Anterior Nutcracker Syndrome with Left Gonadal Vein Varicosities on Multiphasic Computed Tomography: An Unexpected Cause of Pyeloureteral Junction Obstruction

Abstract

The anterior nutcracker syndrome is defined by the compression of the left renal vein between the aorta and superior mesenteric artery, usually related to the occurrence of hematuria. We report the case of an uncommon complication of the nutcracker syndrome. A 75-year-old woman was referred to our institution for left flank pain without hematuria. Multiphasic computer tomography urography showed a condition of left renal vein entrapment between the aorta and superior mesenteric artery with the development of left gonadal vein varicosities at the level of the renal hilum; a pyeloureteral junction compression with dilation of the pyelocalyceal system coexisted. To our knowledge, this is the first report of the association between nutcracker syndrome and pyeloureteral junction obstruction.

Three Unusual Cases of Nutcracker Syndrome Caused by Increased Blood Flow within the Left Renal Vein

“…These collateral veins may dissipate the high pressure gradient, but the weakness of the venous wall might be a predisposing factor for the rupture of the thin-walled septum between the small veins and the collecting system, causing haematuria and flank or abdominal pain [2,4,9]. As recently described, these collateral varicosities at the level of the hilum may also cause the entrapment of the pyeloureteral joint causing obstruction [10]. Other common clinical and laboratory findings are proteinuria, orthostatic intolerance, fatigue and pelvic congestion syndrome [1].…”