Laparoscopic inferior mesentericgonadal vein bypass for. This causes symptoms like flank pain and blood in urine. Maklansky on what is a retroaortic left renal vein. What is a retroaortic left renal vein answers on healthtap. In order to avoid injury to the renal vein in such. Urological symptoms can be caused by increased pressure in the renal vein. Compression of the left renal vein can occur primarily in two anatomic locations 10. 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. The underlying anatomic anomaly, first described by gant in 1937, can lead to left renal venous. Pdf prevalence and incidence of clinical symptoms of the. Renal vein entrapment the nutcracker syndrome brandon t. In nutcracker syndrome, the renal vein coming from your left kidney becomes compressed and blood cant flow through it normally. Impeded outflow of the left renal vein has also been reported in association with a retroaortic course of the left renal vein. The name derives from the fact that, in the sagittal plane andor transverse plane, the sma and aa appear to be a nutcracker crushing a nut.
Compression of the left renal vein can cause blood to flow backward into other nearby veins and make them swell. The urological symptoms were probably due to the increased pressure of the lrv, secondary to posterior nutcracker phenomenon. The patient demonstrated no typical symptoms of nutcracker syndrome. 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.
Mixed nutcracker syndrome with left renal vein duplication. Nutcracker syndrome ncs is a condition in which the left renal vein is compressed causing hypertension of the vessel. Retroaortic left renal vein rlrv draining into the left. Nutcracker syndrome, also called renal nutcracker syndrome is a rare vascular condition. What each clinical anatomist has to know about left renal vein. Patients can present with hematuria and recurrent left. The compression can elevate pressure within the left renal vein, leading to hematuria, and resultant congestion of the left kidney 7, 1719. Surgical treatment of posterior nutcracker syndrome. Retroaortic left renal veins can be compressed between the aorta and the vertebra, referred to as the posterior nutcracker phenomenon. Current management approach for left renal vein entrapment.
Circumaortic left renal vein, also known as circumaortic renal collar is an anomaly of left renal vein when a supernumerary or accessory left renal vein passes posterior to the aorta, apart from the normal renal vein passing anterior to the aorta. The retroaortic left renal vein is present in 2% of patients, and a circumaortic left renal vein is present in 3%. Left venous renal entrapment syndrome, commonly called the nutcracker phenomenon ncp, is characterized by impeded outflow from the left renal vein lrv into the inferior vena cava ivc due to extrinsic lrv compression when passing through the angle between the abdominal aorta and the superior mesenteric artery sma. Unusual coexistence of double inferior vena cava with. 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. An analogous compression of the retroaortic renal vein between the aorta and the vertebral column has been termed the posterior nutcracker phenomenon by other authors 4,5. 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. Nutcracker syndrome gets its name because this compression is like a nutcracker crushing a nut. Recent advances in computed tomography and magnetic resonance imaging techniques make it possible to visualize the vascular structures in. Nutcracker syndrome is a rare disorder that can affect adults or children, though the prevalence and specific causes are unknown. Left venous renal entrapment is commonly called the nutcracker phenomenon, and results in a decreased outflow of blood from the left renal vein lrv to the ivc. The left renal vein generally courses anterior to the abdominal aorta.
Sometimes a retroaortic position of the lrv also promotes an entrapment, this time between the aorta and the vertebral column, which is named posterior nutcracker. In nutcracker syndrome, symptoms are most often caused when the left renal vein coming from the left kidney becomes compressed and blood. This is of no significance unless surgery in that area is necessary, in which case. 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. There are instances when the left renal vein takes a different path, traveling posterior to the aorta.
A retroaortic left renal vein rlrv is located between the aorta and the. Rare causes of hematuria associated with various vascular. Renal nutcracker syndrome genetic and rare diseases nih. Retroaortic left renal vein joann aichroth, traci fox, 20. What each clinical anatomist has to know about left renal. This phenomenon with its associated symptoms of unilateral hematuria and left flank pain is known as the nutcracker syndrome. Furthermore, the venous return from the left gonadal vein returning to the left renal vein is blocked, thus causing testicular pain. 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. Therefore, in addition to the more common conditions, venous hypertension in a retroaortic left renal vein should be considered in the differential diagnosis of occult hematuria, especially when the bleeding can be localized to the left. Current trends in the diagnosis and management of renal. Crosssectional imaging has replaced invasive conventional angiography and venography as the imaging modality of choice for the diagnosis of vascular. The nutcracker syndrome ncs is the clinical equivalent of. Posterior nutcracker syndrome with left renal vein.
With anterior nutcracker syndrome, the left renal vein is compressed between the aorta and the. Pelvic congestion syndrome radiology reference article. Retroaortic left renal vein may cause obstruction of the left ovarian vein leading to symptomatic varices. Axial contrastenhanced ct of the abdomen demonstrated compression of the left. 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.
Instead, blood can flow backwards into other veins and cause them. Anatomical variations and congenital anomalies of renal veins have been described by gillot and bergman et al. In this situation, the retroaortic left renal vein is compressed between the aorta and the vertebral column figure 96. It courses in front of the aorta and behind the superior mesenteric artery sma as it drains into the ivc.
Urological symptoms can be caused by increased pressure in the renal vein resulting in venous hypertension. Hi, the circumaortic left renal vein is a relatively common congenital anomaly, seen in abdominal ct scans, ultrasound, mri or angiography. This is of no significance unless surgery in that area is necessary, in which case its helpful for the surgeon to know ahead of time. This anomaly is potentially hazardous, if unrecognised during retroperitoneal surgery 1. Ultrasound diagnostic criteria for pelvic congestion syndrome. Retroaortic position of the left renal vein facilitates compression of the left renal vein between the aorta and the vertebral column leading to left renal venous hypertension. Among many variations of the left renal vein, the retroaortic course is much less well known. Nutcracker phenomenon and nutcracker syndrome ncbi. Nutcracker syndrome ncs is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery sma. Renal vein stenting for nutcracker syndrome endovascular. The retroaortic or circumaortic renal vein may be compressed between the aorta and. 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. 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.
Circumaortic left renal vein radiology reference article. In certain situations, the syndrome can result from a retroaortic or circumaortic left renal vein. Normally, the left renal vein brings blood out of the left kidney and into the inferior vena cava, the bodys largest vein. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. Retroaortic left renal vein may lead to left renal vein hypertension syndrome, also known as the nutcracker syndrome, a condition in which.
To evaluate the clinical importance of rlrv, we revi. The left renal vein arises from the left kidney to eventually drain into the ivc. Nutcracker syndrome an overview sciencedirect topics. This patient had gross hematuria secondary to posterior nutcracker syndrome characterized by compression of the anomalous retroaortic left renal vein between the aorta and the spine. Retroaortic left renal vein jefferson digital commons thomas. Retroaortic left renal vein radiology reference article. Nutcracker syndrome is a rare cause of haematuria caused by the left renal vein lrv entrapment 15, most usually between the aorta and the superior mesenteric artery sma, known as anterior nutcracker syndrome. Retroaortic left renal vein has an estimated prevalence of 2% 3.
Nutcracker syndrome ncs is a rare entity caused by the left renal vein lrv entrapment,1 most usually between the aorta and the superior mesenteric artery sma, known as anterior ncs. Patients can present with hematuria and recurrent left flank pain. The posterior nutcracker phenomenon occurs when a decreased. The anatomy and embryogenesis of this anomaly are well described in the literature, 60, 61. The normal left renal vein passes anterior to the aorta, to enter the inferior vena cava. An abdominal ct scan showed left renal vein duplication with the retroaortic branch trapped between the vertebral column and the aorta at the level of the aortic bifurcation, suggestive of posterior ncs. Some people may not have symptoms, while others develop severe and. 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. As an analogy, the retroaortic left renal vein constitutes a posterior nutcracker. Combined anterior and posterior nutcracker phenomenon in. The nutcracker syndrome results most commonly from the compression of the left renal vein between the abdominal aorta and superior mesenteric artery, although other variants exist. Renal nutcracker syndrome genetic and rare diseases.
Prevalence and incidence of clinical symptoms of the retroaortic left renal vein article pdf available in urologia internationalis 942 january 2015 with 140 reads how we measure reads. The diagnosis of pelvic congestion syndrome is established by the demonstration of multiple dilated, tortuous parauterine veins with a width 4 mm or an. Normally, the left renal vein brings blood out of the left kidney and. Schematic arrangements of the main types of nutcracker syndrome. Nutcracker syndrome ncs is the most common term for compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. Nutcracker phenomenon refers to compression of the left renal vein, most.
The clinical significance of a retroaortic left renal vein ncbi. Retroaortic left renal vein and nutcracker syndrome are vascular anomalies considered to be of clinical importance, particularly during surgical procedures involving the renal vasculature directly or, in many cases, the abdominal aorta. Retroaortic left renal vein developmental and clinical. The left renal vein drains the left kidney into the inferior vena cava ivc. In addition, compression of a retroaortic left renal vein can. Nutcracker syndrome is a rare entity caused by extrinsic compression on the left renal vein lrv crossing between the superior mesenteric artery and the aorta. In posterior nutcracker syndrome, the left renal vein is typically compressed between the aorta and the spine. The left renal vein lrv was compressed as it passed between the superior mesenteric artery and the right renal artery.
There were multiple small cortical cysts, sandlike stones in the left kidney and duplication of both right and left renal. 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. A 21yearold chinese woman was admitted with a sevenmonth history of unilateral severe hematuria. The ascending lumbar vein, the left adrenal vein, and the left testicular or ovarian vein are smaller veins which typically drain into the left renal vein. Keywords retroaortic left renal vein, nutcracker syndrome, venous hypertension figure 1. At the upmc heart and vascular institute, our surgeons in the division of vascular surgery are experts in treating nutcracker syndrome. The main aim of this article is to establish the actual prevalence of renal vein variations circumaortic renal vein, retroaortic renal vein, double renal vein. 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. 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. If there is both a vein passing in front of and one behind the aorta this is called a circumaortic renal vein. A retroaortic left renal vein is usually asymptomatic. The nutcracker syndrome ncs results most commonly from the compression of the left renal vein lrv between the abdominal aorta aa and superior.
This article reports the treatment of two cases of nutcracker syndrome using laparoscopic inferior mesentericgonadal vein bypass, knowing that this treatment option would avoid renal reperfusion injury and lrv hypertension. The clinical significance of a retroaortic left renal vein. Management of renal nutcracker syndrome by retroperitoneal. Pelvic congestion syndrome ultrasound exam, risk factors. With this new description, it has become necessary to describe the sma compression of an anteaortic lrv as anterior nutcracker syndrome and the compression of a retroaortic lrv as posterior nutcracker syndrome. A retroaortic left renal vein rlrv is located between the aorta and the vertebra and drains into the inferior vena cava. Nutcracker phenomenon ncp, also known as left renal vein entrapment, is characterized by impeded outflow from the left renal vein lrv into the inferior vena cava ivc due to extrinsic lrv compression, often accompanied by demonstrable lateral hilar dilatation and medial mesoaortic narrowing schematic representation of ncpnutcracker syndrome ncs in figure 1. This leads to left renal vein hypertension that may result in rupture of the thinwalled vein into the renal calyceal fornix, with the clinical presentation of intermittent gross or microscopic hematuria. It occurs when arteries compress the left renal kidney vein, often causing intermittent hematuria blood in the urine. An unusual case of left venous renal entrapment syndrome. 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. The condition is of clinical importance when renal surgery is contemplated or during collection of renal or adrenal venous samples. 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.
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