Posterior nutcracker syndrome: a case report

Abstract

Background Posterior nutcracker syndrome is defined by the compression of the left renal vein between the abdominal aorta and a lumbar vertebral body. It can be clinically manifest with intermittent hematuria, gonadal or spermatic reflux resulting in varicocele. Ultrasound is the first-line imaging which require more accurate study with contrast-enhanced computed tomography. Management can be conservative in younger patients with mild hematuria due to the high spontaneous remission rate and invasive with open surgical and endovascular interventions. We describe a very rare case with compression of the left renal vein due to an osteophyte of the spine. Case presentation A 62-year-old Caucasic male came to our radiology department for chronic hepatitis B virus (HBV)-related liver disease follow-up and mild scrotal pain. The ultrasound examination revealed a compression of the left retro-aortic renal vein in the aorto-vertebral space caused by an osteophyte. Duplex Doppler ultrasound revealed flow congestion in the left renal vein and renal failure; power Doppler ultrasound showed left varicocele. Conclusions Doppler ultrasound is the first-line imaging and allows the detection of all the typical signs of posterior nutcracker: left renal vein stenosis, flow congestion and renal failure. Nutcracker syndrome should be suspected in older patients with left varicocele associated with hematuria. Failure to diagnose and treat these patients could have serious consequences for their health.

Ultrasound features of posterior nutcracker syndrome: case series and literature analysis

“…Posterior NCS is a rare disease that is often found after further examinations for microscopic hematuria detected during urine examinations. Underlying anatomical variants, such as a retroaortic LRV or renal collar, aortic pathology like abdominal aneurysms, and lumbar osteophytosis (e.g., vertebral pathology), can result in PNCS (7). Symptoms of renal venous hypertension, such as abdominal flank pain, hematuria, left-sided varicocele, pelvic varices (if decompressed by collaterals), and chronic pelvic pain, are related to pelvic venous disorders that accompany compression of the LRV.…”

“…aneurysms, and lumbar osteophytosis (e.g., vertebral pathology), can result in PNCS(7). Symptoms of renal venous hypertension, such as abdominal flank pain, hematuria, left-sided varicocele, pelvic varices (if decompressed by collaterals), and chronic pelvic pain, are related to pelvic venous disorders that accompany…”

Double nutcracker syndrome in a patient with circumaortic venous ring: a rare case report

“…When the vein has a retroaortic course, the symptomatic compression can also be congenital or acquired and is generally caused by vertebral osteophytosis leading to aortovertebral space narrowing; the condition is referred to as the posterior nutcracker syndrome (PNCS) (3) . In very rare cases, the patients shows double left renal vein with anteroaortic and retroaortic course; this anatomical variant is known as "circumaortic venous ring" or "renal collar" (4) ; in these patients, compression of either one or both renal veins may occur.…”

Vascular compression syndromes: a pictorial review

“…The venous FR is obtained from the PSV ratio of the poststenotic tract and prestenotic tract (poststenotic PSV/prestenotic PSV), while the arterial FR is obtained from the ratio between the PSV of the poststenotic tract and the aortic PSV (poststenotic PSV/aortic PSV). A venous FR of 2.5 corresponds to stenosis of 50% [ 1 ], whereas an FR of 3:1 corresponds to stenosis of 70% [ 2 ]. DU currently can be performed with low-, medium-, or high-end ultrasound devices, as well as portable equipment equipped with color and duplex DU.…”