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Kidney Week

Abstract: SA-PO379

Nutcracker Syndrome Treatment Complications

Session Information

Category: Trainee Case Report

  • 2000 Women's Health and Kidney Diseases


  • Maditz, Rhyan, Cleveland Clinic, Cleveland, Ohio, United States
  • Taliercio, Jonathan J., Glickman Urological and Kidney Institute, Cleveland, Ohio, United States

Nutcracker syndrome is the clinical manifestation caused by the situation that the left renal vein suffers from pressure when passing through the angle between the abdominal aorta and the superior mesenteric artery. The syndrome is characterized by hematuria, albuminuria, lumbar pain, and varicocele. Indications for surgical treatment include severe unrelenting pain, significant hematuria, renal functional impairment, and inefficacy of conservative treatment after one year.

Case Description

29-year-old female with a past medical history of migraines presented to nephrology clinic for evaluation of fatigue, hematuria, and severe left flank pain. She previously was a healthy endurance athlete. Her left flank pain occurs daily and she describes that pain as 10/10 in severity, debilitating, and sharp. CT kidney/pelvis results with a mild narrowing of the left renal vein as it passes between the SMA and aorta and a 1.4 cm left renal cyst. Renal artery duplex subsequently performed revealed left renal vein proximal narrowing and midsegment dilatation suggestive of Nutcracker phenomenon. Venogram performed revealed a 6 mmHg difference between the IVC and the left renal vein confirming the diagnosis of nutcracker syndrome. Patient underwent a left renal vein to inferior vena cava bypass. Unfortunately, the bypass thrombosed and her pain returned. She is currently being considered for autotransplantation of her left kidney. Risks of autotransplantation include a high risk of left nephrectomy in this patient due to a short renal vein segment.


Management of Nutcracker Syndrome is a challenging endeavor. Non-surgical approaches include observation, especially in patients younger than 18 years of age since increase in intra-abdominal and fibrous tissue at the SMA origin during growth releases the obstruction of the left renal vein. In addition, weight gain increases the retroperitoneal adipose tissue, which leads to change in the positioning of the left kidney with reduction of tension on the left renal vein. Surgery is definitive treatment, but does not come without risks as seen in our patient. Surgical complications include deep venous thrombosis, retroperitoneal hematoma, ileus, and renal vein thrombosis. Complications of surgery should be extensively reviewed with patients prior to surgery. In retrospect, weight gain should have been trialed in this endurance athlete prior to surgical bypass.