The Nutcracker syndrome represents a congenital vascular defect in which the left renal vein is compressed between the abdominal aorta and the superior mesenteric artery. The most common symptom of the disease is hematuria, with or without left flank pain. The condition is often underdiagnosed due to the absence of specific symptoms. We present a clinical case of a 56-year-old woman with complaints of general fatigue, intermittent flank pain, and microscopic hematuria. A contrast-enhanced CT scan of the abdomen and pelvis revealed compression of the left renal vein between the superior mesenteric artery and the aorta, along with a bulging left ovarian vein, confirming the diagnosis of Nutcracker syndrome. In this specific case, observation is recommended, but in the event of more pronounced clinical symptoms, such as unbearable pain, severe hematuria, renal failure, or lack of response to conservative treatment, various endovascular interventions may be performed.
Ananthan K, Onida S, Davies AH. Nutcracker syndrome: an update on current diagnostic criteria and management guidelines. Eur J Vasc Endovasc Surg. (2017) 53:886–94. 10.1016/j.ejvs.2017.02.015 [PubMed] [CrossRef] [Google Scholar]
Dunphy L, Penna M, Tam E, El-Kafsi J. Left renal vein entrapment syndrome: nutcracker syndrome! BMJ Case Rep. 2019 Sep 04;12(9)
Grant J. Anonymous method of anatomy Williams & Wilkins, Baltimore, Md (1937), p. 137 Google Scholar)
Grimm LJ, Engstrom BI, Nelson RC, Kim CY. Incidental detection of nutcracker phenomenon on multidetector CT in an asymptomatic population: prevalence and associated findings. J Comput Assist Tomogr. 2013 May-Jun;37(3):415-8.
Gulleroglu K, Gulleroglu B, Baskin E. Nutcracker syndrome. World J Nephrol. 2014 Nov 06;3(4):277-81.
Hartung, O., Grisoli, D., Boufi, M., et al. (2014). Endovascular stenting in the nutcracker syndrome: Is it a durable solution?. Journal of Vascular Surgery, 60(6), 1787-1795.
He, Y., Wu, Z., Chen, S., Tian, L., & Li, D. (2019). Clinical characteristics of nutcracker syndrome. The Chinese Medical Journal, 132(8), 948-954.
Kolber MK, Cui Z, Chen CK, Habibollahi P, Kalva SP. Nutcracker syndrome: diagnosis and therapy. Cardiovasc Diagn Ther. 2021 Oct;11(5):1140-1149.
Kurlinsky AK, Rooke TW. Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc. (2010) 85(6):552–9. 10.4065/mcp.2009.0586 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
Kurklinsky, A. K., & Rooke, T. W. (2014). Nutcracker phenomenon and nutcracker syndrome. Mayo Clinic Proceedings, 89(4), 553-564.].
Polguj M, Topol M, Majos A. An unusual case of left venous renal entrapment syndrome: a new type of nutcracker phenomenon? Surg Radiol Anat. 2013 Apr;35(3):263-7.
Shin JI, Lee JS, Kim MJ. The prevalence, physical characteristics and diagnosis of nutcracker syndrome [letter]. Eur J Vasc Endovasc Surg. (2006) 32(3):335–6. 10.1016/j.ejvs.2006.04.030 [PubMed] [CrossRef] [Google Scholar).
Shin, J. I., Park, J. M., Lee, J. S., & Kim, M. J. (2007). The nutcracker syndrome: Diagnosis and treatment. International Urology and Nephrology, 39(3), 733-736.
Siddiqui WJ, Bakar A, Aslam M, Arif H, Bianco BA, Trebelev AE, et al. Left renal vein compression syndrome: cracking the nut of clinical dilemmas— three cases and review of literature. Am J Case Rep. (2017) 18:754–9. 10.12659/AJCR.905324 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
Tang, B., Zeng, Z., Li, J., & Chen, S. (2015). Chronic pelvic pain in women with nutcracker syndrome: A single-center experience. Vascular, 23(3), 280-286.
Takebayashi S, Ueki T, Ikeda N, Fujikawa A. Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography. AJR Am J Roentgenol. 1999 Jan;172(1):39-43.
Takehara, Y., & Takemura, M. (2013). Imaging findings in nutcracker syndrome: What is the best diagnostic criterion?. European Journal of Radiology, 82(8), 1210-1215
Takehara, Y., & Takemura, M. (2015). Outcomes of nutcracker syndrome with conservative management. American Journal of Nephrology, 42(2), 148-154.
Teksam, M., Truncale, T., Trifan, G., Massoud, T., & Apgar, B. (2009). Nutcracker syndrome: An imaging diagnosis with a multidisciplinary approach. Journal of Vascular and Interventional Radiology, 20(10), 1351-1357.
Wendel, G. D., & Potter, J. L. (2012). Nutcracker syndrome: A case for venous stenting. Journal of Vascular Surgery, 55(5), 1486-1489.
Zhang, H., Li, M., Jin, W., & Shao, G. (2013). Longterm outcomes of patients with nutcracker syndrome. European Journal of Vascular and Endovascular Surgery, 46(3), 315-321.
