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Pelvic congestion syndrome (PCS), which is one of the most common causes of chronic pelvic pain (CPP), is a frequently encountered disease in women that generally receives inadequate diagnosis. It is commonly seen in multiparous women. PCS is defined by CPP persisting for at least six months without evidence of inflammatory disease. Patients with complaints of CPP may be associated with PCS in 30% of cases; however, diagnosing it can be challenging due to overlap with other causes of CPP in the pelvic region. Therefore, exclusion of other causes of CPP is necessary. Recent studies indicate a trend towards preferring endovascular treatment over surgical intervention due to its high success rate and low complication risk. The strong evidence about the diagnosis and treatment of PCS is still incomplete. There are few randomized controlled trials available. It should be discussed and evaluated in a multidisciplinary setting involving gynecologists, GI specialists, pain management experts, physical therapists, and interventional radiologists. The aim of this review is to comprehensively examine current information on the symptoms, pathogenesis, diagnosis, and treatment of PCS. [ABSTRACT FROM AUTHOR]

Superior mesenteric artery (SMA) syndrome or Wilkie's syndrome is a vascular compression disorder that causes the abnormal compression of the third portion of the duodenum by the SMA. It has a low incidence rate, which is higher in young women, and is rarely associated with the Nutcracker phenomenon: a condition of the compression of the left renal vein between the SMA and the aorta, which manifests as pain in the left flank and pelvis. Here, we report on the case of a 54-year-old woman with a history of repeated episodes of abdominal pain caused by the Nutcracker syndrome and Wilkie's syndrome. [ABSTRACT FROM AUTHOR]

Purpose: Left renal vein compression syndrome (LRVCS) remains a challenging diagnosis. This study aimed to correlate imaging and hemodynamic findings with clinical outcomes for patients with LRVCS. Materials and Methods: A retrospective review of 66 renal venography procedures with or without intravascular ultrasound (IVUS) was performed from 2017 to 2023 at a single institution. Patients with prior LRVCS treatment or other indications were excluded (n = 11). Primary outcome measure was correlation of catheter-based endovascular (CBE) findings with clinical outcomes (n = 55). Secondary outcome measures included correlation of CBE findings and LRV (i.e., beak) angle > 32°, beak sign, aortomesenteric angle (AMA < 41°), and hilar-to-aortomesenteric ratio (HTAMR ≥ 4.9) on cross sectional imaging. Descriptive statistics, chi-square testing, and ROC analyses were used. Results: Of the 55 patients, 52 (94.5%) were females (median age 31, range 14–72) and 56.4% (n = 31) had a diagnosis of LRVCS on CBE evaluation. A renocaval pressure gradient of ≥ 3 mmHg, presence of collaterals, and > 50% area stenosis on IVUS were significantly associated with CBE diagnosis of LRVCS (p < 0.001). Surgical treatment (renal autotransplantation or LRV transposition) was recommended to all patients with CBE diagnosis of LRVCS (n = 31). 81.2% (18/22) of patients who underwent surgery reported symptom resolution or improvement. When the cross sectional imaging measurements were compared with CBE evaluation, AMA was the most sensitive (100%), HTAMR and beak sign were highly specific (93.3%), and beak angle was the most predictive (77.4% sensitivity; 86.7% specificity). Conclusion: CBE diagnosis of LRVCS was highly predictive of surgical candidacy and post-surgical symptom resolution. The presence of collaterals, > 50% area stenosis on IVUS, or a renocaval pressure gradient ≥ 3 mmHg had a significant association with a CBE diagnosis of LRVCS. [ABSTRACT FROM AUTHOR]

Haikun Yang,1,2,&ast; Yan Zhang,3,&ast; Wen He1,4 1Meizhou Clinical Institute, Shantou University Medical College, Meizhou, Guangdong Province, People’s Republic of China; 2Department of Gynaecology, Meizhou People’s Hospital, Meizhou, Guangdong Province, People’s Republic of China; 3Department of Radiology, the First People’s Hospital of GuiYang, Guiyang, Guizhou Province, People’s Republic of China; 4Meizhou Academy of Medical Sciences, Meizhou People’s Hospital, Meizhou, Guangdong Province, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Wen He, Email doctorhoman@163.comAbstract: Pelvic congestion syndrome (PCS) is a chronic condition primarily characterized by pelvic pain and heaviness, with vaginal bleeding being a rare but significant symptom. We present two cases of PCS-related vaginal bleeding, emphasizing the necessity of considering PCS in differential diagnoses for abnormal vaginal bleeding. A 28-year-old Chinese woman presented with abnormal vaginal bleeding exacerbated by abdominal pressure during activities like squatting or defecation. Imaging revealed a dilated right ovarian vein, and transcatheter venography confirmed Nutcracker syndrome. After undergoing transcatheter foam sclerotherapy, her symptoms resolved. The second case involves a 29-year-old Chinese woman with similar symptoms; imaging and venography identified a dilated left ovarian vein. Following sclerotherapy, her symptoms also alleviated. These cases underscore the importance of recognizing PCS as a potential cause of abnormal vaginal bleeding and demonstrate the efficacy of transcatheter foam sclerotherapy in managing this condition. Integrating clinical presentation with imaging findings is crucial for timely diagnosis and effective treatment, ultimately improving patient outcomes.Keywords: pelvic congestion syndrome, vaginal bleeding, transcatheter foam sclerotherapy, nutcracker syndrome

Mintesnot Yitagesu Kidane, Adugna Getachew Mideksa, Mubarek Bargicho Adem, Fitsum Gebreegziabher Gebrehiwot, Ramzi Yessuf Adem, Mensur Mohammed Ahmed, Abebe Ketema Aderu, Mintesnot Tadesse Berta Department of Surgery, Urology Division at St. Paul Hospital and Millennium Medical College, Addis Ababa, EthiopiaCorrespondence: Mintesnot Yitagesu Kidane; Adugna Getachew Mideksa, Email minteyit01@gmail.com; adulense@gmail.comAbstract: We report rare case of concomitant left nutcracker syndrome and right ureteropelvic junction obstruction (UPJO) on adult female patient diagnosed by CT urogram after she presented with intermittent bilateral flank pain. For this we did Anderson-Hynes pyeloplasty for right ureteropelvic obstruction, it was laparoscopic initially but due to difficulty of stenting it is changed to open. She had smooth post-op course then discharged on 3rd post-op day. Symptoms of nutcracker syndrome are not that much bothersome for the patient so we planned to follow her conservatively.Keywords: nutcracker syndrome, ureteropelvic junction obstruction, pyeloplasty, UPJO

Stent migration is a rare but significant complication following endovascular procedures. Techniques for managing dislodged stents have included surgical, endovascular, and conservative approaches. This case details a patient who had a covered stent placed within the left renal vein which later migrated to the pulmonary artery causing damage to the tricuspid valve. The migrated stent was successfully removed using a percutaneous endovascular approach utilizing fluoroscopy and transesophageal echocardiogram guidance.

This case report highlights the successful application of a robotic-assisted surgical approach in managing Nutcracker syndrome. The patient, a 36-year-old female presented with severe symptoms and underwent robotic left renal vein transposition after failing conservative management. The procedure was performed through a minimally invasive approach utilizing the Da Vinci robotic system™ which offers enhanced visualization and precision. However, challenges arose during the renal vein anastomosis due to tension and poor flow through the transposition, requiring two revisions with a bovine pericardial patch. Ultimately, an 8 mm ringed PTFE bypass was anastomosed from the distal left renal vein to the Inferior Vena Cava. Despite these challenges, the patient experienced a successful outcome with complete symptom resolution of this complicated pathology. [ABSTRACT FROM AUTHOR]

Objective: This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions. Methods: This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms. Results: Sixteen patients (75% female and mean age 24.4 ± 3.5 years) underwent conservative management. Over a mean follow-up of 27.3 months [13--42, interquartile range (IQR)], the diameter ratio (5.5 [5--6.5, IQR] vs 4.3 [4.1--6], p = NS), the peak velocity ratio (6 [5--7, IQR] vs 4.8 [4.8--5.8], p = NS), beak angle (27° [24--30, IQR] vs 29° [24--32]; p = NS), and aortomesenteric angle (26° [23--29, IQR] vs 28° [24--30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged. Conclusions: This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms. [ABSTRACT FROM AUTHOR]

Purpose: To compare the Doppler sonographic findings of the left renal vein (LRV) of children diagnosed with nutcracker syn)drome with and without orthostatic proteinuria. Methods: Fifty and 53 consecutive children with and without orthostatic proteinuria, respectively, underwent renal Doppler ultrasonography examinations. The peak velocity (PV) was measured at the hilar portion of the LRV and between the aorta and superior mesenteric artery. Renal Doppler ultrasonography findings and clinical data including urine protein-to-creatinine ratio (UPCR) were compared according to the presence or absence of orthostatic proteinuria. Results: Between the two groups, no significant differences were observed in terms of age or sex. The PV ratio between the aortomesenteric and hilar portions was 7.79±2.65 and 6.32±3.01 in children with and without orthostatic proteinuria, respectively (P=0.009). No significant differences were observed between the two groups in terms of the UPCR in the first morning urine sample. However, the UPCR in the afternoon urine sample was significantly higher in children with orthostatic proteinuria than in those without orthostatic proteinuria (0.49±0.46 mg/mg vs. 0.11±0.04 mg/mg, P<0.001). Furthermore, the PV ratio between the aortomesenteric and hilar portions revealed a positive correlation with the ratio of UPCR of the afternoon to that of first morning urine samples (R=0.21, P=0.034). Conclusions: This study suggests that there can be a significant correlation of the PV ratio between the aortomesenteric and hilar portion of the LRV with orthostatic proteinuria in pediatric patients with nutcracker syndrome. [ABSTRACT FROM AUTHOR]

Typhoid fever, caused by Salmonella Typhi, is a severe bacterial infection prevalent in developing countries, and can result in life-threatening complications if untreated. Nutcracker Syndrome is a rare vascular disorder involving compression of the left renal vein between the aorta and the superior mesenteric artery. It can lead to various symptoms and poses diagnostic and management challenges. We present a case study of a patient diagnosed with typhoid fever in a Unit of Critical Emergency Care. Coincidentally, the evaluation through CT-scan revealed the presence of Nutcracker Syndrome. This report underscores the incidental discovery of Nutcracker Syndrome during the assessment of a patient with typhoid fever in a critical emergency care setting.

Purpose: To estimate the incidences of left renal vein (LRV) entrapment by right renal artery (RRA), a phenomenon primarily reported as case reports. Methods: The cross-sectional study consecutively screened renal vessel CT data of 38 (Renal) patients with nephropathy and 305 (Non-renal) patients with peripheral arterial diseases in a teaching hospital in northeast China between November 2018 and March 2023. The LRV compression by adjacent anatomical structures, including but not limited to RRA and multiple compression-related parameters, were investigated through multiplanar analysis of the CT data. Results: The overall LRV entrapment rates by adjacent structures were 41.93% (12/31) and 24.00% (6/25), the rates of RRA-sourced LRV compression 22.58% (7/31) and 20.00% (5/25), and the rates of compression by superior mesenteric artery (SMA) 16.13% (5/31) and 4.00% (1/25) in the Renal and Non-renal groups, respectively, with no significance. The venous segments distal to the RRA-compressed site had a significantly larger transectional lumen area than those of the non-compressed veins in both groups (3.09 ± 1.29 vs. 1.82 ± 0.23, p < 0.001 and 4.30 ± 2.65 vs. 2.12 ± 0.55, p = 0.006; maximum-to-minimum area ratios in Renal and Non-renal groups, respectively). Nearly 80% of RRAs were found arising anteriorly rightwards instead of passing straight to the right. Conclusion: RRA-sourced LRV compression was not rare, and its incidence was higher than that of the compression by SMA in both patient cohorts. RRA could be a more common compression source than SMA concerning LRV entrapment. Further investigations involving different populations, including healthy individuals, are needed. [ABSTRACT FROM AUTHOR]

Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed. Salient imaging features of each entity are illustrated through imaging examples using multiple modalities including ultrasound, fluoroscopy, CT, and MRI. [ABSTRACT FROM AUTHOR]

The text discusses a case of a 34-year-old male who presented with left loin pain and haematuria, along with other symptoms. It explores the possible diagnoses for these symptoms, including LRV entrapment and loin pain haematuria syndrome. The text also provides a comprehensive list of conditions that can cause haematuria and discusses the diagnosis and treatment options for nutcracker syndrome. It includes references to various articles and studies that provide valuable information for researchers and healthcare professionals studying nutcracker syndrome. [Extracted from the article]

Introduction: Nutcracker phenomenon is the compression of the left renal vein between the superior mesenteric artery (SMA) and the abdominal aorta. Nutcracker syndrome refers to the presence of nutcracker phenomenon with symptoms. Between 2016 and 2022, we performed 18 robot-assisted laparoscopic extravascular renal vein stent (RALERVS) placements. We sought to assess patient-reported outcomes of RALERVS placement by a single institution. Methods: We performed a single-center retrospective review of 18 patients with a minimum of 3 months follow-up. Symptoms were assessed utilizing a questionnaire conducted with a 5-point Likert scale at a minimum of 3 months postoperatively. Five on the Likert scale was severe while 1 was none. Primary study outcomes compared pre- and postoperative patient-reported symptom scores. Results: Twelve out of 18 patients responded to the survey. The average length of time from date of operation to completion of survey was 2.6 years. Average age of the cohort was 36 years with a mean BMI of 19.4 kg/m2. There was only one man. Mean operative time was 137 minutes and mean estimated blood loss was 12 mL. Mean preoperative SMA angle was 19° and mean postoperative SMA angle was 36°. Patients reported that flank pain, abdominal pain, nausea, headaches, back pain, pelvic pain, and early satiety improved (p < 0.05). Ten of 12 respondents would recommend RALERVS for nutcracker syndrome. Conclusion: RALERVS demonstrates an effective treatment for nutcracker syndrome. Patients reported improved symptoms at 3 months postoperatively across multiple domains. Further studies need to be conducted to assess long-term durability of the extravascular renal vein graft. [ABSTRACT FROM AUTHOR]

Objective: Nutcracker syndrome (NS) is defined by the compression of the left renal vein by the superior mesenteric artery. The incidence of NS and the exact treatment protocols are not well known. The objective of this study is to analyze children with NS and evaluate the prognosis in follow-up. Methods: All patients were referred to the pediatric nephrology clinic by pediatricians because of proteinuria. The study includes 74 patients (52 girls, 22 boys) with a mean age of 13.15±2.32 and records the presenting symptoms, degree of proteinuria, and radiologic findings. The diameter ratios of the left renal vein before and after stenosis and peak systolic velocity (PSV) ratios were calculated with a Doppler ultrasound, with a peak systolic ratio of 3.0:1 or greater was accepted as the diagnostic criterion for NS. Results: The mean age was 13.15±2.32 (5.33-17.42) years, while the mean follow-up duration was 14.6±9.1 months. Proteinuria was not correlated with the degree of compression. Most patients had a good prognosis, and none of them required medical or surgical treatment. A significant reduction or complete normalization of proteinuria was seen in more than half of the patients under conservative management. Conclusions: Based on our findings, NS seems to have a good prognosis in children who present with isolated proteinuria. [ABSTRACT FROM AUTHOR]

Background: Nutcracker syndrome (NCS) describes a set of symptoms and signs resulting from compression of the left renal vein (LRV). There is a lack of knowledge about its natural course, diagnosis, and management, especially in children. Herein, we present our single-center experience with a large number of patients who have long-term follow-up results. Methods: All patients with NCS diagnosed between January 2011 and March 2021 were included and their data were obtained retrospectively. Results: A total of 123 NCS patients (85 females) were included. The median age at the time of diagnosis was 12 (IQR 10–14) years, and BMI percentiles were below 5% in 38% of the cases. At the time of diagnosis, two-thirds of the patients were asymptomatic. The most common laboratory finding was nephritic proteinuria (98%), followed by microscopic hematuria (16%). Signs of LRV compression were significantly more evident in upright position Doppler ultrasonography (DUS) examination. All patients have been followed conservatively; hematuria and/or proteinuria resolved in 43 of the 108 patients (40%) within 35.8 ± 25.8 months of follow-up. Control DUS was performed in 52 patients after a mean period of 39.1 ± 21.3 months. The median peak velocity and diameter ratios of the LRV in the upright position were found to be decreased significantly when compared to the initial assessment (p < 0.05). Normal DUS findings were noted in 13 patients at the final evaluation. Conclusions: In unexplained proteinuria and/or hematuria, NCS should be considered, especially in asthenic adolescents. Our results support conservative management in children as the first-line treatment approach. [ABSTRACT FROM AUTHOR]

The management of pelvic venous disorders (PeVD) remains controversial. Open surgical and endovascular methods are currently used for treatment, but there are few data in the literature on the morphology and histology of the ectatic ovarian vein (OV). This study aimed to explore the histomorphological changes in a dilated OV in patients with PeVD and compare it with a normal OV obtained post-mortem and a normal great saphenous vein (GSV). Histology of the OV was studied in 16 patients who underwent surgery for PeVD, 10 control cadavers from whom fragments of the OV without visible gross changes were taken at autopsy, and nine control patients in whom the GSV was resected to be used for coronary artery bypass. The OV wall in patients with PeVD consisted of three layers: intima, media, and adventitia. The OV looked very similar to the GSV wall because of a clearly developed layer of smooth muscle fibres. The thickness of the normal OV was significantly different to the OV wall in PeVD (475.3 μm, IQR 370.7, 607.6 vs. 776.3 μm, IQR 668.9, 879.6, p <.001) and did not differ significantly from the thickness of a normal GSV wall (784.3 μm, IQR 722.2, 898.2). The intima-media complex of the OV was significantly thinner than the GSV in PeVD (118.9 μm, IQR 75.6, 159.6 vs. 415 μm, IQR 399.5, 520.0, р <.001); however, the adventitia of the OV was significantly thicker than in normal OV and GSV (599.6 μm, IQR 444.3, 749.7 vs. 373.5 μm, IQR 323.8, 482.0 vs. 308.4 μm, IQR 275.9, 338.2, p <.001). Dilatation of the OV in patients with PeVD was accompanied by a significant increase in the overall thickness of the vein wall, which brings it closer in structure to the GSV. This implies that the OV may be used safely for transposition into the inferior vena cava or iliac vein. [ABSTRACT FROM AUTHOR]

Nutcracker syndrome (NCS), a rare but impactful vascular condition, emerges from the compression of the left renal vein by adjacent major arteries, leading to a diverse array of symptoms such as hematuria, flank pain, and renal challenges. Highlighting the case of a 30‐year‐old male with an atypical presentation of NCS, this report explores the diagnostic complexities arising from its varied presentations and therapeutic options. It emphasizes the critical role of computed tomography (CT) in unveiling the underlying vascular constriction. Through this lens, the case underscores the necessity of considering NCS in the differential diagnosis of abdominal pain, advocating for a prompt and accurate diagnosis to guide effective management strategies, ranging from conservative approaches to surgical intervention. This stresses the importance of heightened awareness and ongoing research for optimizing patient outcomes in the face of this elusive condition. [ABSTRACT FROM AUTHOR]

This article, titled "Left Renal Vein Stent and Gonadal Vein Embolization in a Patient with Recurrent Varicocele and Nutcracker Syndrome—A Case Report," presents a case study of a 62-year-old male who presented with infertility and a history of bilateral testicular recurrent varicocele. The patient underwent various procedures, including catheterization of the left renal vein, embolization of the left gonadal vein, stenting of the left renal vein, and angioplasty. The final venogram showed a patent stent. The article provides detailed information about the patient's condition and the interventions performed. [Extracted from the article]

An acute vascular angle between the superior mesenteric artery and the Aorta may compress the third part of the duodenum (SMA Syndrome) and the Left Renal Vein (Renal Nutcracker Syndrome). Usually, patients are young females with a lean stature. Symptoms of outlet obstruction and pelvic congestion syndrome may be present. Our patient presented with bilious vomiting and unintentional weight loss for the last 6-8 months. On further inquiry, she had dysmenorrhea and left flank pain associated with microscopic haematuria. Duodenojejunostomy with Left Renal Vein (LRV) re-positioning was performed. She recovered uneventfully and has improved intake with mild or no pain troubling her at 6 weeks of surgery. [ABSTRACT FROM AUTHOR]

This article presents the findings of a study on the correlation between renal resistive index (RRI), renal microvessel density (RMD), and fibrosis in patients with chronic kidney disease (CKD). The study found no correlation between RRI and RMD or between RRI and fibrosis across CKD stages 1 to 5. However, RRI negatively correlated with CD34 PPA-glomerulus across CKD stages 2 to 5. The study suggests that RMD may be a useful indicator of renal function in CKD patients, but further research is needed to explore the correlation between RRI and renal microvascular disease. [Extracted from the article]

Nutcracker syndrome (NS) is a rare cause of hematuria and/or proteinuria defined as the left renal vein entrapment between the abdominal aorta and the superior mesenteric artery. The majority of patients, mostly females, are diagnosed in puberty age. We report eight children diagnosed with NS analyzing their clinical features, diagnostics approaches, disease evolution and treatment outcomes. [ABSTRACT FROM AUTHOR]

Nutcracker syndrome (NCS) is a disease caused by compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. Immunoglobulin A (IgA) nephropathy (IgAN) is characterized by the predominance of IgA deposits in the glomerular mesangial area. Hematuria and proteinuria can be present in both diseases, and some patients can be concurrently diagnosed with NCS and IgAN; however, a causal relationship between the two diseases has not yet been clarified. Here, we report two pediatric cases of NCS combined with IgAN. The first patient presenting with microscopic hematuria and proteinuria was diagnosed with NCS at the initial visit, and the second patient was later diagnosed with NCS when proteinuria worsened. Both patients were diagnosed with IgAN based on kidney biopsy findings and treated with angiotensin-converting enzyme inhibitors and immunosuppressants. A high index of suspicion and timely imaging or biopsy are essential for the proper management of NCS combined with glomerulopathy. [ABSTRACT FROM AUTHOR]

Renal nutcracker syndrome (NCS) is the entrapment of the left renal vein between the abdominal aorta and superior mesenteric artery. Although uncommon in pediatric patients, early diagnosis is crucial to avoid potential severe complications, such as anemia or renal vein thrombosis. NCS presents a variety of symptoms, most commonly including "Triade's symptoms"-hematuria, proteinuria, and flank pain. Diagnosis and treatment include invasive and noninvasive management, although due to a lack of pediatric clinical studies, management is widely variable. Conservative diagnosis and treatment are recommended as a firstline option for pediatric patients; however, invasive surgical treatment may be recommended based on symptom severity. This review aims to provide a comprehensive overview of NCS in children to better understand the widely variable incidence, occurrence, and management from early on to allow for early-onset management. [ABSTRACT FROM AUTHOR]

Venous compression syndromes have been described, yet the role of sex is poorly understood. Although iliac vein compression has been discussed more often with the advent of newer technologies, research has fallen short on defining epidemiology, best practices for evaluation and treatment, and differences in responses to treatment between men and females. The authors report on iliac vein compression, nonthrombotic renal vein compression, and other venous compression syndromes in females. Literature searches of PubMed were performed using the following keywords: females/females and May Thurner, venous stenting, venous outcomes, deep venous disease, deep venous compression, venous stenting, renal vein compression, renal vein surgery/stent, popliteal vein entrapment, venous thoracic vein entrapment , and popliteal vein entrapment. The articles prompted the authors to research further as the referenced articles were reviewed. Sex representation has not been addressed adequately in the research of venous compression syndromes, making the discussion of best treatment options and long-term outcomes difficult. More specific understanding of epidemiology and response to interventions will only come from research that addresses these issues directly, understanding that some of these syndromes occur rarely. [ABSTRACT FROM AUTHOR]

The objective of this paper is to report early and mid-term outcomes of the surgical treatment Nutcracker Syndrome (NCS) in a single-center prospective study. Between January 2019 and September 2023, five patients with symptomatic NCS were treated at our center using left renal vein caudal transposition on the inferior vena cava, conducted through a midline incision of approximately 12 cm and a transperitoneal technique. Patient characteristics, presentation, length of hospital stay, and complications were analyzed. All diagnoses were established after clinical evaluation, ultrasound scanning, and radiological investigations, which confirmed left renal vein compression between the aorta and the Superior Mesenteric Artery (SMA). The average operating time was 159 minutes, with an average blood loss of 205 mL. There was no need for blood transfusions. Intensive care stay was not required and there were no early complications. The mean length of stay was 3.5 days. At a mean follow-up of 18.8 months, one patient reported persistent hematuria, and therefore underwent a secondary procedure, which incorporated patch venoplasty using the great saphenous vein. In our experience, left renal vein transposition appears to be a safe and effective procedure for the surgical management of severe NCS.

Introduction: Pelvic congestion syndrome (PCS) is a relatively rare disease caused by various etiologies, including reflux or obstruction of the gonadal, gluteal, or periuterine veins. Consequently, its diagnosis is difficult, and it is often underdiagnosed in clinical practice. The nutcracker syndrome (NCS), which is characterized by symptoms arising from the compression of the left renal vein (LRV) between the superior mesenteric artery and aorta, is one of the etiologies of PCS. Various approaches have been proposed for the treatment of NCS with secondary PCS; nonetheless, no validated methods are currently available. Herein, we report the case of a 60-year-old female patient diagnosed with NCS and secondary PCS. Additionally, we describe the novel manner in which she was successfully treated with endovascular treatment, in the form of LRV stenting. Case report: The patient presented to our department with a chronic unknown etiology of fatigue and dull pain in the lower abdominal, pelvic, and bilateral outer thigh muscles. Contrast-enhanced computed tomography (CT) revealed left ovarian vein reflux and the presence of pelvic varicose veins, leading to the diagnosis of PCS secondary to the NCS. Results: We performed LRV stent placement using a 12 x 40 mm stent (E-Luminex; BARD Inc., Billerica, Massachusetts, USA). Her symptoms resolved after a month post-stenting. The post-stenting contrast-enhanced CT showed resolution of the pelvic varicose veins. Conclusions: LRV stenting is an advantageous treatment option for PCS secondary to the NCS because it is minimally invasive and allows for hemodynamic evaluation during treatment.

Pelvic congestion syndrome is a form of varicose disease, which is considered to be one of the main causes of chronic pelvic pain in women, which is associated with a violation of pelvic veins hemodynamics. Pelvic venous disorders are invisible to clinicians due to the lack of pathognomonic symptoms and manual disease criteria, but it has significant consequences. Today, one of the main diagnostic methods of pelvic venous disorders is a transvaginal US of pelvic veins, including gonadal veins (ovarian veins in women). Thanks to this non-invasive and simple diagnostic method that does not require specific preparation and has no contraindications, we have significant opportunities in diagnosis, as well as in the further evaluation of the postoperative results of surgical correction of pelvic congestion syndrome. The aim of the study was to analyze changes of pelvic veins in patients with pelvic congestion syndrome before and after surgical intervention using the transvaginal US method. Materials and methods. The study included 35 patients which underwent surgical treatment using open surgery and endovascular procedure between April 2019 and February 2022 with pelvic congestion syndrome. All patients underwent transvaginal ultrasound of the pelvic veins before surgery. A control examination was performed after surgical treatment in 4–6 months. The examination was performed on an expert-class ultrasound system “Toshiba Aplio 500” using all international standards for transvaginal examination of pelvic veins to evaluate the changes of illiac, paraovarian, parametrial and ovarian veins from the left side and from the right side in patients with pelvic venous disorders. Conclusions. Transvaginal ultrasound of the pelvic veins can be considered one of the key diagnostic methods, with the help of which it is possible to investigate and evaluate hemodynamic disorders in the veins of the pelvis and pelvic organs in real time. Also, this method can be considered optimal for the control examination of patients who underwent surgical correction of pelvic congestion syndrome.

Superior mesenteric artery syndrome also known as Wilkie's syndrome (WS) and Nutcracker syndrome (NCS) are 2 rare vascular syndromes characterized by the reduction of the aortomesenteric space. In the WS the reduction of the aortomesenteric angle leads to compression of the third portion of the duodenum. In the NCS the reduced aortomesenteric space usually causes a left renal vein (LVR) entrapment and the clinical presentation is a left flank pain, micro/macrohematuria and proteinuria. Arterial hypertension can be an unusual manifestation of the NCS. Herein, we describe the case of a 37-year-old woman with a history of breast cancer and abdominal subocclusion, with a recent onset of arterial hypertension whose enhanced computed tomography (CT) showed a reduced angle between the abdominal aorta and superior mesenteric artery with the CT findings of both the WS and NCS.

In pediatrics, hematuria usually responds to benign etiologies. A rare cause is nutcracker syndrome, defined as compression of the left renal vein between the aorta and the superior mesenteric artery, resulting in elevated pressure in the left renal vein with the development of collateral veins and varicose dilatation. The prevalence of this syndrome is unknown. When symptomatic, it causes hematuria, proteinuria, and chronic pelvic pain. At puberty, the rapid growth and development of the vertebral bodies can produce a narrowing of the angle between the aorta and the superior mesenteric artery. We describe the case of a teenage girl diagnosed with multiple metastatic mucoepithelial carcinoma of bone who presented anemia-producing hematuria. The diagnosis of nutcracker syndrome was arrived at with consideration of the therapeutic options. Finally, with shoe enhancement for scoliosis correction, hematuria was significantly lessened.

Background: Nutcracker syndrome (NCS) is a rare cause of varicocele and its treatment is still controversial. Objective: To summarize the surgical strategy and outcomes of microvascular Doppler (MVD)-assisted microsurgical left spermatic-inferior epigastric vein anastomosis (MLSIEVA) with microsurgical varicocelectomy (MV) at the same incision for treating NCS-associated varicocele. Design, setting, and participants: A retrospective analysis of 13 cases of NCS-associated varicocele between July 2018 and January 2022 was performed. Surgical procedure: A small incision in the body projection corresponding to the deep inguinal ring was chosen as the surgical incision. All patients underwent MLSIEVA and MV with the assistance of MVD. Measurements: Patients received real-time Doppler ultrasound (DUS) before and after surgery; urine red blood cells and protein were tested, with a follow-up time of 12–53 mo. Results and limitations: All patients had no intraoperative complications, and all postoperative symptoms of hematuria or proteinuria, scrotal swelling, and low back pain disappeared. Comparing pre- and postoperative DUS, two patients did not show any improvement in their postoperative measurements. However, in the remaining patients, the internal diameter of the renal vein at the hilum portion and at the aortomesenteric angle portion, as well as their ratio, improved significantly compared with preoperative measurements. No complications or recurrence of varicocele was observed during postoperative follow-up. Conclusions: Our study suggests that MVD-assisted MLSIEVA with MV is feasible with no major short-term complication and effective regarding the treatment of varicocele and NCS. Patient summary: We investigated microsurgery mediated by microultrasound for the treatment of varicocele associated with nutcracker syndrome. We found this procedure to be safe and effective with good long-term results.

Nutcracker syndrome is an extrinsic compression of the left renal vein by the superior mesenteric artery anteriorly and aorta posteriorly, resulting in hallmark manifestations of hematuria, proteinuria, and flank and/or pelvic pain. This report illustrates the case of a patient with a history of left flank pain and intermittent gross hematuria every 2 weeks. The patient denies any pelvic pain or gastrointestinal or lower extremity symptoms. Urinalysis revealed red blood cells, but no infection was noted. The cystoscopy findings were normal. Computed tomography urography showed left renal vein and duodenal compression between the aorta and superior mesenteric artery with a narrow aortic–superior mesenteric artery angle. The patient underwent left renal vein transposition to the distal inferior vena cava via a transabdominal approach. The left renal vein was transected at the inferior vena cava; however, the length was too short to create a tension-free anastomosis. Thus, a bovine pericardium sheet was tubularized and used as an interposition graft. The patient recovered well and is symptom-free. Left renal vein transposition is a well-described surgical technique in the treatment of nutcracker syndrome. The use of a vein or prosthetic graft has been described. This case demonstrates the use of an alternate conduit for reconstruction.

The authors have published on a unique subset of patients whose headaches worsened in the Trendelenburg position and who on time-resolved MR angiography demonstrated left renal vein compression (nutcracker physiology) with retrograde left second lumbar vein (L2LV) flow and regional spinal epidural venous plexus (EVP) congestion. We hypothesized that the spinal EVP congestion subsequently causes a secondary congestion of the cerebral venous system, which then leads to an elevation of CSF pressure above that individuals CSF pressure set point. This results in a daily headache from onset. Thus, eliminating the spinal EVP could conceivably improve or eliminate the manifested headache syndrome. We now present a case series of four patients with long-term follow-up utilizing lumbar vein coil embolization as a new therapeutic approach. In each patient, the MR angiography findings were verified by catheter-based venography. Treatment consisted of endovascular embolization of the second lumbar vein. Four patients have had coil embolization of which three are 1 year or longer from their procedure while one is 10 months posttreatment. All patients were women. Duration of daily headache prior to embolization ranged from 4 to 8 years. Post-embolization: Three patients are either headache free or 90–95% improved with substantial pain free time. There were no procedure-related complications. Our results suggest that embolization of L2LV in a specific patient population with nutcracker physiology may substantially improve head pain issues. This is a minimally invasive outpatient technique with no apparent side effects. [ABSTRACT FROM AUTHOR]

Left renal vein entrapment syndrome also known as nutcracker syndrome (NCS) is a vascular anomaly that occurs due to compression of the left renal vein from the outside, causing reduced left renal venous blood flow and thus venous congestion. This may be either asymptomatic or present with various clinical scenarios but is rarely associated with hypertension (HT). In this paper, we report an NCS case diagnosed in a young female patient who presented with HT.

Introduction: Abdominal pain and flank pain cause a significant proportion of emergencydepartment (ED) visits. The diagnosis often remains unclear and is frequently associated withrepeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank painis compression of the left renal vein between the aorta and the superior mesenteric artery known asnutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameterproximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describesuch a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the finaldiagnosis and intervention occurred.Case Report: A 16-year-old female, long-distance runner presented four times complaining ofintractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visiturinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomographyrevealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred tovascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements andeliminated symptoms.Conclusion: Emergency physicians must maintain a large list of possible diagnoses during theevaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndromemay mimic other causes of abdominal and flank pain such as renal colic and requires appropriatereferral.

Nutcracker syndrome (NCS) is the clinical manifestation of unilateral renal venous hypertension. It develops secondary to the nutcracker phenomenon caused by compression of the left renal vein between the superior mesenteric artery and the aorta. We present the case of a 43-year-old female with a history of left flank pain, pelvic congestion, and hematuria secondary to NCS. The patient frequently required high-dose non-steroidal anti-inflammatory medications with minimal relief. She initiated a kidney donor evaluation after electing to undergo a nephrectomy for the possible long-term resolution of NCS symptoms. If diagnosed early, NCS does not generate pathology within the kidney. This finding allows an individual with medically refractory NCS to avoid the morbidity of a complex surgical procedure by instead donating their kidney. Attention to this treatment modality could provide individuals with NCS resolution of symptoms while providing someone with end-stage renal disease with a life-saving organ. [ABSTRACT FROM AUTHOR]

Background: Nutcracker syndrome (NCS) caused by left renal vein (LRV) entrapment, is one of the most common causes of orthostatic proteinuria. In stereotype, orthostatic proteinuria is often accompanied by left renal vein obstruction and is found in young and underweight individuals. Here, we report a rare case with orthostatic proteinuria in an old obese female caused by a rare type of congenital inferior vena cava (IVC) interruption. Case presentation: A 65-year-old obese woman, who suffered from fluctuated proteinuria, had been misdiagnosed as chronic glomerulitis for 30 years. Instead of having any sign of NCS, she had a unique type of IVC interruption. Most venous blood from infrarenal IVC and right kidney drained into her LRV, and then through the expanded communicating vessel, drained into the left ascending lumbar vein which extended as hemiazygos vein. To the best of our knowledge, this is one of the first cases reported of orthostatic proteinuria attributed to the subsequent hemodynamic irregularity caused by IVC interruption without nutcracker phenomenon. Conclusion: Adult-onset orthostatic proteinuria is relatively rare, hard to be recognized and could be misdiagnosed as chronic glomerulonephritis. The case provided a novel differential diagnostic condition for those who suffered from fluctuated proteinuria of unknown causes. [ABSTRACT FROM AUTHOR]

Nutcracker syndrome is a rare inborn vascular abnormality in which the left renal vein is trapped and compressed between the superior mesenteric artery and the aorta. Compression leads to congestion and dilation of the left renal vein, erythrocyturia with or without proteinuria, pelvic congestion and pelvic pain in women and varicocele and/or swelling of the left testicle in men. The affected individuals may report low abdominal pain and discomfort in the left flank. The diagnosis is based on imaging studies (abdominal ultrasound, computed tomography with contrast enhancement, angiography, magnetic resonance imaging). Nutcracker syndrome is part of the differential diagnosis of hematuria and pelvic pain. The treatment is interventional (percutaneous transluminal angioplasty of the left renal vein) or surgical. The authors present a 46-year-old female patient with nutcracker syndrome diagnosed using contrast-enhanced computed tomography for hematuria since childhood. [ABSTRACT FROM AUTHOR]

Background: Intestinal malrotation is a congenital anomaly resulting from abnormal or incomplete rotation and fixation of the midgut during embryogenesis. It commonly presents in the neonatal period (75%) with sudden onset bilious vomiting and rarely beyond infancy (<10%). Aim: The aim of the study was to highlight the clinical features, radiological findings, and treatment outcomes of patients with malrotation presenting beyond infancy. Materials and Methods: Eleven consecutive cases of delayed presentation of malrotation presented over a period of 5 years (2017-2021). Data were analyzed retrospectively. Results: Out of the 11 patients, four were female and seven were male. The age of patients ranged from 14 months to 18 years. Patients beyond infancy present usually with diffuse pain abdomen compared to neonates which present with sudden onset bilious vomiting and therefore difficult to diagnose. Five patients had associated abnormalities such as intussusception or nutcracker syndrome or mesenteric cyst or jejunal stricture or mesenteric lymphadenopathy along with malrotation. Patients underwent ultrasonography, upper gastrointestinal contrast study, and contrast-enhanced computed tomography abdomen to confirm the diagnosis. All patients underwent the Ladd procedure with four requiring resection anastomosis and one requiring excision of the mesenteric cyst. Eight out of eleven patients had favorable outcomes, two develop adhesive intestinal obstruction and required re-exploration, and one had persistent complaints of hematochezia. Conclusion: Malrotation beyond infancy is a rare diagnosis. Malrotation in older children is usually not suspected because of the wide range of symptoms. A high index of suspicion on ultrasound or computed tomography is required to demonstrate the reversal of superior mesenteric artery and superior mesenteric vein position and related conditions. Early intervention and treatment can prevent catastrophic events such as intestinal volvulus and intestinal ischemia in these patients. [ABSTRACT FROM AUTHOR]

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Nutcracker syndrome refers to the compression of the left renal vein, usually between the aorta and the superior mesenteric artery. Flank pain is the most common complaint and hematuria can be seen among the laboratory findings. This syndrome, which is more common in women with low body mass index, can be difficult to diagnose. A 41-year-old female patient with persistent left flank pain was admitted to our family medicine outpatient clinic. Despite many polyclinic applications, there was no finding that could explain the pain in the patient, who did not have any features in her history. Computed tomography requested in our family medicine outpatient clinic revealed that the left renal vein was compressed between the aorta and the superior mesenteric artery, and the patient was diagnosed with nutcracker syndrome. Nutcracker syndrome is difficult to diagnose and is a diagnosis of exclusion to be considered in patients presenting with atypical left flank pain. A wide variety of methods are used in the treatment, from conservative treatment to the endovascular stent and surgical treatment, depending on the severity of the symptoms. [ABSTRACT FROM AUTHOR]