Fellows Course Case: Nutcracker Syndrome and Renal Vein Stenting

A Classic Nutcracker Syndrome Presentation

A 48 year old woman with pelvic varicosities, dyspareunia, flank pain, and hematuria, previously treated with hysterectomy for presumed endometriosis, showed the classic beak sign on CT venogram, with the left renal vein compressed between the mesenteric artery and aorta.

Treatment with Coil Embolization and Renal Vein Stenting

Faculty treated the collateralized ovarian vein with coil embolization causing controlled thrombosis, then used intravascular ultrasound to confirm renal vein compression and deployed a stent, emphasizing that patients typically gain considerable but not complete symptom improvement.

Why Pediatric Nutcracker Syndrome Is Rarely Treated

Panelists argued against treating pediatric nutcracker syndrome, noting sizing a stent in a growing child is impractical and that symptoms often improve as the fat pad between the SMA and aorta develops, with flank pain sometimes migrating toward pelvic congestion over time.

Weighing Stenting, Open Surgery and Staged Treatment

Faculty noted open surgical correction fails in roughly a third of patients within two years, warned stent undersizing risks migration, and favored staging coil embolization or stenting first to treat the underlying etiology before adding further procedures.