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Nutcracker Syndrome
T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Compression of left renal vein between aorta and superior mesenteric artery (SMA)
              • Causes left renal venous outflow obstruction
                • Results in left renal venous hypertension
                  • May have accompanying hematuria
                  • May have engorged edematous left kidney with intrarenal/perirenal varices
                • Secondary pelvic congestion syndrome may occur
                  • Due to retrograde flow in left gonadal vein

          IMAGING

          • General Features

            • Imaging Recommendations

              • Ultrasonographic Findings

                • CT Findings

                  • MR Findings

                    • Angiographic Findings

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Gross Pathologic & Surgical Features

                            • Microscopic Features

                              CLINICAL ISSUES

                              • Presentation

                                • Demographics

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Image Interpretation Pearls

                                          Selected References

                                          1. Wang X et al: Results of endovascular treatment for patients with nutcracker syndrome. J Vasc Surg. 56(1):142-8, 2012
                                          2. Chen S et al: Endovascular stenting for treatment of Nutcracker syndrome: report of 61 cases with long-term followup. J Urol. 186(2):570-5, 2011
                                          3. Fitoz S et al: Nutcracker syndrome in children: the role of upright position examination and superior mesenteric artery angle measurement in the diagnosis. J Ultrasound Med. 26(5):573-80, 2007
                                          4. Scholbach T: From the nutcracker-phenomenon of the left renal vein to the midline congestion syndrome as a cause of migraine, headache, back and abdominal pain and functional disorders of pelvic organs. Med Hypotheses. 68(6):1318-27, 2007
                                          5. Shin JI et al: Doppler ultrasonographic indices in diagnosing nutcracker syndrome in children. Pediatr Nephrol. 22(3):409-13, 2007
                                          6. Zhang H et al: The left renal entrapment syndrome: diagnosis and treatment. Ann Vasc Surg. 21(2):198-203, 2007
                                          7. Ahmed K et al: Current trends in the diagnosis and management of renal nutcracker syndrome: a review. Eur J Vasc Endovasc Surg. 31(4):410-6, 2006
                                          8. Culafic D et al: Spontaneous splenorenal shunt in a patient with liver cirrhosis and hypertrophic caudal lobe. J Gastrointestin Liver Dis. 15(3):289-92, 2006
                                          9. Rudloff U et al: Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg. 20(1):120-9, 2006
                                          10. Chang CT et al: Nutcracker syndrome and left unilateral haematuria. Nephrol Dial Transplant. 20(2):460-1, 2005
                                          11. Cuellar i Calabria H et al: Nutcracker or left renal vein compression phenomenon: multidetector computed tomography findings and clinical significance. Eur Radiol. 15(8):1745-51, 2005
                                          12. Kim SJ et al: Long-term follow-up after endovascular stent placement for treatment of nutcracker syndrome. J Vasc Interv Radiol. 16(3):428-31, 2005
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Pathology

                                                • Clinical Issues

                                                  TERMINOLOGY

                                                  • Definitions

                                                    • Compression of left renal vein between aorta and superior mesenteric artery (SMA)
                                                      • Causes left renal venous outflow obstruction
                                                        • Results in left renal venous hypertension
                                                          • May have accompanying hematuria
                                                          • May have engorged edematous left kidney with intrarenal/perirenal varices
                                                        • Secondary pelvic congestion syndrome may occur
                                                          • Due to retrograde flow in left gonadal vein

                                                  IMAGING

                                                  • General Features

                                                    • Imaging Recommendations

                                                      • Ultrasonographic Findings

                                                        • CT Findings

                                                          • MR Findings

                                                            • Angiographic Findings

                                                              DIFFERENTIAL DIAGNOSIS

                                                                PATHOLOGY

                                                                • General Features

                                                                  • Gross Pathologic & Surgical Features

                                                                    • Microscopic Features

                                                                      CLINICAL ISSUES

                                                                      • Presentation

                                                                        • Demographics

                                                                          • Natural History & Prognosis

                                                                            • Treatment

                                                                              DIAGNOSTIC CHECKLIST

                                                                              • Consider

                                                                                • Image Interpretation Pearls

                                                                                  Selected References

                                                                                  1. Wang X et al: Results of endovascular treatment for patients with nutcracker syndrome. J Vasc Surg. 56(1):142-8, 2012
                                                                                  2. Chen S et al: Endovascular stenting for treatment of Nutcracker syndrome: report of 61 cases with long-term followup. J Urol. 186(2):570-5, 2011
                                                                                  3. Fitoz S et al: Nutcracker syndrome in children: the role of upright position examination and superior mesenteric artery angle measurement in the diagnosis. J Ultrasound Med. 26(5):573-80, 2007
                                                                                  4. Scholbach T: From the nutcracker-phenomenon of the left renal vein to the midline congestion syndrome as a cause of migraine, headache, back and abdominal pain and functional disorders of pelvic organs. Med Hypotheses. 68(6):1318-27, 2007
                                                                                  5. Shin JI et al: Doppler ultrasonographic indices in diagnosing nutcracker syndrome in children. Pediatr Nephrol. 22(3):409-13, 2007
                                                                                  6. Zhang H et al: The left renal entrapment syndrome: diagnosis and treatment. Ann Vasc Surg. 21(2):198-203, 2007
                                                                                  7. Ahmed K et al: Current trends in the diagnosis and management of renal nutcracker syndrome: a review. Eur J Vasc Endovasc Surg. 31(4):410-6, 2006
                                                                                  8. Culafic D et al: Spontaneous splenorenal shunt in a patient with liver cirrhosis and hypertrophic caudal lobe. J Gastrointestin Liver Dis. 15(3):289-92, 2006
                                                                                  9. Rudloff U et al: Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg. 20(1):120-9, 2006
                                                                                  10. Chang CT et al: Nutcracker syndrome and left unilateral haematuria. Nephrol Dial Transplant. 20(2):460-1, 2005
                                                                                  11. Cuellar i Calabria H et al: Nutcracker or left renal vein compression phenomenon: multidetector computed tomography findings and clinical significance. Eur Radiol. 15(8):1745-51, 2005
                                                                                  12. Kim SJ et al: Long-term follow-up after endovascular stent placement for treatment of nutcracker syndrome. J Vasc Interv Radiol. 16(3):428-31, 2005