Nutcracker Syndrome: Report of 3 cases managed with conservative treatment and review of the literature

Objective

Mesoaortic compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery has been termed "Nutcracker Phenomenon". Gross hematuria, microematuria and mild proteinuria are the most common symptoms, frequently associated to flank pain, left side varicocele with pelvic congestion. All these syntoms has been termed Nutcracker Syndrome. The factors responsable of different clinic manifestations are unknown. The physiopatological mechanism underlying this clinical syndrome is based on increasing pressure upstream of the obstruction. Venous pressure is increased in the gonadal, perirenal and renal veins and submucosal plexus. This condition clearly justifies capillary bleeding from mucosa of the upper urinary tract.

Methods and results

We introduce 3 cases of Nutcracker Syndrome with radiological and clinical findings that leaded to the correct diagnosis, managed with Surveillance. This report reviews the literature on clinical findings and current trends in the diagnosis, treatment and long term results. In first case report the patient presented gross haematuria, causing anemia. Patient initially refused to undergo to transposition of the left renal vein with interposition of vascular graft. This condition caused several episodes of haematuria, treated with blad transusions. Finelly the patient has been undergone to percutaneous endovascular stenting. The physicians had to performe right nephrectomy after this procedure due to the migration of the stent into the inferior vena cava. The other patients showed a progressive spontaneous resolution of the syntoms. We have to underline that in one case index of intraparenchimal resistence was quite normal, possiblyhard physical exercise has unmasked a border-line situation. We support this theory beacause when the patient suspended physical activity, symptoms disappeared and laboratory parameters normalized. in the last case what determined the resolution of the symptoms is unkown. Probably the patient had a waight increasing thad could have plaid a role in the decreasing entity of pressure of aortomesenteric compass due to increasing of mesenterial fat.

Discussion

Worldwide Litterature review suggests different approaches for the diagnoses and managment of this syndrome for example active sourveillace, endovascular percoutaneous stentig ( inficed of higt risk of failure), transposition of left renal vein, mesenteric artery transposition, kidney autotransplantation. We have the best results with transposition of left renal vein, with less risck of postoperatively complications compared to ather endoscopic or surgical procedures. We realized that every patient needs a personalised treatmend secondary to symptoms entity. There are only exclusion criteria for diagnosys due to rarety of this illness. All laboratoristic ed imaging studies are performed to exclude upper urinary cancer, calculi and artherovenous fistula.