A new notable compression source of left renal vein entrapment: right renal artery.

PURPOSE: To estimate the incidences of left renal vein (LRV) entrapment by right renal artery (RRA), a phenomenon primarily reported as case reports. METHODS: The cross-sectional study consecutively screened renal vessel CT data of 38 (Renal) patients with nephropathy and 305 (Non-renal) patients with peripheral arterial diseases in a teaching hospital in northeast China between November 2018 and March 2023. The LRV compression by adjacent anatomical structures, including but not limited to RRA and multiple compression-related parameters, were investigated through multiplanar analysis of the CT data. RESULTS: The overall LRV entrapment rates by adjacent structures were 41.93% (12/31) and 24.00% (6/25), the rates of RRA-sourced LRV compression 22.58% (7/31) and 20.00% (5/25), and the rates of compression by superior mesenteric artery (SMA) 16.13% (5/31) and 4.00% (1/25) in the Renal and Non-renal groups, respectively, with no significance. The venous segments distal to the RRA-compressed site had a significantly larger transectional lumen area than those of the non-compressed veins in both groups (3.09 ± 1.29 vs. 1.82 ± 0.23, p < 0.001 and 4.30 ± 2.65 vs. 2.12 ± 0.55, p = 0.006; maximum-to-minimum area ratios in Renal and Non-renal groups, respectively). Nearly 80% of RRAs were found arising anteriorly rightwards instead of passing straight to the right. CONCLUSION: RRA-sourced LRV compression was not rare, and its incidence was higher than that of the compression by SMA in both patient cohorts. RRA could be a more common compression source than SMA concerning LRV entrapment. Further investigations involving different populations, including healthy individuals, are needed.

Posterior Nutcracker Syndrome Caused by Abdominal Aortic Aneurysm: A Case Report.

Posterior-type nutcracker syndrome (NCS) is a rare disease characterized by the compression of the left renal vein between the aorta and the vertebral body. The optimal management strategy for NCS remains a subject of debate, with surgical intervention being considered for selected patients. Here we report the case of a 68-year-old male who presented with a one-month history of abdominal and flank pain as well as hematuria. Abdominal computed tomography angiography revealed the compression of left renal vein between an abdominal aortic aneurysm (AAA) and the vertebral body. The patient was suspected to have a posterior-type NCS, which significantly improved following open surgical repair of the AAA. In cases of posterior-type NCS, surgical intervention should be performed selectively in symptomatic patients, and open surgery is the preferred treatment modality for this condition. For posterior-type NCS associated with AAA, open surgical repair may represent the optimal choice for decompression of the NCS.

Anterior and Posterior Nutcracker Syndrome Combined with May-Thurner Syndrome: First Report of This Unique Case.

BACKGROUND: Anterior nutcracker syndrome is defined as the compression of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta, whereas posterior nutcracker syndrome refers to the compression of the retroaortic LRV between the aorta and the vertebral column-the presence of the circumaortic left renal vein may predispose to "combined nutcracker syndrome". May-Thurner syndrome consists of obstruction of the left common iliac vein caused by the crossing right common iliac artery. We report a unique case of combined nutcracker syndrome associated with May-Thurner syndrome. CASE PRESENTATION: A 39-year-old Caucasian female came to our radiology unit for triple-negative breast cancer computed tomography (CT) staging. She complained of pain in hermid-back and low-back regions and intermittent abdominal pain in the left flank region. Multidetector computed tomography (MDCT) incidentally revealed a circumaortic left renal vein draining to the inferior vena cava, with bulbous dilatation of both the antero-superior and posterior-inferior branches, which was associated with pathological serpiginous dilation of the left ovarian vein with varicose pelvic veins. Axial CT imaging of the pelvis also showed compression of the left common iliac vein by the overlying right common iliac artery consistent with May-Thurner syndrome without signs of venous thrombosis. CONCLUSION: Contrast-enhanced CT is the best imaging modality for suspected vascular compression syndromes. CT findings showed a combination of anterior and posterior nutcracker syndrome in the left circumaortic renal vein, associated with May-Thurner syndrome, which has not previously been described in the literature.

CT Evaluation of the Findings of Nutcracker Syndrome in Patients with Bladder Cancer after Radical Cystectomy and Ileal Neobladder Formation: A Correlation with Hematuria.

Purpose: Patients with bladder cancer may show hematuria after radical cystectomy with ileal neobladder formation, causing anxiety regarding tumor recurrence. Here, we aim to show that the nutcracker syndrome (NCS) can be a cause of hematuria post-operation, and is a common, rather than a rare syndrome. Materials and Methods: A retrospective review of contrast-enhanced abdominopelvic CT (CE-APCT) and urine analysis (UA) findings of 255 patients with bladder cancer who underwent radical cystectomy and ileal neobladder formation between 2011 and 2016 was performed. In the CE-APCT review, the left renal vein flow patterns were evaluated to determine the presence of NCS findings. In the UA review, patients were classified according to the percentage of UA tests with positive hematuria among the total number of UA tests. Results: CT findings of NCS were present in 31.9% of the 135 patients. In the positive hematuria group, there were 26% more patients with NCS findings than those without. Conclusion: NCS findings are prevalent even for bladder cancer patients after surgery, and there is a strong correlation between NCS findings and hematuria. Furthermore, the prevalence of NCS findings is much higher than urinary tract recurrence after the surgery.

Causa rara de dolor abdominal recurrente; coexistencia del síndrome de Wilkie y el síndrome del cascanueces / A rare cause of recurrent abdominal pain; the coexistence of Wilkie's syndrome and nutcracker syndrome

El síndrome del cascanueces es un síndrome que presenta síntomas clínicos como hematuria, proteinuria ortostática, congestión pélvica, varicocele del lado izquierdo, hipertensión y dolor en fosa renal. Estos síntomas se producen por la compresión de la vena renal izquierda entre la aorta y la arteria mesentérica superior. En el síndrome de Wilkie, la tercera porción del duodeno está comprimida entre la arteria mesentérica superior y la aorta abdominal, lo que provoca diversos síntomas gastrointestinales. La coexistencia de estos dos síndromes constituye una afección rara y se incluye como casos clínicos en la bibliografía. En este artículo, se presentan los resultados clínicos y radiológicos de un paciente de 17 años que presentaba dolor abdominal recurrente debido al síndrome de Wilkie, acompañado del síndrome del cascanueces que le provocaba proteinuria, por lo que el paciente fue derivado a los consultorios externos de reumatología pediátrica con un diagnóstico preliminar de fiebre mediterránea familiar.

Nutcracker syndrome is a syndrome that has clinical symptoms such as hematuria, orthostatic proteinuria, pelvic congestion, left-sided varicocele, hypertension, and flank pain. These symptoms occur because of the compression of the left renal vein between the aorta and the superior mesenteric artery. In Wilkie's syndrome, the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta, causing various gastrointestinal symptoms. The coexistence of these two syndromes is a rare condition and is included as case reports in the literature. This article presents the clinical and radiological results of a 17-year-old male patient who had recurrent abdominal pain due to Wilkie's syndrome, which was accompanied by nutcracker syndrome that caused proteinuria, and for this reason, the patient was referred to the Pediatric Rheumatology outpatient clinic with a preliminary diagnosis of familial Mediterranean fever.

Wilkie's and Nutcracker's syndromes overlapping a case of functional dyspepsia

We present the case of a patient suffering from a mixed-type functional dyspepsia who markedly reduced his diet to improve his symptoms leading him to malnourishment and a subsequent Wilkie's and Nutcracker's syndromes which exacerbated his pain. Our aim by presenting this case is to raise awareness as to what extent a so-called functional dyspepsia can evolve and of the possible overlap with these two entities in case of severe malnutrition.

Presentamos el caso de un paciente diagnosticado de dispepsia funcional de tipo mixto, el cual redujo marcadamente su dieta para mejorar sus síntomas, llevándolo a una desnutrición y a un posterior síndrome de Wilkie y del Cascanueces que agudizó su dolor. Nuestro objetivo con la presentación de este caso es concienciar de hasta qué punto puede evolucionar una denominada dispepsia funcional y del posible solapamiento de estas dos entidades en caso de desnutrición severa.

Systematic review of endovascular versus laparoscopic extravascular stenting for treatment of nutcracker syndrome.

OBJECTIVE: The aim of the present study was to assess the current strategies of endovascular and laparoscopic extravascular stenting for symptomatic compression of the left renal vein (LRV), most frequently between the aorta and superior mesenteric artery (nutcracker syndrome [NCS]). METHODS: We performed a systematic review of all studies of endovascular and laparoscopic extravascular LRV stenting for NCS using the PubMed/MEDLINE, Scopus, Embase, Cochrane, Science Citation Index Expanded, Emerging Sources Citation Index, and Epistemonikos databases. Data were collected in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidelines. The English, Spanish, and German language literature was searched from January 1, 1946 to February 9, 2022. The outcomes assessed included symptom resolution, hematuria resolution, and reintervention at follow-up. RESULTS: The search yielded 3498 reports. After removing the duplicates and those without the full text available, 1724 studies were screened. Of these, 11 studies were included in the present review. Of the 11 studies, 7 were on endovascular stenting and 4 on laparoscopic extravascular stenting; all 11 studies were retrospective, single-center case series. Of the 233 patients, 170 (80 women) had undergone endovascular stenting and 63 (9 women) had undergone extravascular stenting. The follow-up period varied from 1 to 60 months after endovascular stenting and 3 to 55 months after extravascular stenting. The symptoms had resolved in 76% (range, 50%-100%) after endovascular stenting and 83% (range, 71%-100%) after extravascular stenting. Hematuria had resolved in 86% (range, 60%-100%) after endovascular stenting and 89% (range, 77%-100%) after extravascular stenting. Of 185 patients, 9 had required reintervention after endovascular stenting and none after extravascular stenting. CONCLUSIONS: Endovascular and laparoscopic extravascular stenting are less invasive and, thus, more attractive treatment options that have been more recently developed for the management of NCS. The results from the present study have shown that symptom and hematuria resolution must be provided before they can be considered preferred management options for patients affected by NCS. Given the limited number of patients involved, no definitive conclusion could be drawn regarding the superiority of one technique compared with the other.

A rare cause of recurrent abdominal pain; the coexistence of Wilkie's syndrome and nutcracker syndrome. / Causa rara de dolor abdominal recurrente; coexistencia del síndrome de Wilkie y el síndrome del cascanueces.

Nutcracker syndrome is a syndrome that has clinical symptoms such as hematuria, orthostatic proteinuria, pelvic congestion, left-sided varicocele, hypertension, and flank pain. These symptoms occur because of the compression of the left renal vein between the aorta and the superior mesenteric artery. In Wilkie's syndrome, the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta, causing various gastrointestinal symptoms. The coexistence of these two syndromes is a rare condition and is included as case reports in the literature. This article presents the clinical and radiological results of a 17-year-old male patient who had recurrent abdominal pain due to Wilkie's syndrome, which was accompanied by nutcracker syndrome that caused proteinuria, and for this reason, the patient was referred to the Pediatric Rheumatology outpatient clinic with a preliminary diagnosis of familial Mediterranean fever.

El síndrome del cascanueces es un síndrome que presenta síntomas clínicos como hematuria, proteinuria ortostática, congestión pélvica, varicocele del lado izquierdo, hipertensión y dolor en fosa renal. Estos síntomas se producen por la compresión de la vena renal izquierda entre la aorta y la arteria mesentérica superior. En el síndrome de Wilkie, la tercera porción del duodeno está comprimida entre la arteria mesentérica superior y la aorta abdominal, lo que provoca diversos síntomas gastrointestinales. La coexistencia de estos dos síndromes constituye una afección rara y se incluye como casos clínicos en la bibliografía. En este artículo, se presentan los resultados clínicos y radiológicos de un paciente de 17 años que presentaba dolor abdominal recurrente debido al síndrome de Wilkie, acompañado del síndrome del cascanueces que le provocaba proteinuria, por lo que el paciente fue derivado a los consultorios externos de reumatología pediátrica con un diagnóstico preliminar de fiebre mediterránea familiar.

An Unusual Cause of Abdominal Pain in a Middle-Aged Female: The Nutcracker Syndrome.

A middle-aged female presented with lower abdominal pain associated with nausea and vomiting and was admitted to the acute hospital. She was thoroughly investigated and treated presumably as having a urinary tract infection. However, she was admitted again shortly after discharge with persistent symptoms. A careful evaluation and review were done, and she was diagnosed with nutcracker syndrome based on the clinical assessment, computed tomography (CT), and ultrasound (US) findings.

Daily persistent headache with nutcracker physiology and spinal epidural venous congestion: Treatment with lumbar vein embolization.

Nutcracker phenomenon (NCP) can cause various congestion syndromes secondary to the superior mesenteric artery (SMA) compressing the left renal vein (LRV) resulting in venous reflux. It has recently been suggested that reflux into the lumbar vein (LV) and epidural venous plexus (EVP) may cause headaches in some patients with NCP. This report illustrates an example of a patient with refractory headaches and imaging findings suggestive of NCP that underwent treatment with percutaneous LV embolization. The patient is a 60-year-old female with daily persistent headaches for 5 years that failed numerous headache preventative medications. Time-resolved magnetic resonance angiography demonstrated NCP with reflux and congestion of the LV and EVP. Catheter-based venography confirmed these findings and the patient was treated with percutaneous embolization of the LV. This case report demonstrates the use of LV embolization to prevent EVP reflux and treat daily headaches due to NCP. The patient's headache resolved the next day. She has been headache-free for 5 months post-treatment. These findings support prior data suggesting that NCP can cause retrograde LV flow, EVP congestion, and elevated cerebrospinal fluid pressures leading to daily persistent headaches. Percutaneous embolization of the LV may be a minimally invasive treatment option for refractory headaches in patients with NCP, retrograde LV flow, and EVP congestion.

Surgical Treatment of Wilkie's Syndrome by Vascular Transposition.

Introduction Superior mesenteric artery syndrome (SMAS), also called mesenteric duodenal compression syndrome, Wilkie's syndrome, chronic duodenal ileus or cast syndrome, is a rare clinical condition defined as a compression of the third portion of the duodenum in between the SMA and abdominal aorta (AA), due to narrowing of the space between them. SMAS is primarily attributed to loss of the intervening mesenteric fat pad, leading to partial or complete duodenal obstruction. Its manifestations are complex and non-specific, including postprandial epigastric pain, nausea, vomiting, early satiety, weight loss and anorexia. SMAS may present as an acute syndrome, or it may have an insidious onset with chronic symptoms. SMAS mainly affects females between 10 and 40 years of age. This study aims to discuss the safety and efficacy of vascular decompression of the duodenum by infrarenal transposition of SMA. Methods This single-centre prospective clinical study analysed 37 patients with Wilkie's syndrome who underwent infrarenal transposition of the SMA between January 2012 and December 2021. The indications for the surgery were severe weight loss, uncontrolled upper abdominal pain, vomiting and other gastrointestinal (GI) symptoms that were severely debilitating to patients' daily lives, along with radiological findings such as aortomesenteric angle < 25°, aortomesenteric distance <8 mm and distention of proximal part of the duodenum and the stomach. Ten patients (27%) concurrently had Nutcracker syndrome and seven patients (18.9%) had Dunbar syndrome (median arcuate ligament syndrome). Three female patients (8.1%) had all three above-mentioned vascular compression syndromes, which were treated in the same surgery. One male patient (2.7%) was after a laparoscopic duodenojejunostomy with symptoms that relapsed three months postoperatively, which was cured after the infrarenal transposition of SMA. Results Technical operative and clinical success were achieved in all patients. There were no cases of anastomotic failure, SMA thrombosis or intestinal ischemia. All of the patients are currently living symptom-free. One patient (2.7%), four days postoperatively, had a lymphocele formed in the retroperitoneum, which was successfully drained by a CT-guided percutaneous pigtail catheter. Another patient (2.7%) after three months of surgery needed a re-laparotomy for adhesive obstruction of the second part of the duodenum and was treated by adhesiolysis and omentoplasty. One patient (2.7%), 2-year postoperatively, had a proximal SMA stenosis up to 60% where drug-eluting balloon percutaneous transluminal angioplasty (DEB PTA) was performed successfully. Finally, the upper GI symptoms were resolved in all 37 patients (100%). Conclusion Wilkie's syndrome, although rare, is frequently late-diagnosed or underdiagnosed. In cases of failure of conservative therapy, infrarenal transposition of the SMA can be considered a safe and feasible surgical option with more physiologically favourable outcomes comparable to gastrointestinal bypasses, especially in patients concurrently suffering from Nutcracker syndrome. Simultaneously, it also restores physiologic duodenal passage of gastroduodenal content without the need of creating a digestive tract anastomosis. To our best knowledge, we have the highest number of SMA transposition surgeries performed in a single centre for the treatment of Wilkie's syndrome.

Vascular compression syndromes: the value of Doppler ultrasonography.

Vascular compression syndromes arise when a vessel in a tight anatomic space is entrapped by another structure, resulting in diverse symptoms for which different imaging tests are used to diagnose. Radiologists need to be familiar with vascular compression syndromes and to be able to identify their most representative findings. This paper aims to review the principal symptoms of vascular compression, describing and illustrating the key findings on Doppler ultrasonography that enable accurate diagnosis and guide further workup, avoiding unnecessary invasive tests and pointing to the appropriate treatment.

Fortuitous Discovery of Nutcracker Syndrome During Acute Appendicitis: A Case Report.

Nutcracker syndrome (NCS) belongs to a group of rare vascular disorders. It refers to compression of the left renal vein (LRV) generally between the abdominal aorta (AA) and the superior mesenteric artery (SMA). It is one of the most unknown causes of chronic abdominal pain. Herein, we present the case of a young patient who came to the emergency department for acute abdominal pain. Patient's history revealed an uncharacterized chronic epigastric pain evolving for 13 years. The imaging showed acute appendicitis and NCS; the latter finding was the principal explanation for the patient's chronic pain. We hope that the concise and synthetized structure of this case report will help physicians acquire the necessary reflexes to notice and diagnose this already underdiagnosed syndrome.

Atypical Posterior Nutcracker Syndrome in a 17-Year-Old Male Without Hematuria.

Retro-aortic left renal vein (RLRV) is an anatomical variation, where the left renal vein (LRV) courses posterior to the aorta and anterior to the vertebrae before it eventually drains into the inferior vena cava (IVC). RLRV is a rare finding, with a prevalence of around 1%-2%, and only a small minority of RLRVs cause symptoms. RLRV symptoms occur secondary to compression of the LRV between the abdominal aorta and vertebrae, otherwise known as posterior nutcracker syndrome (PNCS). The most common symptoms of PNCS are hematuria and flank pain. We present a 17-year-old male, who came in with recurring left flank pain without hematuria, initially thought to be renal colic secondary to nephrolithiasis. On further investigations, an aberrant posterior renal vein was seen on CT suggestive of PNCS. The patient was treated successfully with RLRV vascular stent placement by interventional radiology. This case report adds to the limited number of PNCS cases observed in children and to the even rarer cases of PNCS without hematuria. This case also acts as a reminder for pediatricians to keep a wide scope of differentials in patients presenting with flank pain and provides an outline of both diagnostic and treatment modalities available for these patients.

Splenic vein enlargement, a rare cause of nutcracker syndrome.

Abnormal enlargement of the splenic vein is one of the etiologies of nutcracker syndrome that should be considered when examining the causes of this syndrome. Because knowing rare etiologies can help correct diagnose and reduce mortality.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

[Box: see text]With the support of the American College of Obstetricians and Gynecologists, the American Vein & Lymphatic Society, the American Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and Interventional Radiology Society of Europe, the European Venous Forum, the International Pelvic Pain Society, the International Union of Phlebology, the Korean Society of Interventional Radiology, the Society of Interventional Radiology, and the Society for Vascular Surgery.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVPA,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Hematúria levando ao diagnóstico de duas condições singulares na prática clínica - síndrome de quebra-nozes e traço falcêmico: um relato de caso / Hematuria leading to the diagnosis of two singular conditions in clinical practice - renal nutcracker syndrome and sickle cell trait: a case report

RESUMO: A hematúria é definida como o achado de mais que duas hemácias por campo de aumento na análise microscópica de urina coletada por jato médio. Na sua forma macroscópica, caracteriza-se por sua coloração típica (avermelhada ou marrom), acompanhada pela presença de mais de 106 hemácias/ml na sedimentoscopia. É uma condição que necessita de investigação da causa e apresenta-se com prevalência incerta e definição às vezes imprecisa, mas com vasto diagnóstico diferencial. Dentre as possíveis causas, encontramos a presença do traço falciforme, aparentemente subdiagnosticado, e a síndrome de quebra-nozes, possibilidade mais rara. No caso relatado a seguir, foram diagnosticadas simultaneamente as duas causas acima citadas, descobertas após a investigação do primeiro episódio de hematúria macroscópica em uma mulher jovem previamente hígida. Com o objetivo de chamar a atenção para a concomitância de duas possíveis e incomuns causas de hematúria numa mesma paciente, relatamos o caso a seguir. (AU)

ABSTRACT: Hematuria is defined as the finding more than two red blood cells per field of analysis in the microscopic analysis of the urine collected by the medium jet. In its macroscopic form, it is characterized by its typical coloration (reddish or brown), accompanied by the presence of more than 106 red cells/ml in urinary sediment. It is a condition that needs investigation and it presents itself sometimes with imprecise definition, but with vast differential diagnosis. Among the possible etiologies, there is the presence of the sickle cell trait, apparently underdiagnosed, and the renal nutcracker syndrome, a rarer possibility. In the case reported below, these two findings were diagnosed simultaneously, following an investigation of the first episode of macroscopic hematuria in a young and previously healthy woman. In order to draw attention to the simultaneous presence of two unusual causes of hematuria in the same patient, we report the following case. (AU)

Spontaneous spermatic vein thrombosis in pediatric patients: A condition to be considered. / Trombosis espontánea de la vena espermática en la edad pediátrica: una entidad a tener en cuenta.

Spermatic vein thrombosis is a very rare pathology, with 25 cases published only, 6 of which in patients under 15 years of age. We present the case of a male patient, as well as a review of the literature. A 12-year old boy presented at emergency with 3-day progressive testicular pain. Following abdominal Doppler ultrasound imaging, he was diagnosed with left spermatic vein thrombosis and nutcracker syndrome. Admission and enoxaparin treatment were decided upon. Patient evolution was satisfactory, with subsequent ultrasound imaging demonstrating the absence of thrombus. The patient is currently under follow-up and without treatment. Various treatments are mentioned in the literature, with conservative management being the treatment of choice.

La trombosis de la vena espermática es una patología muy poco frecuente, con solo 25 casos publicados, 6 de los cuales menores de 15 años. De esta manera presentamos el caso de un varón, así como la revisión de la literatura. Un paciente de 12 años de edad acudió a Urgencias por dolor testicular de aumento progresivo, de 3 días de evolución. Mediante ecografía doppler abdominal se diagnosticó de trombosis de la vena espermática izquierda y síndrome de cascanueces. Se decidió ingreso y tratamiento con enoxaparina. La evolución del paciente fue satisfactoria, en la ecografía posterior se observó la desaparición del trombo. El paciente se encuentra en seguimiento y sin tratamiento. Existen varios tratamientos reflejados en la literatura, siendo el de elección el manejo conservador.

Robotic assisted extravascular stent placement for nutcracker phenomenon of the left renal vein: a case series.

Nutcracker phenomenon of the left renal vein is a rare anatomic anomaly that can present with chronic flank/pelvic pain, pelvic congestion, and hematuria. Conventional treatment options (superior mesenteric artery transposition, endovascular stent placement, auto-transplantation) involve substantial risk, morbidity, or the need for chronic anti-coagulation. We now report our institution's robotic experience with extravascular left renal vein stent placement. A retrospective, single surgeon series from December 2016 to May 2019 was reviewed. After positioning and port placement (three robotic ports, one assistant), the left renal vein was exposed and dissected free circumferentially down to the inferior vena cava insertion. The distance between the renal vein ostium and adrenal vein was measured and a 1 cm-diameter ringed polytetrafluoroethylene vascular stent of this length placed. The stent edges were secured to itself with 3-0 polyglactin sutures. Demographics, surgical, and functional outcomes were collected. Six patients with mean age of 45 ± 6 years and body mass index of 20.3 ± 3.3 g underwent the procedure. Mean operative time was 143 ± 20 min. Estimated blood loss was minimal. Mean graft length utilized was 2.25 ± 0.3 cm. Median day of discharge was 1.5 days (range 1-3). No high-grade complications occurred. All patients received immediate pain relief and 50% also saw other symptomatic improvements. Robotic assisted extravascular left renal vein stent placement appears safe and effective in a small cohort with short follow-up. Further long-term follow-up for pain relief and graft-related complications are needed.