Posterior nutcracker syndrome – a systematic review

Abstract

Posterior nutcracker syndrome (PNCS) is the entrapment of the left renal vein between the aorta and the vertebral column. Although uncommon, it is still an important diagnosis due to the high morbidity associated with the risk of secondary anaemia from haematuria, from long-term left renal vein hypertension, vascular thrombosis, and even blood clots in the urinary system. A literature search of PubMed and EMBASE databases was performed and 27 publications containing 27 cases were included for the final analysis. The following frequency of clinical signs and symptoms was noted: twenty-five patients had haematuria, 13 patients had flank pain, and two had hypertension. Overall, male-female distribution was balanced and there were more adult than paediatric (age < 18 years) patients. All symptoms of patients with conservative treatment were either well-controlled or under spontaneous resolution. Conservative management instead of surgical treatment should be preferred in most cases. Taken together, despite the low incidence of PNCS, its recognition and management are highly important. This systematic study explores the evidence base for conservative and medical options.

3D-Printed PEEK Extravascular Stent in the Treatment of Nutcracker Syndrome: Imaging Evaluation and Short-Term Clinical Outcome

“…Nutcracker syndrome (NCS), also known as left renal vein (LRV) entrapment syndrome, is characterized by impeded outflow from the LRV into the inferior vena cava due to an abnormally narrow angle between the abdominal aorta (AA) and the superior mesenteric artery (SMA) or between the AA and the spine ( Gulleroglu et al, 2014 ; de Macedo et al, 2018 ; Park et al, 2018 ), resembling a nut between the jaws of a nutcracker. This phenomenon results in the formation of venous reflux, renal hilar varices, and an increase in LRV pressure, which mainly cause hematuria, proteinuria, and left flank/abdominal pain, as well as pelvic congestion in females and left-sided varicocele in males.…”

Unusual Drainage of the Bifurcated Left Renal Vein Into a Dilated Lumbar Azygos Vein and Inferior Vena Cava

“…20 Renal venous anomalies are usually asymptomatic, but retroaortic course, called also posterior nutcracker syndrome, may cause flank pain, macrohematuria or microhematuria, proteinuria, abdominal pain, left gonadal varicose veins, and pelvic congestion syndrome. [5][6][7] To our best knowledge, the case where one of the bifurcated branches of the left renal vein drained into the lumbar AV, which continued in the chest as a dilated AV, while the other left renal vein branch drained into the IVC, had not been reported previously.…”

“…Renal venous anomalies are usually asymptomatic, but retroaortic course, called also posterior nutcracker syndrome, may cause flank pain, macrohematuria or microhematuria, proteinuria, abdominal pain, left gonadal varicose veins, and pelvic congestion syndrome. 5 –7…”

“…3,4 In case of a retroaortic left renal vein course, compression between aorta and vertebral column may cause venous dilatation, and in consequence the posterior nutcracker syndrome resulting in episodes of hematuria, proteinuria, flank pain, thrombosis, and dilatation of the left ovarian or testicular veins which may cause pelvic congestion syndrome. [5][6][7][8] Case Report…”

Left renal vein transposition for posterior Nutcracker syndrome

“…The incidence of retro-aortic LRV is rare (< 2%), and the subsequent development of NCS is exceedingly rare with less than 30 documented cases in the literature. 1,2 Written informed consent was obtained from the patient for publication of this case report and accompanying images. Figure 2).…”