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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 59-63

Nutcracker syndrome at a Glance


1 Department of Nephrology, 404 General Military Hospital, Larissa, Greece
2 Department of Neurosurgery, University of Thessaly, Larissa, Greece
3 School of Medicine, European University Cyprus, Nicosia, Cyprus

Date of Submission03-Dec-2020
Date of Acceptance30-Dec-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
Dr. Dimitrios C Karathanasis
Department of Nephrology, 404 General Military Hospital, Larissa
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_27_20

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  Abstract 


The term of nutcracker phenomenon describes the entrapment of the left renal vein (LRV) between the superior mesenteric artery and the aorta without accompanying symptoms. The clinical term of nutcracker syndrome corresponds to the additional presence of symptoms. It is a rare anatomical and functional disorder that appears mainly with hematuria and left kidney pain and may be accompanied by albuminuria and pelvic congestion syndrome with varicose veins. It is diagnosed primarily by Doppler ultrasound where the main parameters are the anteroposterior diameter and the flow velocity in the dilated LRV and secondarily by computed tomography where the characteristic finding is the “beak sign” at the site of the stenosis. Therapeutically, surveillance or conservative management is initially chosen due to the high probability of spontaneous remission, while in a persistent and intense clinical picture, the main treatment options are the placement of an endovascular stent and the transposition of the LRV.

Keywords: Hematuria, left renal vein entrapment, nutcracker


How to cite this article:
Karathanasis DC, Karaolia AC, Karathanasis CRD. Nutcracker syndrome at a Glance. J Renal Nutr Metab 2020;6:59-63

How to cite this URL:
Karathanasis DC, Karaolia AC, Karathanasis CRD. Nutcracker syndrome at a Glance. J Renal Nutr Metab [serial online] 2020 [cited 2021 Jun 13];6:59-63. Available from: http://www.jrnm.in/text.asp?2020/6/3/59/313632




  Introduction Top


The term of nutcracker syndrome (NS) was proposed by de Schepper in 1972 to describe trapping of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta.[1] It was first described in 1950 by El-Sadr and Mina,[2] while in 1971, Chait et al. were the first who likened the aorta and upper mesenteric artery to the arms of a nutcracker.[3] Later, NS was associated with orthostatic albuminuria in children.[4],[5] While the nutcracker phenomenon (NP) is just an anatomical term that describes the entrapment of the LRV between the SMA and the aorta, NS is the corresponding clinical term which denotes the presence of symptoms.

There are three types of NS depending on the location of the entrapment:

Anterior nutcracker syndrome

It is the classic and most common entrapment of the LRV between the SMA and the aorta.

Etiology:

  1. Normally, trapping of the LRV is avoided because the SMA protrudes from the aorta at an angle of 90° and after following an anterior course for 4–5 mm then goes downhill. In NS, the protrusion angle of the SMA is acute[6],[7]
  2. Posterior renal ptosis with subsequent pressure of the LRV over the aorta[8]
  3. A high course of the LRV[8]
  4. Low or lateral origin of the SMA[8]
  5. Fibrous tissue at the origin of the SMA[9]
  6. Pancreatic neoplasms, para-aortic lymphadenopathy, and significant lordosis of the lumbar spine[10]
  7. NP on the right side has been observed in a gravid uterus.[11]


Posterior nutcracker syndrome

Entrapment of the LRV in a retroaortic position between the aorta and the vertebral column.[10]

Combination of anterior and posterior nutcracker syndrome

The LRV divides into an anterior branch trapped between the SMA and the aorta and a posterior arm trapped between the aorta and the vertebrae (renal collar).[12]


  Incidence Top


The exact incidence of the syndrome has not been determined. Asymptomatic dilatation of the LRV has been found at a rate of 72%.[13],[14] A study of 7 million school-age children in Korea found 65 cases (9.3/million).[15] There has been an increase in the incidence in adolescence and in the third to fourth[16] or second to third decade of life.[17] It has been observed that a low body mass index predisposes to the onset of the syndrome.[18] There seems to be no consensus on gender as some studies have found a slightly increased incidence in women compared to men,[10],[16] while newer research does not find a difference in gender.[17]


  Clinical Presentation Top


It should be clear that the term NP corresponds to asymptomatic patients while symptomatic ones are considered to have NS. The absence of symptoms is common, especially in children.[10] Although the main symptoms are hematuria and left flank pain, a significant number of other findings can be identified.[19]

Hematuria

It manifests as microhematuria which is four times more frequent than macrohematuria.[20] Increased pressure in the LRV and consequently in the entire venous system of the left kidney leads to rupture of the thin wall of the small veins at points of close contact with the urine collecting system. Cystoscopy shows that the hematuria comes from the left ureteric orifice. Rarely hematuria can lead to anemia.[19]

Left flank pain

Seldom, it is accompanied by abdominal pain and has been attributed to the formation and removal of blood clots.[21]

Orthostatic proteinuria

It was observed and early correlated with NS in children. It is usually moderate.[4],[5],[19] The frequency of symptoms of hematuria, albuminuria, and left kidney pain is proportional to the degree of narrowing of the LRV.[22]

Chronic fatigue

It has been linked to chronic fatigue in children.[23]

Varicose veins

The increase in pressure in the LRV and its tributaries leads to the development of varicose veins and collateral veins. The main veins that are distended are the left gonadal vein, the left ureteral vein, the capsular veins, the left lumbar ascending vein which ends up in the LRV with an ascending course, and the suprarenal vein which has a descending course. Left ovarian vein dilatation can lead to vulvar varices, left limb varicosities, and pelvic congestion syndrome, manifested by dysmenorrhea.[9],[24],[25] Left testicular vein dilatation may result in left-sided varicocele and left limb varicose veins.[9],[25],[26]

Thrombosis of the left renal vein

It has been described as a rare complication.[27]


  Diagnosis Top


The diagnosis is based on imaging findings. It is notable that in the upright position, the weight of the intestine makes the angle of the SMA with the aorta more acute. Imaging tests performed in a supine or decubitus position may not show the entrapment.[28]

Renal Doppler ultrasound

It has a sensitivity of 69%–90% and a specificity of 89%–100% and is considered a first-choice test.[14],[29] Typical findings are first the dilatation of the peripheral part of the LRV and second the increased pressure in the LRV concerning the pressure in the inferior vena cava. For the evaluation of these findings, the anteroposterior diameter of the LRV (DLRV) and the flow velocity in the LRV (VLRV) are measured. While normally the gradient of pressure between the peripheral part of LRV and the inferior vena cava is up to 1 mmHg, in NS is >3 mmHg.[30]

For adults, it has been suggested that if the DLRV ratio (DLRV at the level of the renal hilum to DLRV at the level of stenosis) is >5, then the diagnosis of NS is safe with a sensitivity of 69% and a specificity of 89%. Furthermore, if the VLRV ratio (VLRV at the site of stenosis to VLRV at the level of the renal hilum) is >5, then the diagnosis of NS has a sensitivity of 80% and a specificity of 94%. Furthermore, the combination of the above two criteria sets the diagnosis with 90% sensitivity and 100% specificity.[8],[10],[25],[31]

For children, it has been suggested that the diagnosis of NS is set if the DLRV ratio is >4.2 and if the VLRV ratio is >4.[32] Recent research has disclosed that if the DLRV ratio is >2.25, then the diagnosis of NS has 91% sensitivity and specificity.[22]

Computed tomography

The most typical finding at the point of stenosis is the “beak sign” formed by the protrusion of SMA with an acute angle from the aorta.[33] According to Kim et al., if the DLRV ratio is >4.9, then the diagnosis of NS has a sensitivity of 66.7% and a specificity of 100%. The main disadvantage of computed tomography (CT) is radiation.[34]

Magnetic resonance imaging

It provides a detailed display of the point of entrapment without the disadvantage of radiation.[33]

Three-dimensional computed tomography

It provides the advantage of a detailed display without being un invasive method.[35]

Digital subtraction angiography

It provides the most complete illustration, but it is an invasive method that is applied not exclusively for diagnostic purposes but mainly for the application of therapeutic options.


  Management Top


In general, treatment is divided into conservative, stenting, and open surgery. As a rule, children are treated conservatively as spontaneous remission has been observed over time.[36]

Conservative

Conservative treatment is reserved for patients with mild symptoms and mild hematuria and is recommended for up to 2 years.[21],[36] Depending on the case, it includes:

  1. Surveillance
  2. Treatment of orthostatic albuminuria with angiotensin inhibitors[10],[29]
  3. Treatment of pelvic congestion by applying elastic compression stockings.[37]


Stenting

Endovascular methods are a top priority as they have fewer complications than open methods.[37] The initial attempt of balloon angioplasty[38] was quickly sidelined by the implementation of stents.[37]

The placement of an endovascular expandable stent to treat the NS was first described by Neste et al. in 1996.[39] The growing experience confirmed the safety and efficacy of the option.[40] There was a reduction of the blood pressure in the LRV and an alleviation of symptoms within 6 months.[41] Possible complications include stent migration, thrombosis, and restenosis.[42] Stent migration appears a frequency of 7.3%, and it occurs due to displacement, early mobilization of the patient, constant pressure from the pulsating aorta, or finally due to large dilatation of the distal part of the LRV causing insufficient adherence of the stent to the venous wall.[41],[43]


  Surgery Top


Surgical treatment is reserved only for patients with severe clinical manifestations such as persistent pain or severe macroscopic hematuria.

The surgical options are:

  1. Removal of the fibrous tissue that surrounds and strangles the LRV at the point of stenosis[44]
  2. Transposition of the LRV (renocaval venous reimplantation). It is considered as the surgical method of choice. Beyond the open surgery,[45],[46] it has been successfully performed laparoscopically.[47],[48] Recently, robotic-assisted laparoscopic transposition of the LRV has been proposed initially by Wang et al. with metal clamps[49] and later by Chau et al. with vessel loops.[50] The most common complications of LRV transposition, especially in open surgery, include hemorrhage, retroperitoneal hematoma, and LRV thrombosis.[37] The combination of LRV reimplantation with stent placement has also been tested[51]
  3. Bypass of the LRV. A portion of the saphenous vein is used to create a bypass between the LRV and the inferior vena cava at a level below the LRV[43]
  4. Transposition of the SMA below the LRV. It appears an increased risk of bleeding and thrombosis resulting in intestinal ischemia[29]
  5. Left kidney nephropexy[8] or even auto-transplantation[52]
  6. Installation of external stents. It was originally proposed by Barnes et al. in 1988.[53] Lately, three-dimensional printing extravascular titanium stents have been tested successfully[54]
  7. Decongestion of the LRV. It has three options: (a) shunting between the LRV and the splenic vein,[55],[56] (b) shunting between the left gonadal vein and the inferior mesenteric vein,[57] and (c) transposition of the left gonadal vein to the inferior vena cava.[43]



  Posterior Nutcracker Syndrome Top


It is a developmental anomaly of the embryonic circumaortic venous ring.[58] It appears an incidence of 1%–2.4%.[12],[59]Unlike anterior NS, it concerns mainly adults and especially men.[60] The main clinical manifestation is hematuria,[61] which in contrast to anterior NS presents either as microhematuria or macrohematuria by the same frequency.[60] According to management, transposition of the LRV is recommended as the method of choice.[62]


  Conclusions Top


NS should not be confused with NP. Underdiagnosis due to its rarity could be avoided if clinicians bear in mind NS in cases of hematuria. Diagnosis can be easily made by either renal Doppler ultrasound or CT. The main CT elements of the extended LRV are the anteroposterior diameter and the flow rate. Although conservative treatment is the usual approach, in cases with severe clinical manifestations, endovascular stent or even transposition of the LRV is performed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
de Schepper A. Nutcracker phenomenon of the renal vein and venous pathology of the left kidney. J Belge Radiol 1972;55:507-11.  Back to cited text no. 1
    
2.
EL-Sadr AR, Mina E. Anatomical and surgical aspects in the operative management of varicocele. Urol Cutaneous Rev 1950;54:257-62.  Back to cited text no. 2
    
3.
Chait A, Matasar KW, Fabian CE, Mellins HZ. Vascular impressions on the ureters. Am J Roentgenol Radium Ther Nucl Med 1971;111:729-49.  Back to cited text no. 3
    
4.
Shintaku N, Takahashi Y, Akaishi K, Sano A, Kuroda Y. Entrapment of left renal vein in children with orthostatic proteinuria. Pediatr Nephrol 1990;4:324-7.  Back to cited text no. 4
    
5.
Lee SJ, You ES, Lee JE, Chung EC. Left renal vein entrapment syndrome in two girls with orthostatic proteinuria. Pediatr Nephrol 1997;11:218-20.  Back to cited text no. 5
    
6.
Shokeir AA, El-Diasty TA, Ghoneim MA. The nutcracker syndrome: New methods of diagnosis and treatment. Br J Urol 1994;74:139-43.  Back to cited text no. 6
    
7.
Hartung O. Nutcracker syndrome. Phlebolymphology 2009;16:246-52.  Back to cited text no. 7
    
8.
Wendel RG, Crawford ED, Hehman KN. The 'nutcracker' phenomenon: An unusual cause for renal varicosities with haematuria. J Urol 1980;123:761-3.  Back to cited text no. 8
    
9.
Zhang H, Li M, Jin W, San P, Xu P, Pan S. The left renal entrapment syndrome: Diagnosis and treatment. Ann Vasc Surg 2007;21:198-203.  Back to cited text no. 9
    
10.
Kurklinsky AK, Rooke TW. Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc 2010;85:552-9.  Back to cited text no. 10
    
11.
Radisic MV, Feldman D, Diaz C, Froment RO. Unexplained hematuria during pregnancy: Right-sided nutcracker phenomenon. Int Urol Nephrol 2007;39:709-11.  Back to cited text no. 11
    
12.
Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat 1999;21:77-81.  Back to cited text no. 12
    
13.
Buschi AJ, Harrison RB, Norman A, Brenbridge AG, Williamson BR, Gentry RR, et al. Distended left renal vein: CT/sonographic normal variant. AJR Am J Roentgenol 1980;135:339-42.  Back to cited text no. 13
    
14.
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. Am J Roentgenol 1999;172:39-43.  Back to cited text no. 14
    
15.
Park YH, Choi JY, Chung HS, Koo JW, Kim SY, Namgoong MK, et al. Hematuria and proteinuria in a mass school urine screening test. Pediatr Nephrol 2005;20:1126-30.  Back to cited text no. 15
    
16.
Bhanji A, Malcolm P, Karim M. Nutcracker syndrome and radiographic evaluation of loin pain and hematuria. Am J Kidney Dis 2010;55:1142-5.  Back to cited text no. 16
    
17.
Orczyk K, Łabetowicz P, Lodziński S, Stefańczyk L, Topol M, Polguj M. The nutcracker syndrome. Morphology and clinical aspects of the important vascular variations: A systematic study of 112 cases. Int Angiol 2016;35:71-7.  Back to cited text no. 17
    
18.
Ozkurt H, Cenker MM, Bas N, Erturk SM, Basak M. Measurement of the distance and angle between the aorta and superior mesenteric artery: Normal values in different BMI categories. Surg Radiol Anat 2007;29:595-9.  Back to cited text no. 18
    
19.
Venkatachalam S, Bumpus K, Kapadia SR, Gray B, Lyden S, Shishehbor MH. The nutcracker syndrome. Ann Vasc Surg 2011;25:1154-64.  Back to cited text no. 19
    
20.
Shin JI, Park JM, Lee JS, Kim MJ. Effect of renal Doppler ultrasound on the detection of nutcracker syndrome in children with hematuria. Eur J Pediatr 2007;166:399-404.  Back to cited text no. 20
    
21.
Hohenfellner M, Steinbach F, Schultz-Lampel D, Schantzen W, Walter K, Cramer BM, et al. The nutcracker syndrome: New aspects of pathophysiology, diagnosis and treatment. J Urol 1991;146:685-8.  Back to cited text no. 21
    
22.
Hangge PT, Gupta N, Khurana A, Quencer KB, Albadawi H, Alzubaidi SJ, et al. Degree of left renal vein compression predicts nutcracker syndrome. J Clin Med 2018;7:107.  Back to cited text no. 22
    
23.
Takahashi Y, Ohta S, Sano A, Kuroda Y, Kaji Y, Matsuki M, et al. Does severe nutcracker phenomenon cause pediatric chronic fatigue? Clin Nephrol 2000;53:174-81.  Back to cited text no. 23
    
24.
Scultetus AH, Villavicencio JL, Gillespie DL. The nutcracker syndrome: Its role in the pelvic venous disorders. J Vasc Surg 2001;34:812-9.  Back to cited text no. 24
    
25.
Little AF, Lavoipierre AM. Unusual clinical manifestations of the Nutcracker Syndrome. Australas Radiol 2002;46:197-200.  Back to cited text no. 25
    
26.
Mohamadi A, Ghasemi-Rad M, Mladkova N, Masudi S. Varicocele and nutcracker syndrome: Sonographic findings. J Ultrasound Med 2010;29:1153-60.  Back to cited text no. 26
    
27.
Mallat F, Hmida W, Jaidane M, Mama N, Mosbah F. Nutcracker syndrome complicated by left renal vein thrombosis. Case Rep Urol. 2013;2013:168057. doi: 10.1155/2013/168057.  Back to cited text no. 27
    
28.
Fitoz S, Ekim M, Ozcakar ZB, Elhan AH, Yalcinkaya F. Nutcracker syndrome in children. J Ultrasound Med 2007;26:573-80.  Back to cited text no. 28
    
29.
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.  Back to cited text no. 29
    
30.
Nishimura Y, Fushiki M, Yoshida M, Nakamura K, Imai M, Ono T, et al. Left renal vein hypertension in patients with left renal bleeding of unknown origin. Radiology 1986;160:663-7.  Back to cited text no. 30
    
31.
Kim SH, Cho SW, Kim HD, Chung JW, Park JH, Han MC. Nutcracker syndrome: Diagnosis with Doppler US. Radiology 1996;198:93-7.  Back to cited text no. 31
    
32.
Park SJ, Lim JW, Cho BS, Yoon TY, Oh JH. Nutcracker syndrome in children with orthostatic proteinuria: Diagnosis on the basis of Doppler sonography. J Ultrasound Med 2002;21:39-45.  Back to cited text no. 32
    
33.
Ahmed K, Sampath R, Khan MS. Current trends in the diagnosis and management of renal nutcracker syndrome: A review. Eur J Vasc Endovasc Surg 2006;31:410-6.  Back to cited text no. 33
    
34.
Kim KW, Cho JY, Kim SH, Yoon JH, Kim DS, Chung JW, et al. Diagnostic value of computed tomographic findings of nutcracker syndrome: Correlation with renal venography and renocaval pressure gradients. Eur J Radiol 2011;80:648-54.  Back to cited text no. 34
    
35.
Kaneko K, Kiya K, Nishimura K, Shimizu T, Yamashiro Y. Nutcracker phenomenon demonstrated by three-dimensional computed tomography. Pediatr Nephrol 2001;16:745-7.  Back to cited text no. 35
    
36.
Shin JI, Park JM, Lee SM, Shin YH, Kim JH, Lee JS, et al. Factors affecting spontaneous resolution of hematuria in childhood nutcracker syndrome. Pediatr Nephrol 2005;20:609-13.  Back to cited text no. 36
    
37.
Hulsberg PC, McLoney E, Partovi S, Davidson JC, Patel IJ. Minimally invasive treatments for venous compression syndromes. Cardiovasc Diagn Ther 2016;6:582-92.  Back to cited text no. 37
    
38.
Takahashi Y, Sano A, Matsuo M. An effective “transluminal balloon angioplasty” therapy for pediatric chronic fatigue syndrome with nutcracker phenomenon. Clin Nephrol 2000;53:77-8.  Back to cited text no. 38
    
39.
Neste MG, Narasimham DL, Belcher KK. Endovascular stent placement as a treatment for renal venous hypertension. J Vasc Interv Radiol 1996;7:859-61.  Back to cited text no. 39
    
40.
Avgerinos ED, Saadeddin Z, Humar R, Salem K, Singh M, Hager E, et al. Outcomes of left renal vein stenting in patients with nutcracker syndrome. J Vasc Surg Venous Lymphat Disord 2019;7:853-9.  Back to cited text no. 40
    
41.
Wang X, Zhang Y, Li C, Zhang H. Results of endovascular treatment for patients with nutcracker syndrome. J Vasc Surg 2012;56:142-8.  Back to cited text no. 41
    
42.
Baril DT, Polanco P, Makaroun MS, Chaer RA. Endovascular management of recurrent stenosis following left renal vein transposition for the treatment of Nutcracker syndrome. J Vasc Surg 2011;53:1100-3.  Back to cited text no. 42
    
43.
de Macedo GL, Dos Santos MA, Sarris AB, Gomes RZ. Diagnosis and treatment of the Nutcracker syndrome: A review of the last 10 years. J Vasc Bras 2018;17:220-8.  Back to cited text no. 43
    
44.
Pastershank SP. Left renal vein obstruction by a superior mesenteric artery. J Can Assoc Radiol 1974;25:52-4.  Back to cited text no. 44
    
45.
Hohenfellner M, D'Elia G, Hampel C, Dahms S, Thüroff JW. Transposition of the left renal vein for treatment of the nutcracker phenomenon: Long-term follow-up. Urology 2002;59:354-7.  Back to cited text no. 45
    
46.
Kim JY, Joh JH, Choi HY, Do YS, Shin SW, Kim DI. Transposition of the left renal vein in nutcracker syndrome. Eur J Vasc Endovasc Surg 2006;31:80-2.  Back to cited text no. 46
    
47.
Hartung O, Azghari A, Barthelemy P, Boufi M, Alimi YS. Laparoscopic transposition of the left renal vein into the inferior vena cava for nutcracker syndrome. J Vasc Surg 2010;52:738-41.  Back to cited text no. 47
    
48.
Gunka I, Navratil P, Lesko M, Jiska S, Raupach J. Laparoscopic left renal vein transposition for nutcracker syndrome. Ann Vasc Surg 2016;31:209.e1-5.  Back to cited text no. 48
    
49.
Wang P, Jing T, Qin J, Xia D, Wang S. Robotic-assisted laparoscopic transposition of the left renal vein for treatment of the nutcracker syndrome. Urology 2015;86:e27-8.  Back to cited text no. 49
    
50.
Chau AH, Abdul-Muhsin H, Peng X, Davila VJ, Castle EP, Money SR. Robotic-assisted left renal vein transposition as a novel surgical technique for the treatment of renal nutcracker syndrome. J Vasc Surg Cases Innov Tech 2018;4:31-4.  Back to cited text no. 50
    
51.
Jayaraj A, Gloviczki P, Peeran S, Canton L. Hybrid intervention for treatment of the nutcracker syndrome. J Vasc Surg Cases 2015;1:268-71.  Back to cited text no. 51
    
52.
Chuang CK, Chu SH, Lai PC. The nutcracker syndrome managed by autotransplantation. J Urol 1997;157:1833-4.  Back to cited text no. 52
    
53.
Barnes RW, Fleisher HL 3rd, Redman JF, Smith JW, Harshfield DL, Ferris EJ. Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): Repair by a new stenting procedure. J Vasc Surg 1988;8:415-21.  Back to cited text no. 53
    
54.
Wang H, Guo YT, Jiao Y, He DL, Wu B, Yuan LJ, et al. A minimally invasive alternative for the treatment of nutcracker syndrome using individualized three-dimensional printed extravascular titanium stents. Chin Med J (Engl) 2019;132:1454-60.  Back to cited text no. 54
    
55.
Chung BI, Gill IS. Laparoscopic splenorenal venous bypass for nutcracker syndrome. J Vasc Surg 2009;49:1319-23.  Back to cited text no. 55
    
56.
Yih ND, Chyen LH, Cunli Y, Jaywantraj PS, Isip AB, Anil SA. Renosplenic shunting in the nutcracker phenomenon: A discussion and paradigm shift in options? A novel approach to treating nutcracker syndrome. Int J Angiol 2014;23:71-6.  Back to cited text no. 56
    
57.
Xu D, Gao Y, Chen J, Wang J, Ye J, Liu Y. Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome. J Vasc Surg 2013;57:1429-31.  Back to cited text no. 57
    
58.
Gay SB, Armistead JP, Weber ME, Williamson BR. Left infrarenal region: Anatomic variants, pathologic conditions, and diagnostic pitfalls. Radiographics 1991;11:549-70.  Back to cited text no. 58
    
59.
Reed MD, Friedman AC, Nealey P. Anomalies of the left renal vein: Analysis of 433 CT scans. J Comput Assist Tomogr 1982;6:1124-6.  Back to cited text no. 59
    
60.
Park JH, Lee GH, Lee SM, Eisenhut M, Kronbichler A, Lee KH, et al. Posterior nutcracker syndrome – A systematic review. Vasa 2018;47:23-9.  Back to cited text no. 60
    
61.
Gibo M, Onitsuka H. Retroaortic left renal vein with renal vein hypertension causing hematuria. Clin Imaging 1998;22:422-4.  Back to cited text no. 61
    
62.
Skeik N, Gloviczki P, Macedo TA. Posterior nutcracker syndrome. Vasc Endovasc Surg 2011;45:749-55.  Back to cited text no. 62
    




 

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Introduction
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Posterior Nutcra...
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