The Nutcracker Syndrome: New Aspects of Pathophysiology, Diagnosis and Treatment

Hohenfellner, Markus; Steinbach, F.; Schultz-Lampel, D.; Schantzen, W.; K, Walter; Cramer, Benvon; Thüroff, Joachim W.; Hohenfellner, R.

doi:10.1016/s0022-5347(17)37893-x

Cited by 169 publications

(159 citation statements)

References 19 publications

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“…Clinical treatment is indicated when symptoms are tolerable, such as mild hematuria and pelvic pain that can be controlled with analgesics 13 . Surgical treatment is indicated in cases with persistent hematuria associated with anemia, functional renal failure and uncontrolled pelvic pain, or if conservative treatment is ineffective after 2 years' clinical follow-up [14][15][16][17] . In the case described here, the patient had already been on clinical treatment for a long time, without effective control of the pelvic symptoms being achieved and with persistent intermittent hematuria.…”

Section: Discussionmentioning

confidence: 99%

Tratamento endovascular da Sindrome de Quebra-nozes (Nutcracker)

Cunha

Souza

Feitosa³

et al. 2013

J. vasc. bras.

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Nutcracker syndrome refers to signs and symptoms secondary to compression of the left renal vein, most commonly between the superior mesenteric artery and the aorta, leading to impaired outflow to the vena cava. Diagnosis of this syndrome is often difficult and as result is late in most cases. We report on the case of a 51-year-old woman successfully treated with embolization of the ovarian vein and insertion of a self expandable stent in the left renal vein. Technical details and pitfalls are discussed.Keywords: Nutcracker Syndrome; Nutcracker phenomenon; renal vein entrapment; Pelvic Congestion Syndrome. ResumoA Síndrome do Quebra-nozes se refere a um conjunto de sinais secundários à compressão da veia renal esquerda, mais comumente entre a artéria mesentérica superior e a aorta, levando ao comprometimento do fluxo para a veia cava. O diagnóstico desta síndrome frequentemente é difícil e, por esta razão, o diagnóstico é demorado, em muitos casos. É relatado, nesta publicação, o caso de uma mulher de 51 anos, tratada com sucesso pela embolização da veia ovariana associada ao implante de stent autoexpansível na veia renal esquerda. São discutidos os aspectos técnicos e as dificuldades do procedimento. phlebography showed the superior mesenteric artery pressing down on the left renal vein and significant dilation of the ovarian vein (Figures 2 and 3). The short sheath was changed for an 8F long sheath and selective catheterization of ovarian vein was conducted preparatory to embolization with a Renegade® microcatheter and release four 12×30 mm Interlock® springs, followed by infusion of 5 ml of 3% polidocanol in a dense foam (Figure 4). A 16 mm×60 mm self-expanding Wallstent® was then implanted in the left renal vein and angioplasty conducted with a 12×40 mm XXL balloon, taking care to maintain an anchorage area both proximally and distally, to avoid migration to the cava ( Figure 5). Control phlebography showed that satisfactory correction of left renal vein compression and Palavras-chave:

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Section: Discussionmentioning

confidence: 99%

Tratamento endovascular da Sindrome de Quebra-nozes (Nutcracker)

Cunha

Souza

Feitosa³

et al. 2013

J. vasc. bras.

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“…Nutcracker syndrome is a vascular compression disorder, and refers to compression of the left renal vein between the superior mesenteric artery and the aorta. Its prevalence is unknown (1). Although often asymptomatic, this condition may occur with haematuria -more frequently micro-haematuria, flank or abdominal pain and varicocele, ovarian vein syndrome, LRV hypertension and pelviureteric varices may be part of this syndrome.…”

Section: Panel Bmentioning

confidence: 99%

Renal nutcracker syndrome

Copetti

2017

AMA

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A: The peak velocity in the LRV is 18.3 cm/sec. B; The peak velocity in the LRV in aortomesenteric portion is 110.8 cm/sec. There is evidence of "mosaic" color pattern due to the turbulent flow.A previously healthy, 31 year old woman was admitted to the emergency room with left flank pain and macrohaematuria, which began after jogging. The physical examinaTransversal scan of the abdomen. RK=Right kidney; LK=Left kidney; IVC=Inferior vena cava; AO=aorta; SMA=superior mesenteric artery, LRV=left renal vein. The arrow indicates the point of LRV compression. Panel Btion and her vital signs were normal. Ultrasonography showed that both kidneys were of normal size and echostructure, with no hydronephrosis or bladder abnormalities. The left renal vein (LRV) was enlarged (15 mm) with a winding course. Examination by Doppler ultrasound showed that blood flow was low with evidence of spontaneous echo contrast. The LRV was narrow (2 mm) between the aorta and the superior mesenteric artery (SMA) (Panel A). Color Doppler ultrasound showed a "mosaic" pattern of blood flow in the LRV, beyond the origin of the SMA. The peak velocity of systolic blood flow measured in the hilar tract and in the aortomesenteric portion of the LRV was 18.3 cm/sec and 110.8 cm/sec respectively (ratio 6.05), with a pressure gradient of 5 mmHg (Panel B). Diagnosis: Renal NutPanel A

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“…However, in some adults, the reduction of adipose tissue at the initial part of SMA, as well as the enlargement of lymph nodes or tumors, could also result in the LRV compression. Although some patients have severe and persistent symptoms, commonly including hematuria, left flank pain or gonadal vein syndrome, varicocele, orthostatic proteinuria, and orthostatic intolerance [8] [9], many patients, especially in children, are asymptomatic. However, hypertension is not included in the traditional clinical manifestations of the syndrome [1].…”

Section: Discussionmentioning

confidence: 99%

An Incidental Detection of Nutcracker Phenomenon in an Adolescent with Transient High Blood Pressure: A Case Report

Min¹,

Chen²,

Wang³

et al. 2016

CRCM

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Nutcracker phenomenon (NCP) is caused by a compression of left renal vein between aorta and superior mesenteric artery. The traditional clinical manifestations of nutcracker syndrome is usually accompanied with abdominal pain, hematuria, orthostatic proteinuria, and varicocele formation, however, hypertension is rarely reported as main clinical feature. We describe a male adolescent with manifestation of hypertension who was identified as NCP. Renal ultrasound and computed tomography angiography have provided evidences of left renal vein dilatation, probably due to the compression through the decreased angle between aorta and superior mesenteric artery. There were no other signs for secondary hypertension for the blood levels of renin and aldosterone being between normal limits and urinalysis being negative of hematuria and proteinuria. This patient was conservatively observed without any anti-hypertensive drugs and was asked for appropriately putting on weight. Three months later, the hypertension symptom was alleviated. In conclusion, although there were no established direct pathogenetic links between hypertension and NCP, no other definite etiology was shown to be the cause of this main manifestation. Thus we speculate that the NCP might be the main cause of hypertension in this patient.

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The Nutcracker Syndrome: New Aspects of Pathophysiology, Diagnosis and Treatment

Cited by 169 publications

References 19 publications

Tratamento endovascular da Sindrome de Quebra-nozes (Nutcracker)

Tratamento endovascular da Sindrome de Quebra-nozes (Nutcracker)

Renal nutcracker syndrome

An Incidental Detection of Nutcracker Phenomenon in an Adolescent with Transient High Blood Pressure: A Case Report

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