The term posterior nutcracker phenomenon refers to the compression of the retroaortic left renal vein between the aorta a and b, arrowhead and the vertebral column a and b, arrow. A retroaortic left renal vein rlrv is located between the aorta and the vertebra and drains into the inferior vena cava. Some people may not have symptoms, while others develop severe and persistent symptoms. Unusual coexistence of double inferior vena cava with. Transverse grayscale image of the normal course of the left renal vein arrow anterior to the abdominal aorta ao and posterior to the superior mesenteric artery sma. Retroaortic left renal vein developmental and clinical. The syndrome is manifested by left flank and abdominal pain, with or without unilateral.
Retroaortic left renal vein is an anomaly of the renal vein that may cause damage to the vessel and lead to nutcracker syndrome, which results in. Retroaortic left renal vein radiology reference article. Maklansky on what is a retroaortic left renal vein. The term posterior nutcracker syndrome refers to the left renal venous hypertension secondary to the compression of the retroaortic left renal vein, which crosses between the aorta and the vertebral column. In certain situations, the syndrome can result from a retroaortic or circumaortic left renal vein.
Retroaortic left renal veins can be compressed between the aorta and the vertebra, referred to as the posterior nutcracker phenomenon. Retroaortic left renal vein may cause obstruction of the left ovarian vein leading to symptomatic varices. Current management approach for left renal vein entrapment. Urological symptoms can be caused by increased pressure in the renal vein. Retroaortic left renal vein, fig 9a, is one of the most common congenital anomalies and may cause left renal vein hypertension according to the criteria for nutcracker syndrome, 59. Some people may not have symptoms, while others develop severe and. Management of renal nutcracker syndrome by retroperitoneal. Nutcracker syndrome ncs is a rare entity defined by the symptomatic hypertension of the left renal vein lrv compressed in the majority of cases between the superior mesenteric artery and the aorta. Nutcracker syndrome due to left renal vein compression by.
The abdominopelvic computer tomography apct revealed left renal vein lrv duplication with a dilated retroaortic branch, entrapped between the aorta and the vertebral column, promoting the renal nutcracker syndrome. Instead, blood can flow backwards into other veins and cause them. Posterior nutcracker syndrome ncs is a rare anomaly in which the left renal vein passes behind the aorta which compresses it against the vertebral column, restricting the venous drainage of the left kidney. Retroaortic left renal vein may lead to left renal vein hypertension syndrome, also known as the nutcracker syndrome, a condition in which extrinsic compression of. With just ten known cases of the latter syndrom, first described in 1986 5, the anterior configuration remains far more. Renal vein stenting for nutcracker syndrome endovascular. Renal nutcracker syndrome ncs is a condition that occurs when the left renal vein the vein that carries blood purified by the left kidney becomes compressed. A retroaortic left renal vein rlrv is located between the aorta and the. Retroaortic left renal vein jefferson digital commons thomas. Normally, the left renal vein brings blood out of the left kidney and into the inferior vena cava, the bodys largest vein. Hematuria, pelvic or back pain and left varicocele are the most commonly symptoms.
Nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Posterior nutcracker syndrome associated with interrupted. If there is both a vein passing in front of and one behind the aorta this is called a circumaortic renal vein. The underlying anatomic anomaly, first described by gant in 1937, can lead to left renal venous. A left renal vein passing behind the abdominal aorta is termed a retroaortic left. In nutcracker syndrome, the renal vein coming from your left kidney becomes compressed and blood cant flow through it normally. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. Despite potential serious consequences, diagnosing ncs is often challenging, circuitous and commonly delayed. Schematic arrangements of the main types of nutcracker syndrome. Retroaortic left renal vein joann aichroth, traci fox, 20. The entrapment of the left renal vein lrv between the abdominal aorta ao. Crosssectional imaging has replaced invasive conventional angiography and venography as the imaging modality of choice for the diagnosis of vascular.
This is of no significance unless surgery in that area is necessary, in which case. Doppler us findings in 16 patients with the nutcracker syndrome and in 18 healthy control subjects were compared. Posterior nutcracker syndrome with left renal vein. The phenomenon results in left renal venous hypertension.
The left renal vein drains the left kidney into the inferior vena cava ivc. Ultrasound diagnostic criteria for pelvic congestion syndrome. Surgical treatment of posterior nutcracker syndrome. The nutcracker syndrome ncs results most commonly from the compression of the left renal vein lrv between the abdominal aorta aa and superior mesenteric artery sma, although other variants exist. What each clinical anatomist has to know about left renal vein entrapment syndrome nutcracker syndrome. A retroaortic left renal vein is usually asymptomatic. Nutcracker syndrome is a disorder caused by compression of the left renal vein between the aorta and the superior mesenteric artery sma. Rlrv and nutcracker syndrome are vascular anomalies considered to be of clinical importance especially during surgical procedures of the renal vasculature. Entrapment of the left renal vein lrv between the abdominal aorta and superior mesenteric artery sma causing the classic clinical triad of hematuria, varicocele, and left abdominal or flank pain was first described in 1950. The name derives from the fact that, in the sagittal plane andor transverse plane, the sma and aa with some imagination appear to be a nutcracker crushing a nut the renal vein. The clinical significance of a retroaortic left renal vein ncbi.
Nutcracker syndrome ncs is caused by compression of left renal vein lrv, usually between the aorta and the superior mesenteric artery sma. Rarely, the third portion of the duodenum accompanies left renal vein on the anterior nutcracker syndrome and this phenomenon is also known as the superior mesenteric artery syndrome wilkies syndrome. A new variant of the posterior nutcracker phenomenon. Learn about the symptoms and treatments for this vascular disease. An abdominal ct scan showed left renal vein duplication with the retroaortic branch trapped between the vertebral column and the aorta at the. Nutcracker syndrome is a vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric artery sma and aorta, although other variations can exist 1 this can lead to renal venous hypertension, resulting in rupture of thinwalled veins into the collecting system with resultant hematuria. Renal nutcracker syndrome genetic and rare diseases.
With anterior nutcracker syndrome, the left renal vein is compressed between the aorta and the superior mesenteric artery. What is a retroaortic left renal vein answers on healthtap. What each clinical anatomist has to know about left renal vein. Recall that the longer left renal vein has to pass in front of the aorta and behind the sma before it reaches the inferior vena cava. Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. The clinical significance of a retroaortic left renal vein. Rare causes of hematuria associated with various vascular. Hi, the circumaortic left renal vein is a relatively common congenital anomaly, seen in abdominal ct scans, ultrasound, mri or angiography. When the left renal vein courses posterior to the aorta it is referred to as retroaortic left renal vein rlrv. Anterior and posterior nutcracker syndrome accompanying. Rlrv is an uncommon condition in which the left renal vein passes posterior to the abdominal aorta and anterior to the vertebrae. Patients can present with hematuria and recurrent left flank pain. Renal vein entrapment the nutcracker syndrome brandon t. Urological symptoms can be caused by increased pressure in the renal vein resulting in venous hypertension.
Posterior ncs refers to the condition, in which vascular narrowing was secondary to the compression of the retroaortic left renal vein while it is crossing between the aorta and the vertebral column. Nutcracker syndrome ncs is a condition in which the left renal vein is compressed causing hypertension of the vessel. The compression can elevate pressure within the left renal vein, leading to hematuria, and resultant congestion of the left kidney 7, 1719. This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. N2 imaging description the nutcracker phenomenon, also known as left renal vein entrapment, refers to the compression of the left renal vein between the aorta and the superior mesenteric artery figures 96. The pelvic congestion syndrome ultrasound exam evaluates blood flow direction and diameter of the bilateral internal iliac veins, bilateral ovarian veins, and the left renal vein. Although uncommon, it is still an important diagnosis due to the high.
The anatomy and embryogenesis of this anomaly are well described in the literature, 60, 61. Duplication of the inferior vena cava with azygos continuation, retroaortic left renal vein and iliac vein variations. The development of ncs is associated with the formation of the left renal vein lrv from the aortic collar during the sixth to eighth week of gestation and abnormal angulation of the superior mesenteric artery from the aorta. The doppler ultrasonography showed turbulent pattern of venous blood flow of the posterior renal vein branch behind the aorta. In some people the left renal vein passes behind the abdominal aorta instead of in front of it, this is termed a retroaortic left renal vein, which is also known as the vein of schnitker. Anatomical variations and congenital anomalies of renal veins have been described by gillot and bergman et al. Among many variations of the left renal vein, the retroaortic course is much less well known. The most typical nutcracker morphological features imply compression of the lrv. Recent advances in computed tomography and magnetic resonance imaging techniques make it possible to visualize the vascular structures in. Nutcracker syndrome ncs is the most common term for compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. Current trends in the diagnosis and management of renal. Regression of the anterior instead of the posterior part leads to the retroaortic. A retroaortic left renal vein rlrv is located between the aorta and the lumbar vertebrae and drains into the inferior vena cava ivc or left common iliac vein. Retroaortic left renal vein rlrv draining into the left.
It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Nutcracker syndrome is caused by compression of the left renal vein between the aorta and the superior mesenteric artery where it passes in the fork formed at the bifurcation of these arteries. Nutcracker syndrome occurs when nearby arteries compress the left renal kidney vein. Meissner the nutcracker syndrome is characterized by entrapment and compression of the left renal vein between the abdominal aorta and the superior mesenteric artery sma figure 1. What each clinical anatomist has to know about left renal.
Although uncommon, it is still an important diagnosis due to the high morbidity associated with the risk of secondary anaemia from haematuria, from longterm left renal vein hypertension, vascular thrombosis, and even blood clots in the urinary system. Posterior nutcracker syndrome pncs is the entrapment of the left renal vein between the aorta and the vertebral column. Nutcracker syndrome ncs is the most common term for compression of the left. Compression of the left renal vein can cause blood to flow backward into other nearby veins and make them swell.
Case reports nutcracker syndrome due to left renal vein compression by an aberrant right renal artery antonio basile, md,1 dimitrios tsetis, md,2 giacomo calcara, md,1 michele figuera md,3 francesco coppolino, md, 4maria teresa patti, md,1 massimo midiri, phd, and antonio granata, md5 classic nutcracker syndrome is caused by left renal vein compression between the superior. Nutcracker syndrome ncs is a rare entity caused by the left renal vein lrv entrapment, most usually between the aorta and the superior mesenteric artery sma, known as anterior ncs. The nutcracker syndrome ns is a rare condition due to left renal vein lrv hypertension caused by compression of the lrv, either between the superior mesenteric artery and abdominal aorta, or between the vertebral column and the abdominal aorta in case of a retroaortic lrv. The nutcracker syndrome ncs is the clinical equivalent of. Retroaortic left renal vein has an estimated prevalence of 2% 3 clinical presentation. Retroaortic left renal vein rlrv is a normal anatomical variant where the left renal vein is located between. A left renal vein passing behind the abdominal aorta is termed a retroaortic left renal vein rlrv, and this anomaly is a relatively uncommon condition. Recent advances in computed tomography and magnetic resonance imaging techniques make it possible to visualize the vascular structures in detail.
Mixed nutcracker syndrome with left renal vein duplication. The nutcracker syndrome ncs is the clinical equivalent of nutcracker phenomenon characterized by a complex of. Sometimes a retroaortic position of the lrv also promotes an entrapment, this time between the aorta and the vertebral column, which is named posterior ncs. In addition, compression of a retroaortic left renal vein can. The posterior nutcracker phenomenon occurs when a decreased space. The condition is of clinical importance when renal surgery is contemplated or during collection of renal or adrenal venous samples. They did not tell me that i had nodules on the left side of my thyroid, screwed up the cancer test, didnt tell me i had a pinched nerve, or a retroaortic renal veinnutcracker syndrome. The normal left renal vein passes anterior to the aorta, to enter the inferior vena cava. Nutcracker syndrome gets its name because this compression is like a nutcracker crushing a nut.
Rlrv may lead to left renal vein hypertension lrvh syndrome, also known as nutcracker syndrome ncs. Pelvic congestion syndrome ultrasound exam, risk factors. Various anatomic anomalies have been considered the causes of nutcracker syndrome ncs. The anteroposterior ap diameter and peak velocity pv were measured at the hilar portion of the left renal vein lrv and at the lrv between the aorta and the superior mesenteric artery.
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