Nutcracker syndrome

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**Nutcracker syndrome**
*Classification & external resources*
DiseasesDB	32367

A picture of a nutcracker. The legs of this nutcracker, with some imagination, could represent the superior mesenteric artery and abdominal aorta in nutcracker syndrome.

In medicine, the nutcracker syndrome — also known as nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein — is a compression of the left renal vein between the abdominal aorta (AA) and superior mesenteric artery (SMA).^[1] The popular name "nutcracker syndrome" derives from the fact that, in the sagittal view, the SMA and AA (with some imagination) appear to be a nutcracker crushing a nut (the renal vein).

1 Signs and symptoms
2 Diagnosis
3 Treatment
4 References
5 External links

[edit] Signs and symptoms

The syndrome is associated with hematuria, which can lead to anemia^[2], abdominal complaints or pain^[3] (classically left flank pain^[4]), nausea, and/or vomiting, due to compression of the duodenum which also passes between the SMA and abdominal aorta). Because the left gonad drains via the left renal vein, it can also result in left testicular pain^[3] in men or left lower quadrant pain in women.

Unusual manifestations of the nutcracker syndrome include varicocele formation and varices in the lower limbs.^[5]

[edit] Diagnosis

Nutcracker syndrome can be diagnosed with:

Left renal venography — considered to be the gold standard test.
Computed tomography (CT).
Abdominal ultrasonography — not definitive but has been found to be useful.^[6]

[edit] Treatment

Treatment depends on the severity and symptoms. Treatments include:

Endovascular stenting.^[4]
Renal vein re-implantation.^[7]
Gonadal vein embolization.^[7]

[edit] References

^ Sugimoto I, Takashi O, Ishibashi H, Takeuchi N, Nagata Y, Honda Y. Left Renal Vein Entrapment Syndrome (Nutcracker Syndrome) treated with Left Renal Vein Transposition. Jnp J Vasc Surg. 2001 10:503-507. Abstract.
^ Oteki T, Nagase S, Hirayama A, Sugimoto H, Hirayama K, Hattori K, Koyama A. Nutcracker syndrome associated with severe anemia and mild proteinuria. Clin Nephrol. 2004 Jul;62(1):62-5. PMID 15267016.
^ ^a ^b Hilgard P, Oberholzer K, Meyer zum Buschenfelde KH, Hohenfellner R, Gerken G. [The "nutcracker syndrome" of the renal vein (superior mesenteric artery syndrome) as the cause of gastrointestinal complaints] Dtsch Med Wochenschr. 1998 Jul 31;123(31-32):936-40. PMID 9721569.
^ ^a ^b Barnes RW, Fleisher HL 3rd, Redman JF, Smith JW, Harshfield DL, Ferris EJ. Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): repair by a new stenting procedure. J Vasc Surg. 1988 Oct;8(4):415-21. PMID 3172376
^ Little AF, Lavoipierre AM. Unusual clinical manifestations of the Nutcracker Syndrome. Australas Radiol. 2002 Jun;46(2):197-200. PMID 12060163.
^ Takebayashi S, Ueki T, Ikeda N, Fujikawa A. Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography. AJR Am J Roentgenol. 1999 Jan;172(1):39-43. PMID 9888735.
^ ^a ^b Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D. Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg. 2006 Jan;20(1):120-9. PMID 16374539.