Anterior and posterior nutcracker syndrome accompanying left circumaortic renal vein in an adolescent. Case report

Abstract

The left renal vein (LRV) has many developmental variations; the two most common are the circumaortic and the retrocaval. Anterior nutcracker syndrome is the compression of the LRV between the aorta and superior mesenteric artery, whereas posterior nutcracker syndrome occurs between the vertebral column and the aorta. An adolescent male (aged 16 years) was referred to the emergency department for flank pain. CT findings showed the combination of anterior and posterior nutcracker syndrome in the left circumaortic renal vein, which has not previously been described in an adolescent.

Left renal vein transposition for posterior Nutcracker syndrome

“…Multiple techniques have been described to treat pNCS, including conservative management, 8 , 9 , 10 LRV transposition, 11 , 12 , 13 , 14 left gonadal vein transposition, 15 nephrectomy with autotransplantation, 16 LRV venoplasty and stenting, 17 , 18 hybrid LRV transposition with stenting, 19 and extravascular stenting. 20 …”

Left double polar renal arteries, left triplicate (preaortic, accessory and retroaortic) renal veins associated with extrinsic pelviureteric junction obstruction and posterior nutcracker phenomenon

“… 9 The two most common variants are the circumaortic left renal vein (CLRV) and RLRV. 10 Double renal veins are common unlike triple and quadruple renal veins that are very rarely reported in literature. 11 …”

Doppler US and CT Diagnosis of Nutcracker Syndrome

“…Retroaortic LRV, where the retroaortic portion of the circumaortic LRV may be compressed between the aorta and vertebra, can result in posterior NCS (Fig. 3) (2425262728). NCS may also occur in patients with a left-sided IVC or double IVC, where the LRV is not compressed anatomically, but the prominent flow from the lower extremity may cause functional obstruction of venous flow from the left kidney (Fig.…”

“…In addition, when collateral venous pathways develop, renal venous hypertension may be relieved. Therefore, reassurance and general supportive care are treatment options in most cases with NCS (122846). However, if hematuria is severe and persistent, surgical or other interventional management may be considered (5283538474849505152) although the effectiveness of these surgical or interventional treatments is not yet fully established.…”