Left Renal Vein Compression Syndrome: Cracking the Nut of Clinical Dilemmas – Three Cases and Review of Literature

摘要

Objective: Unusual clinical course Background: The term nutcracker phenomenon (NCP) elucidates anatomical structure and hemodynamics, whereas nut-cracker syndrome (NCS) refers to clinical manifestations. We present three cases of similar clinical features of hematuria and flank pain with different clinical outcomes. Care Report: Case 1: A 36-year-old Caucasian female with a past medical history (PMH) of HIV infection presented for eval- uation of hematuria. Computed tomography (CT) without contrast showed pelvic venous congestion and nar- rowing of the extra-renal left renal vein (LRV). After the failure of conservative management, renal auto-trans- plantation was attempted but failed because of extensive venous collateral; the patient subsequently required a total hysterectomy due to recurrence of symptoms. Case 2: A 41-year-old Caucasian female with extensive PMH presented with chronic abdominal pain. A CT scan of the abdomen and pelvis showed pelvic venous con- gestion. The patient underwent angioplasty and stent placement of the LRV. Subsequently, a left ovarian vein embolization was performed. On follow-up visits, her symptoms improved. Case 3: A 36-year-old female with PMH of HIV infection, gastroesophageal reflux disease, and hypertension presented with hematuria and flank pain. Her venogram revealed 1 mm Hg pressure gradient across stenosis, suggestive of LRV hypertension. Over the months of her follow-up after discharge, her hematuria gradually decreased from daily to intermittent non- daily frequency, without any intervention. Conclusions: The treatment of NCS includes observation, percutaneous angioplasty, open or endovascular surgery, or ne- phrectomy. In patients younger than 18 years of age, the best option is a conservative approach with observa- tion for at least two years, as approximately 75% of patients have complete resolution of hematuria.