Dr Paulino Souza Neto Vascular Surgery, Endovascular Surgery

English » Venous Diseases » Nut Cracker syndrome

This Pathology is characterized by the entrapment of the left renal vein between the Aorta and The superior Mesenteric artery. Normally the vein is located between them but when the angle formed by the two arteries is acute (narrow), the left renal vein might be compressed leading to poor outflow. The consequences are the restriction of the venous return leading to the rupture of the capillary vessels within the nefron causing microscopic bleeding (Micro-hematuria). Fortunately this is not frequent and might occur after physical effort. The venous system is capable of developing efficient collateral circulation draining in this case to the left gonadal vein (Ovarian vein in females and Testicular vein in males), but also to the Hemiazygos vein that drains the flow to the pelvis and chest. Therefore the major clinical manifestations of  this syndrome are left chest venous hypertension and pelvic venous congestion. There is indication for treatment in patients with complications such as Hematuria, asymmetric renal function attributable to this condition and Pelvic Venous Congestion. The majority of patients present with Venous Congestion and the left chest venous hypertension presents only as an aesthetic complication but may cause increase in bleeding during left breast surgery.

The open treatment  with a saphenous bypass is dedicated to the exceptions. The rule is to treat the symptomatic patients with left Renal vein angioplasty. Additionally the embolization of the pelvic varicose veins might be needed.

Indications and the best treatments are decisions to be taken by the physician in conjunction with the patient. 

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