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Mixed nutcracker syndrome with left renal vein duplication: A severe and exceptional presentation in an 18-year-old boy.

Mallat F, Hmida W, Othmen MB, Mosbah F - Urol Ann (2015 Apr-Jun)

Bottom Line: Ultimately it may be associated with substantial morbidity and even life-threatening events.Our purpose is to raise clinician's awareness for this condition so that they will be more likely to diagnose it.This will facilitate prompt diagnosis and treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Hospital of Sahloul, Sousse, Tunisia.

ABSTRACT
The nutcracker syndrome (NCS) is rare and often misdiagnosed because it embraces an extended non-pathognomonic spectrum of symptoms that imply a difficult diagnosis. Ultimately it may be associated with substantial morbidity and even life-threatening events. Mixed NCS with renal vein duplication is an exceptional variety, have previously been reported to the best of our knowledge. We report a rare case of an 18-year-old boy who presented with a long history of abdominal, pelvic and left flank pain, fatigue and higher bilateral varicocele. Computed tomographic angiography, Doppler ultrasonography and venography were performed revealed left renal vein duplication with dilated retroaortic and preaortic branchs, entrapped respectively between the aorta and the vertebral column and in the aortico-mesenteric space, with extensive and complex varices of the deep pelvic venous plexus; promoting the mixed renal NCS. Auto transplantation of the left kidney was suggested, but refused by the patient; and only the varicocele was managed. The patient is still suffering from his severe initial symptoms. Diagnosis is difficult and should be considered in patients with inexplicable flank or abdominal pain. Our purpose is to raise clinician's awareness for this condition so that they will be more likely to diagnose it. This will facilitate prompt diagnosis and treatment.

No MeSH data available.


Related in: MedlinePlus

Diagnostic phlebography (left) with a 4F cobra catheter. Higher grade pelvic varicosities with contralateral filling of the left spermatic vein and confirmed the extrinsic compression of the two branchs of the LRV with spermatic and collaterals venous reflux
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Figure 5: Diagnostic phlebography (left) with a 4F cobra catheter. Higher grade pelvic varicosities with contralateral filling of the left spermatic vein and confirmed the extrinsic compression of the two branchs of the LRV with spermatic and collaterals venous reflux

Mentions: Surgery for NCS by auto transplantation of the left kidney was suggested; however, the patient refused and was referred to the vascular and endovascular surgery service to evaluate the possibility of a minimally invasive treatment of varicocele such as a radiologic embolization. He was then submitted to venography, Through a puncture of the femoral vein, the LRV was catheterized showing clamping of the two LRV branchs, with a significant increase in its proximal diameter, besides extensive varices of the deep pelvic venous plexus, with inverted venous reflux in the left spermatic vein, which also had a diameter about 2-3 times larger than expected [Figures 5 and 6]. Endovascular therapeutic alternative was initially suggested by left anterograde embolization of varicocele and embolization of pelvic varices. However, this alternative has not been made because of the principal spermatic vein and the collateral veins were impossible to cannulate and because of the high occurrence of vital complications. And the patient was lost to follow up thereafter.


Mixed nutcracker syndrome with left renal vein duplication: A severe and exceptional presentation in an 18-year-old boy.

Mallat F, Hmida W, Othmen MB, Mosbah F - Urol Ann (2015 Apr-Jun)

Diagnostic phlebography (left) with a 4F cobra catheter. Higher grade pelvic varicosities with contralateral filling of the left spermatic vein and confirmed the extrinsic compression of the two branchs of the LRV with spermatic and collaterals venous reflux
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4374268&req=5

Figure 5: Diagnostic phlebography (left) with a 4F cobra catheter. Higher grade pelvic varicosities with contralateral filling of the left spermatic vein and confirmed the extrinsic compression of the two branchs of the LRV with spermatic and collaterals venous reflux
Mentions: Surgery for NCS by auto transplantation of the left kidney was suggested; however, the patient refused and was referred to the vascular and endovascular surgery service to evaluate the possibility of a minimally invasive treatment of varicocele such as a radiologic embolization. He was then submitted to venography, Through a puncture of the femoral vein, the LRV was catheterized showing clamping of the two LRV branchs, with a significant increase in its proximal diameter, besides extensive varices of the deep pelvic venous plexus, with inverted venous reflux in the left spermatic vein, which also had a diameter about 2-3 times larger than expected [Figures 5 and 6]. Endovascular therapeutic alternative was initially suggested by left anterograde embolization of varicocele and embolization of pelvic varices. However, this alternative has not been made because of the principal spermatic vein and the collateral veins were impossible to cannulate and because of the high occurrence of vital complications. And the patient was lost to follow up thereafter.

Bottom Line: Ultimately it may be associated with substantial morbidity and even life-threatening events.Our purpose is to raise clinician's awareness for this condition so that they will be more likely to diagnose it.This will facilitate prompt diagnosis and treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Hospital of Sahloul, Sousse, Tunisia.

ABSTRACT
The nutcracker syndrome (NCS) is rare and often misdiagnosed because it embraces an extended non-pathognomonic spectrum of symptoms that imply a difficult diagnosis. Ultimately it may be associated with substantial morbidity and even life-threatening events. Mixed NCS with renal vein duplication is an exceptional variety, have previously been reported to the best of our knowledge. We report a rare case of an 18-year-old boy who presented with a long history of abdominal, pelvic and left flank pain, fatigue and higher bilateral varicocele. Computed tomographic angiography, Doppler ultrasonography and venography were performed revealed left renal vein duplication with dilated retroaortic and preaortic branchs, entrapped respectively between the aorta and the vertebral column and in the aortico-mesenteric space, with extensive and complex varices of the deep pelvic venous plexus; promoting the mixed renal NCS. Auto transplantation of the left kidney was suggested, but refused by the patient; and only the varicocele was managed. The patient is still suffering from his severe initial symptoms. Diagnosis is difficult and should be considered in patients with inexplicable flank or abdominal pain. Our purpose is to raise clinician's awareness for this condition so that they will be more likely to diagnose it. This will facilitate prompt diagnosis and treatment.

No MeSH data available.


Related in: MedlinePlus