Nutcracker syndrome: intravascular stenting approach

The clinical syndrome caused by impingement of the left renal vein (LRV) between the superior mesenteric artery (SMA) and abdominal aorta has been termed Nutcracker syndrome [1]. Although often asymptomatic, it may result in varicocele, ovarian vein syndrome, haematuria, flank or abdominal pain, LRV hypertension, and pelviureteral varices. Surgical approaches for Nutcracker syndrome include nephrectomy, nephropexy, renocaval reimplantation, or auto-transplantation. We satisfactorily treated a middle-aged man with Nutcracker syndrome accompanied by renal enlargement, persistent haematuria, proteinuria and hypertension with a new intravascular stent. A 47-year-old man was referred from a urologist for hypertension, microscopic haematuria and left renomegaly; left varicocelectomy was performed 7 years ago. Physical examination was unremarkable except for a palpable left kidney. Ultrasonography revealed a normal-sized right kidney of 10.5 cm in length and a large left kidney that was 18 cm long. Urinalysis revealed microscopic haematuria and minimal proteinuria. IVP and ultrasonography revealed enlargement of the left renal pelvis and a convolution at the pelviureteral junction. The kidney biopsy specimen showed nonspecific proliferative change. Repeated ultrasonography and Doppler flow analysis revealed a patent LRV, which abruptly narrowed between the aorta and the SMA. Doppler velocimetric study showed that the diameter of the hilar and aortomesenteric portions of the LRV were 13.3 mm and 2 mm respectively (Figure 1).