Condition – Rare Venous Problems

Rare Venous Problems

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Nutcracker syndrome or renal vein entrapment syndrome, occurs when the arteries near the kidney compress the left renal vein.

It gets its name because this compression is like a nutcracker crushing a nut.

There are 2 types:

  • Anterior nutcracker syndrome, is the most common and occurs when the normally-placed left renal vein is compressed between the abdominal aorta and the superior mesenteric artery.
  • Posterior nut cracker syndrome occurs when the left renal vein is compressed between an artery (usually the abdominal aorta) and the bones of the spine.

It is postulated that the compression of the left renal vein increases blood flow in other nearby veins and their engorgement causes the symptoms such as flank pain and blood in urine.

Nutcracker syndrome risk factors and prognosis

Nutcracker syndrome is a rare disorder that can affect adults or children, though the prevalence and specific causes are unknown.

It’s more common in women in their 30s and 40s who are tall and slim. Symptoms may appear after rapid weight loss.

Nutcracker syndrome is not hereditary, though it may be triggered by multiparity or pregnancy.

The prognosis for renal nutcracker syndrome is unclear.

In some cases, more commonly in children, it can resolve spontaneously.

However, without treatment, it is suggested it may predispose a person to left renal vein thrombosis and kidney damage. In cases presenting with hematuria, it can lead to anemia

Nutcracker syndrome symptoms

Nutcracker syndrome symptoms are many and very variable in severity. They can be asymptomatic especially in children. Symptoms are often worsened by physical activity.

The most common symptoms of nutcracker syndrome include:

  • Flank pain (abdominal pain).
  • Blood in urine (hematuria).
  • Venous pelvic congestion symptoms in women, (pain and heaviness in the pelvis or genital area, pain during sexual intercourse, Severe menstrual cramping, Gluteal and vulvar varicose veins ).
  • Men may develop varicoceles.

Other symptoms of nutcracker phenomenon can include:

  • Leg Varicose veins.
  • Painful urination.
  • Low energy
  • orthostatic intolerance (light-headedness or palpitations when standing upright).

Nutcracker Syndrome Investigations

Initialy a duplex ultrasound scan is undertaken, a CT venogram is then considered

Nutcracker Syndrome Treatment

The best treatment for renal nutcracker syndrome is controversial.

Nutcracker syndrome treatments can vary based on age, symptoms, and their severity.

In mild symptoms no treatment is needed.

Invasive treatment can involve endovenous stenting or surgery.

In this CT venogram the left renal vein is enlarged by compression between the aorta and the superiormesenteric artery.


Daryll Baker is a Consultant Vascular Surgeon at the Royal Free Hospital London and Clinical Lead for North Central Region Vascular Services.

He read Medicine at Oxford University and trained in Vascular Surgery in Nottingham, London and Edinburgh. He obtained his research PhD from the University of Wales.


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