get to the right sided vena cava. Ovarian vein is also linked with the nutcracker syndrome, where the left renal vein is compressed between the aorta and superior mesenteric artery.
The syndrome is characterized by a complex of ymptoms with substantial variations, the diagnosis is difficult and. A, the left renal vein shows the point of compression of the sma and a very large left gonadal vein normal, 34 mm diameter. A diagnosis of nutcracker syndrome was made and a left renal. Some people may not have symptoms, while others develop severe and. Symptoms of pelvic venous congestion chronic pelvic pain, dyspareunia, dysuria, and dysmenorrhea have been attributed to massive gonadal reflux. Renal nutcracker syndrome genetic and rare diseases. On rare occasions the kidney vein will go behind the aorta. Pelvic congestion syndrome pelvic venous incompetence. Ovarian vein definition of ovarian vein by the free. Anticoagulation was started and three weeks later, cta showed complete disappearance. In this article, we refer to this heterogeneous group of. We finally went to mayo clinic and she was diagnosed there.
The reflux within the ovarian vein is thought to contribute to the pelvic congestion syndrome, be a cause of pelvic varicose veins and lower limb varicose veins. Doppler ultrasound, computed tomography ct and selective left renal vein phlebography are useful to. Laboratory tests for those cases frequently show signs of microhematuria, usually associated with the nutcracker syndrome, an anatomical variation in which the superior mesenteric artery sma and the aorta perform a clamping of the left renal vein, with consequent reflux in the proximal portion of that vein and of the left ovarian vein. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. Gonadal vein transposition for the treatment of nutcracker syndrome. Dilated left gonadal vein and pelvic varices indicate left renal vein lrv ouflow obstruction by the superior mesenteric artery sma i ordered a renal duplex and a ct venogram for procedural planning. I just recently had a major surgery for something called nutcracker syndrome.
She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. The underlying anatomic anomaly, first described by gant in 1937, can lead to left renal venous. Some people may not have symptoms, while others develop severe and persistent symptoms. We present a patient whose complaint of ank pain led to the diagnosis of a renal vein thrombosis. The syndrome is responsible for a hypercoagulable state. The lumen diameter of the left ovarian vein before opening into the lrv was 5. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. However, in some women, the veins in the lower abdomen have weakened, making their veins inefficient at moving the blood back up to their heart. No treatment is necessary in cases uncomplicated by thrombophlebitis or pulmonary embolism. My daughter has nutcracker syndrome testicular disorders. The nutcracker syndrome is a vascular disorder, but the signs and symptoms are mainly urological or gynecological.
She had surgery, which is left renal vein transposition, where. The nutcracker syndrome ncs results most commonly from the compression of the left renal vein lrv between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. It can cause many symptoms in both children and adults, such as flank pain and blood in the urine. Veins carry blood from all areas of your body back to the heart. Retrograde catheterization of the left renal vein shows mesoaortic compression vertical arrow, of the left renal vein and perirenal varicosities horizontal arrow. Pelvic congestion syndrome pcs is a condition that causes chronic pelvic pain due to problems with your veins in your lower abdomen.
When the kidney vein goes in front of the aorta, it may be pinched by the intestinal artery sma superior mesenteric artery anterior nutcracker syndrome. In this article, we refer to this heterogeneous group of disorders as vascular compression. It occurs when arteries, most often the abdomens aorta and superior mesenteric artery, squeeze the left renal kidney vein. Patients with left renal vein compression nutcracker syndrome can be referred for ovarian vein transposition. Renal nutcracker syndrome ncs is a condition that occurs when the left renal vein the vein that carries blood purified by the left kidney becomes compressed. The nutcracker syndrome ncs is the clinical equivalent of. Unusual coexistence of double inferior vena cava with. The presence of hematuria, proteinuria, and pain albeit atypically right sided made it nutcracker syndrome. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Ovarian vein definition of ovarian vein by medical. Although renal vein thrombosis rvt has numerous etiologies, it occurs most commonly in patients with nephrotic syndrome ie, 3 gday protein loss in the urine, hypoalbuminemia, hypercholesterolemia, edema.
Retrograde catheterization of left renal and gonadal veins. Meissner the nutcracker syndrome is characterized by entrapment and compression of the left renal vein between the abdominal aorta and the superior mesenteric artery sma figure 1. Reimplantation of the left renal vein into the infrarenal inferior vena cava is the standard surgical procedure for nutcracker syndrome. If this treatment option is not available, then the decision to embolize the left ovarian vein should be made based on the degree of left renal venous collateralization. Pelvic varices can be seen in 10% of women in the general population and up to 60% of patients with pelvic varices may develop pelvic congestion syndrome. Following are the common symptoms that have been studied in the nutcracker syndrome.
In this case, abdominal computed tomography angiography was helpful in diagnosing the nutcracker syndrome complicated by the renal vein thrombosis. Pelvic congestion syndrome occurs mostly because of ovarian vein reflux, but it can also occur because of the obstruction of ovarian vein outflow resulting in reversed flow 8, 9. Nutcracker 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. Nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Such patients have a higher likelihood of being misdiagnosed owing to low levels of awareness among providers about the condition. Renal vein entrapment the nutcracker syndrome brandon t. The veins from each plexus ascend and unite to form single veins. Ovarian vein thrombosis is a common incidental finding in patients who have undergone total abdominal hysterectomy and bilateral salpingooophorectomy with retroperitoneal lymph node dissection. Nutcracker syndrome is a variation of nutcracker phenomenon or renal vein entrapment syndrome, in which the arteries near the kidney compress the left renal kidney vein.
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