The nutcracker syndrome (NS) is a constellation of symptoms that arise as a result of venous hypertension within the left renal vein (LRV) caused by compression between the superior mesenteric artery (SMA) and the aorta.
We report 18 years old girl with chronic abdominal pain, diagnosed with NS which was treated by endovascular stenting (EVS) with a new adjunct technique of monitoring the SMA angle during the procedure. She presented with lower abdominal pain for 1 year. No symptoms suggestive of Nutcracker Syndrome. Examination was unremarkable. She was extensively investigated. Computed tomography of the abdomen revealed compression of the left renal vein by the superior mesenteric artery and the aorta with varicosities of its tributaries. The superior mesenteric angle calculated on computed tomography scan was 47 degrees. A subsequent selective venogram showed preferential contrast flow into the left lumbar plexus and the left gonadal vein. During the endovascular stenting, the catheter was angled into the superior mesenteric artery origin for angle monitoring. A 14x60 mm self expanding nitinol stent was deployed. Post stenting run showed good stent expansion, no reflux into the left renal vein and an increased superior mesenteric angle to 55 degrees. Post procedure, she recovered well. Her symptom was relieved. 1 year post procedure she remains asymptomatic, no evidence of stent migration with patent non dilated left renal vein.
EVS plus SMA angle monitoring is an attractive inexpensive new technique which can be used but needs further evaluation due to the potential subsequent risk involved.