It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. However, obstruction of the gonadal outflow may produce similar symptoms. We present a patient whose complaint of flank pain led to the diagnosis of a renal vein thrombosis. Nutcracker syndrome is a rare vein compression disorder.
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. The syndrome is responsible for a hypercoagulable state. It could make you more likely to have a dvt deep vein. 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. Pelvic congestion syndrome pelvic venous incompetence. Renal nutcracker syndrome genetic and rare diseases. Veins carry blood from all areas of your body back to the heart. The mild nutcracker syndrome can be witnessed in children during the changes their body undergoes due to growth. Nutcracker syndrome complicated by left renal vein thrombosis. Mesoaortic compression of the left renal vein nutcracker syndrome produces both obstruction and reflux, resulting in symptoms of pelvic congestion. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. We present a patient whose complaint of ank pain led to the diagnosis of a renal vein thrombosis.
No treatment is necessary in cases uncomplicated by thrombophlebitis or pulmonary embolism. Gonadal vein transposition for the treatment of 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. 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. 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. More rarely, an ovarian varicocele may develop as a result of backpressure from the inferior vena cava or left renal vein. Doppler ultrasound, computed tomography ct and selective left renal vein phlebography are useful to. 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.
Ovarian vein definition of ovarian vein by the free. The left kidney vein has to cross over the left sided aorta to get to the right sided vena cava. Imaging techniques found a large kidney with nutcracker syndrome. In this article, we refer to this heterogeneous group of disorders as vascular compression. 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. Anticoagulation was started and three weeks later, cta showed complete disappearance. 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. Nutcracker syndrome accompanying pelvic congestion.
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. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. 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. The right ovarian vein opens into the inferior vena cava and the left ovarian vein into the renal vein. Diseases associated with the renal vein include renal vein thrombosis rvt and nutcracker syndrome renal vein entrapment syndrome.
Retrograde catheterization of the left renal vein shows mesoaortic compression vertical arrow, of the left renal vein and perirenal varicosities horizontal arrow. Maythurner syndrome, also known as iliac vein compression syndrome or cocketts syndrome, affects two blood vessels that go to your legs. Posterior nutcracker syndrome pncs is the entrapment of the left renal vein between the aorta and the vertebral column. Multidetector ct of vascular compression syndromes in the. Management of renal nutcracker syndrome by retroperitoneal. On rare occasions the kidney vein will go behind the aorta. Ovarian vein embolization for the treatment of pelvic congestion syndrome. Reimplantation of the left renal vein into the infrarenal inferior vena cava is the standard surgical procedure for nutcracker syndrome.
Unusual coexistence of double inferior vena cava with. It can cause many symptoms in both children and adults, such as flank pain and blood in the urine. Renal vein entrapment the nutcracker syndrome brandon t. In this case, abdominal computed tomography angiography was helpful in diagnosing the nutcracker syndrome. Hematuria, pelvic or back pain and left varicocele are the most commonly symptoms. 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. Such patients have a higher likelihood of being misdiagnosed owing to low levels of awareness among providers about the condition. A 40yearold woman with a solitary left kidney suffered from left lumbar pain and hematuria.
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 ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. In this case, abdominal computed tomography angiography was helpful in diagnosing the nutcracker syndrome complicated by the renal vein thrombosis. 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.
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. Some people may not have symptoms, while others develop severe and persistent symptoms. The veins from each plexus ascend and unite to form single veins. The lumen diameter of the left ovarian vein before opening into the lrv was 5. 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. 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. In this article, we refer to this heterogeneous group of. 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.
The presence of hematuria, proteinuria, and pain albeit atypically right sided made it nutcracker syndrome. 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. I just recently had a major surgery for something called nutcracker syndrome. A, the left renal vein shows the point of compression of the sma and a very large left gonadal vein normal, 34 mm diameter. My daughter has nutcracker syndrome testicular disorders. Compression of the subclavian vein at the thoracic outlet which leads to subclavian vein thrombosis is called what. Ovarian vein is also linked with the nutcracker syndrome, where the left renal vein is compressed between the aorta and superior mesenteric artery.
A diagnosis of nutcracker syndrome was made and a left renal. The nutcracker syndrome is a vascular disorder, but the signs and symptoms are mainly urological or gynecological. 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. She was diagnosed in april 2009 after over a year and a half of trying to figure out what was wrong. 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. The case describes an underreported disorder, nutcracker syndrome ncs, which presents with nonspecific symptoms and predisposes patients to developing renal vein thrombosis. Nutcracker syndrome ncs describes left renal vein compression between the superior mesenteric artery and the aorta. Vulvovaginal varicosities and pelvic congestion syndrome.
Some people may not have symptoms, while others develop severe and. We finally went to mayo clinic and she was diagnosed there. Retrograde catheterization of left renal and gonadal veins. She had surgery, which is left renal vein transposition, where. The underlying anatomic anomaly, first described by gant in 1937, can lead to left renal venous. A totally laparoscopic transposition of the left renal vein was performed.
Although uncommon, it is still an important diagnosis due to the high. 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. 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. Laparoscopic transposition of the left renal vein into the. Case report nutcracker syndrome complicated by left renal. 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. 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.
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. This is because both mts and pcs are anatomic variants in the structure of abdominal veins that predispose the patient to all three issues. Nutcracker syndrome is the result of extrinsic compression of what. Pelvic congestion syndrome pcs is a condition that causes chronic pelvic pain due to problems with your veins in your lower abdomen. The syndrome is characterized by a complex of ymptoms with substantial variations, the diagnosis is difficult and.
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. Symptoms of pelvic venous congestion chronic pelvic pain, dyspareunia, dysuria, and dysmenorrhea have been attributed to massive gonadal reflux. The nutcracker syndrome ncs is the clinical equivalent of. Following are the common symptoms that have been studied in the nutcracker syndrome. Patients with left renal vein compression nutcracker syndrome can be referred for ovarian vein transposition.
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