Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): Repair by a new stenting procedure (original) (raw)

1988, Journal of Vascular Surgery

Compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta has been termed the nutcracker syndrome. Although often asymptomatic, this syndrome may result in varicocele, ovarian vein syndrome, and rarely LRV hypertension, pelviureteral varices, hematuria, and flank pain. Previous surgical approaches have included nephrectomy, variceal ligation, nephropexy, or renocaval reimplantation. We report a new LKV stenting procedure that provided relief for a young woman incapacitated by daily left flank pain and microscopic hematuria. Phlebography of the LKV revealed mesoaortic compression associated with a pressure gradient of 12 mm Hg and preferential outflow down large pelviureteral varices. At operation compression of the LRV was corrected with an external stent of reinforced polytetrafluoroethylene. The patient was asymptomatic and free of hematuria for 9 months after operation and follow-up phlebography documented normal renocaval flow, elimination of the pressure gradient, and reduction of the pelviureteral varices. This represents the first description in the vascular surgical literature of this venous compression syndrome, which has been recognized in previous urologic and radiologic reports reviewed herein. Vascular surgeons should be cognizant of the nutcracker syndrome, and we recommend this new stenting procedure as a more simple and physiologic therapy than previous approaches to this problem. (J VASC SuRG 1988;8:415-21.) Compression of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta by a mechanism similar to that of a nutcracker has been recognized by anatomists for 50 years. 1'2 Mesoaortic compression of the LRV has been considered the pathogenesis of the left-sided predominance of varicoceles 3'~ and the ovarian vein syndrome. 5,6 However, the nutcracker syndrome has been invoked only recently to explain the less common condition of left flank pain and hematuria associated with RLV hypertension and pelviureteral varices. 7 Such clinical problems of es-From the Departments of Surgery (Drs. Barnes and Fleisher), Urology (Dr. Redman), and Radiology (Drs. Harshfield and Ferris), University of Arkansas for Medical Sciences, and the practice of nephrology (Dr. Smith).