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Nutcracker Syndrome
Matthew Piotrowski, Sashi Inkollu, Alan Lumsden, Carlos Bechara
Houston Methodist Hospital, Houston, TX

INTRODUCTION: A 31 year old woman with no significant past medical history had been experiencing left sided flank and abdominal pain that radiated down her left posteromedial thigh for a four month period. The pain was worse after prolonged sitting, experienced minimal relief with lying down, and was present all day, not just worse at the end of the day. Additionally, she denies dyspareunia. There were no abnormalities on her complete blood count or basic metabolic panel. Her urinalysis was significant for microscopic hematuria. After seeing a primary care doctor, gastroenterologist, and a gynecologist as well as having a colonoscopy and CT scan, she was diagnosed with pelvic congestion syndrome, and referred to an interventional radiologist for ovarian vein embolization. She sought a second opinion at Houston Methodist Hospital, had a dyna MRI performed, and was determined to have Nutcracker Syndrome.
METHODS: A midline laparotomy incision was made. Once in the abdomen, the transverse colon was elevated and the ligament of Treitz was incised to gain access toward the retroperitoneum. The retroperitoneum was incised to expose the dilated left renal vein. The superior mesenteric artery was carefully retracted, while the renal vein was dissected out to expose the left adrenal vein and posterior lumbar veins. Those veins are ligated to provide length of the renal vein to transpose it to the inferior vena cava (IVC). The gonadal vein is spared. Attention is turned to the proximal renal vein to dissect out its confluence to the IVC. Proximal and distal control of the left renal vein is obtained, a partially occluding clamp is placed on the IVC, and the left renal vein is transected. After closing the IVC with a 4-0 running prolene suture, the partially occluding clamp is moved caudal and a venotomy is made in the IVC and extended with Potts scissors. The left renal vein is anastomosed in an end to side fashion with 5-0 prolene, with the end result being a tension free anastomosis. The abdomen was closed in standard fashion, the patient was extubated, and the patient left the OR without complication.
RESULTS: Her postoperative course was uncomplicated. She had been initiated on a diet by postoperative day 2. She was discharged home on postoperative day 4. She stated that her previous pain was significantly improved.
CONCLUSIONS: Left renal vein transposition is a safe and effective operation for patients with Nutcracker Syndrome.


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