Nutcracker syndrome
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In medicine, the nutcracker syndrome (NCS) — also known as nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein — is a compression of the left renal vein between the abdominal aorta (AA) and superior mesenteric artery (SMA).[1] The name derives from the fact that, in the sagittal view, the SMA and AA (with some imagination) appear to be a nutcracker crushing a nut (the renal vein).
This condition is not to be confused with superior mesenteric artery syndrome, which is the compression of the third portion of the duodenum by the SMA and the AA.
Signs and symptoms
NCS is associated with hematuria (which can lead to anemia[2]) and abdominal pain (classically left flank pain[3]).
Since the left gonad drains via the left renal vein it can also result in left testicular pain[4] in men or left lower quadrant pain in women. Nausea and vomiting can result due to compression of the splanchnic veins.[4] An unusual manifestation of NCS includes varicocele formation and varices in the lower limbs.[5].
Diagnosis
Nutcracker syndrome can be diagnosed with:
- Left renal venography — considered to be the gold standard test.
- Computed tomography (CT).
- Abdominal ultrasonography — not definitive but has been found to be useful.[6]
Treatment
Treatment depends on the severity and symptoms. Treatments include:
- Endovascular stenting.[3]
- Renal vein re-implantation.[7]
- Gonadal vein embolization.[7]
Differential diagnosis
References
- ^ Sugimoto I, Takashi O, Ishibashi H, Takeuchi N, Nagata Y, Honda Y (2001). "Left Renal Vein Entrapment Syndrome (Nutcracker Syndrome) treated with Left Renal Vein Transposition" ([dead link]). Jnp J Vasc Surg. 10: 503–7.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Oteki T, Nagase S, Hirayama A; et al. (2004). "Nutcracker syndrome associated with severe anemia and mild proteinuria". Clin. Nephrol. 62 (1): 62–5. PMID 15267016.
{{cite journal}}: Explicit use of et al. in:|author=(help); Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ a b Barnes RW, Fleisher HL, Redman JF, Smith JW, Harshfield DL, Ferris EJ (1988). "Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): repair by a new stenting procedure". J. Vasc. Surg. 8 (4): 415–21. doi:10.1067/mva.1988.avs0080415. PMID 3172376.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ a b Hilgard P, Oberholzer K, Meyer zum Büschenfelde KH, Hohenfellner R, Gerken G (1998). "[The "nutcracker syndrome" of the renal vein (superior mesenteric artery syndrome) as the cause of gastrointestinal complaints]". Dtsch. Med. Wochenschr. (in German). 123 (31–32): 936–40. PMID 9721569.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ Little AF, Lavoipierre AM (2002). "Unusual clinical manifestations of the Nutcracker Syndrome". Australas Radiol. 46 (2): 197–200. doi:10.1046/j.1440-1673.2001.01037.x. PMID 12060163.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Takebayashi S, Ueki T, Ikeda N, Fujikawa A (1999). "Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography". AJR Am J Roentgenol. 172 (1): 39–43. PMID 9888735.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ a b Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D (2006). "Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature". Ann Vasc Surg. 20 (1): 120–9. doi:10.1007/s10016-005-5016-8. PMID 16374539.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ Ahmed K, Sampath R, Khan MS (2006). "Current trends in the diagnosis and management of renal nutcracker syndrome: a review". Eur J Vasc Endovasc Surg. 31 (4): 410–6. doi:10.1016/j.ejvs.2005.05.045. PMID 16431142.
{{cite journal}}: CS1 maint: multiple names: authors list (link)
External links
- Kimura K, Araki T (1996). "Images in clinical medicine. Nutcracker phenomenon". N. Engl. J. Med. 335 (3): 171. doi:10.1056/NEJM199607183350305. PMID 8657215.
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