Anterior nutcracker syndrome. Contrast-enhanced axial and (a) sagittal (b) abdominal computed tomography. In image a, compression of the left renal vein (LRV) between the superior mesenteric artery (SMA) (*) and the abdominal aorta (Ao) is observed, creating a beak-like appearance (double arrows). Image b shows significant narrowing of the LRV secondary to compression CT: Celiac trunk

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... with Nutcracker syndrome, treatment of LOV obstruction secondary to LRV compression should focus on relieving anatomical compression rather than embolization. Symptoms in Nutcracker syndrome patients typically include flank pain and microhematuria. Acute narrowing of the LRV, known as the "beak sign," is a significant diagnostic indicator (Fig. 4). A ratio of the narrowed to the dilated portion of the LRV greater than 4.9 (>4:1 normally) is strongly suggestive of the syndrome. [34] The pressure gradient between the LRV and IVC is generally 1 mmHg or less, although evidence regarding the use of pressure gradients in diagnosis is inconclusive. Different studies have indicated a ...

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... choice between surgical treatment and stenting for Nutcracker syndrome depends on the type of anatomical anomaly. In anterior Nutcracker syndrome, when the LRV is compressed between the superior mesenteric artery and the aorta, placing a stent may be sufficient (Fig. 4). However, in posterior Nutcracker syndrome, where the LRV is compressed between the vertebra and the aorta, surgical transposition may be required to relieve the obstruction. [36] Several methods have been described for the surgical treatment of Nutcracker syndrome. Open surgery can be performed in young women with persistent and ...