From Nutcracker Phenomenon to Nutcracker Syndrome: A Pictorial Review

Pelvic Varicose Veins in Women. Russian Experts Consensus

Pelvic Varicose Veins in Women. Russian Experts Consensus.

Treatment rationale in nutcracker syndrome with concurrent pelvic congestion syndrome

The optimal management strategy of nutcracker syndrome is debated, especially in the setting of concurrent pelvic congestion syndrome. In this article, we describe our treatment algorithm as illustrated by four different case scenarios. In our experience, renocaval pressure gradients are often inconclusive, but evaluation of the left renal vein waveform as well as a "test PTA" with evidence of a waist in the balloon can be helpful in unmasking a relevant stenosis. We consider nutcracker syndrome not to be a contraindication for ovarian vein embolization. Decision for simultaneous or sequential stenting should be based on angiographic findings and clinical course.

Establishment and analysis of an animal model for nutcracker syndrome

BACKGROUND

This study investigated the effects of renal vein congestion of varying durations on kidney damage by establishing an animal model of Nutcracker Syndrome (NCS). In addition, we assessed whether renal damage improved after relieving the congestion.

METHOD

We established a rat model of NCS and relieved renal congestion through secondary surgery, with renal vein reperfusion confirmed by animal ultrasound. Histopathological changes in congested kidneys were evaluated at 3, 6, and 9 days using HE and Masson staining, and the expression of renal injury factors was determined using q-PCR.

RESULTS

Renal tissue pathology changes were evident with prolonged obstruction time. Compared to the sham-operated group, no apparent fibrosis was observed in the kidneys at 3 days post-congestion, whereas fibrosis was most severe at 9 days post-congestion, with no significant improvement observed even after blood flow restoration. Six days post-congestion relief, some alleviation of renal fibrosis occurred. q-PCR results indicated a significant reduction in the expression of fibrosis markers after 3 or 6 days of renal vein ligation release. Following blood flow restoration on the 9th day post-congestion, no significant changes in fibrosis markers were noted.

CONCLUSION

Prolonged renal vein congestion in a rat model of NCS resulted in severe kidney damage and significant fibrosis after 9 days. While relieving congestion within 6 days led to some improvement, no reduction in fibrosis occurred after 9 days, underscoring the importance of congestion duration in renal pathology.

Retroaortic Left Renal Vein: A Case Report

A retroaortic left renal vein (RLRV) is the term applied to a left renal vein that passes posterior to the abdominal aorta. Typically, the left renal vein traverses horizontally, passing anterior to the abdominal aorta and inferior to the superior mesenteric artery (SMA), before draining into the medial side of the inferior vena cava (IVC). Here, we present a case highlighting type I of the four distinct retroaortic variations observed in the left renal vein. Its prevalence is often underrepresented in medical education despite a clinically significant prevalence in the general population. It is crucial to possess preoperative awareness of this variant to mitigate potential complications linked to vascular damage to the RLRV. These complications encompass severe hemorrhage, renal injury, the necessity for nephrectomy, and, in extreme cases, fatal outcomes during retroperitoneal surgery or interventional procedures. This case report aims to emphasize the significance of incorporating RLRV anomalies into medical education to improve clinical awareness and diagnostic accuracy. The RLRV discussed in this case report was discovered posthumously in an anatomical donor.

Coexisting nutcracker phenomenon and refractory hypertension in a patient with IgA nephropathy: A case report and literature review

The entrapment of the left renal vein (LRV) may contribute to changes in hemodynamics within kidney and could also be associated with IgA nephropathy (IgAN). Although the relationship between the nutcracker phenomenon and IgAN has not yet been elucidated, it is speculated that this patient's refractory hypertension is a combined effect of nutcracker syndrome (NCS) and IgAN.

A unique posterior nutcracker syndrome combined with Wilkie syndrome: A singular case

Left renal vein variants are not commonly observed in the general population. Usually, the renal vein runs in front of the aorta before entering the inferior vena cava, while the most common variants include the presence of a circumaortic or retroaortic renal vein. However, when present, left venal rein variants are important to recognize due to their potential clinical and surgical relevance. In this regard, CE-CT is an instrument with high sensitivity and specificity in detecting vascular anomalies and can certainly help diagnose. In this article, we present a unique case of a left venal rein compressed between the left iliac artery and vertebral bodies associated with the presence of a superior mesenteric artery Syndrome, another rare entity that occurs when the duodenum is compressed between the aorta and the superior mesenteric artery.

Outcomes of conservative management in patients with nutcracker syndrome

OBJECTIVE

This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions.

METHODS

This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms.

RESULTS

Sixteen patients (75% female and mean age 24.4 ± 3.5 years) underwent conservative management. Over a mean follow-up of 27.3 months [13-42, interquartile range (IQR)], the diameter ratio (5.5 [5-6.5, IQR] vs 4.3 [4.1-6], p = NS), the peak velocity ratio (6 [5-7, IQR] vs 4.8 [4.8-5.8], p = NS), beak angle (27° [24-30, IQR] vs 29° [24-32]; p = NS), and aortomesenteric angle (26° [23-29, IQR] vs 28° [24-30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged.

CONCLUSIONS

This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms.

Nutcracker syndrome: a case-based review

The nutcracker phenomenon, also known as left renal vein entrapment, occurs when there is extrinsic compression of the left renal vein, most often between the abdominal aorta and the superior mesenteric artery. Nutcracker syndrome refers to the constellation of clinical symptoms that may arise from the nutcracker phenomenon, typically inclusive of haematuria, flank/pelvic pain, orthostatic proteinuria and (in male patients) varicocele. We provide a short review of the nutcracker syndrome including various diagnostic and therapeutic modalities. We utilise our own experience with a patient as a case study and highlight the modern management option of endovascular stenting.

Hemodynamics in nutcracker syndrome: implications for diagnosis

BACKGROUND

Nutcracker syndrome is a disease characterized by complex symptoms, making its diagnosis challenging and often delayed, often resulting in a painful experience for the patients.

OBJECTIVE

This study aimed to investigate the pathogenesis of nutcracker syndrome through the perspective of hemodynamics by simulating blood flow with varying compression degrees of the left renal vein.

METHODS

3D patient-specific vascular models of the abdominal aorta, superior mesenteric artery and left renal vein were constructed based on CT images of patients suspected of having nutcracker syndrome. A hemodynamic simulation was then conducted using computational fluid dynamics to identify the correlation between alterations in hemodynamic parameters and varying degrees of compression.

RESULTS

The study indicated the presence of an evident gradient in velocity distribution over the left renal vein with relatively high degrees of stenosis (α ≤ 50°), with maximum velocity in the central region of the stenosis. Additionally, when the compression degree of the left renal vein increases, the pressure distribution of the left renal vein presents an increasing number of gradient layers. Furthermore, the wall shear stress shows a correlation with the variation of blood flow velocity, i.e., the increase of wall shear stress correlates with the acceleration of the blood flow velocity.

CONCLUSIONS

Using computational fluid dynamics as a non-invasive instrument to obtain the hemodynamic characteristics of nutcracker syndrome is feasible and could provide insights into the pathological mechanisms of the nutcracker syndrome supporting clinicians in diagnosis.

Bilateral Renal Hilar Nutcracker Phenomenon in a Male Cadaver

Nutcracker phenomenon (NCP) typically refers to the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. Similar to the classic NCP, the renal vein can also get entrapped between the segmental branches of the renal artery at the renal hilum, which has been referred to as 'renal hilar nutcracker phenomenon (RHNP).' During routine dissection of a male cadaver of 67 years, the renal veins of both sides at the renal hilum were seen between the segmental branches of renal arteries, which we identified as the 'renal hilar nutcracker phenomenon.' The disposition of the rest of the perihilar structures was normal. 'Renal hilar nutcracker phenomenon' can have similar clinical presentation like that of the nutcracker phenomenon. Hence, knowledge of such anatomical variation at the renal hilum is desirable.

Ultrasound characteristics of abdominal vascular compression syndromes

Abdominal vascular compression syndrome (AVCS) is caused by the compression of abdominal blood vessels by adjacent structures or the compression of abdominal organs by neighboring blood vessels. Such compressions can result in a variety of clinical symptoms. They are not commonly seen in ultrasound practices, and their presence may have been underrecognized and underdiagnosed. This article reviews the clinical features, ultrasound characteristics, and diagnostic criteria of four types of AVCS, namely, celiac artery compression syndrome, renal vein compression syndrome, iliac vein compression syndrome, and superior mesenteric artery syndrome to increase awareness of these conditions among ultrasound practitioners. The ultrasound criteria for AVCS are primarily based on studies with small sample sizes, and therefore, it is important to exercise caution if these criteria are used.

Venous compression syndromes in females: A descriptive review

Venous compression syndromes have been described, yet the role of sex is poorly understood. Although iliac vein compression has been discussed more often with the advent of newer technologies, research has fallen short on defining epidemiology, best practices for evaluation and treatment, and differences in responses to treatment between men and females. The authors report on iliac vein compression, nonthrombotic renal vein compression, and other venous compression syndromes in females. Literature searches of PubMed were performed using the following keywords: females/females and May Thurner, venous stenting, venous outcomes, deep venous disease, deep venous compression, venous stenting, renal vein compression, renal vein surgery/stent, popliteal vein entrapment, venous thoracic vein entrapment, and popliteal vein entrapment. The articles prompted the authors to research further as the referenced articles were reviewed. Sex representation has not been addressed adequately in the research of venous compression syndromes, making the discussion of best treatment options and long-term outcomes difficult. More specific understanding of epidemiology and response to interventions will only come from research that addresses these issues directly, understanding that some of these syndromes occur rarely.

Atypical case of coexistent vascular compression syndromes: median arcuate ligament syndrome and nutcracker syndrome

Vascular compression syndromes, including median arcuate ligament syndrome (MALS) and nutcracker syndrome (NCS), are poorly understood and frequently delayed diagnoses. This case describes a young adult female presenting with chronic vomiting, abdominal pain and weight loss, with dependence on nasogastric feeding. Subsequent to her gastrointestinal symptoms, she developed haematuria and orthostatic intolerance. Investigations confirmed NCS and possible MALS, with superadded gastroparesis and bradygastria. Under the joint care of general and vascular surgeons, she underwent a gastrojejunostomy and panelled renocaval bypass which led to partial resolution of her symptoms. It is hypothesised that gastroparesis may have been caused by MALS via a neurogenic mechanism, or coexistent compression of the duodenum by the superior mesenteric artery. This case highlights the difficulty in diagnosis of vascular compression syndromes, the overlap between the conditions and the potential for multiple coexistent conditions which complicate diagnosis and lead to increased lead-time and morbidity for patients.

Superior Mesenteric Artery Syndrome and Nutcracker Syndrome as the Presentation of Crohn's Disease in a Young Patient: A Case Report and Review of Literature

Superior mesenteric artery syndrome and nutcracker syndrome are rare vascular complications most often seen after marked weight loss caused by compression of the duodenum and left renal vein between the superior mesenteric artery and the aorta, respectively. The coexistence of superior mesenteric artery syndrome and nutcracker syndrome has been rarely reported. Herein, we present the case of a 16-year-old male with intermittent periumbilical abdominal pain, bilious vomiting, and weight loss who was found to have both of these vascular complications of significant weight loss as the initial presentation of Crohn's disease. This report provides insight into the diagnosis and treatment of these syndromes while highlighting the importance for practitioners to keep vascular complications on their differential diagnosis of vomiting and abdominal pain in patients with Crohn's disease.

Anterior Nutcracker syndrome in a young male patient: a case report and review of literature

INTRODUCTION AND IMPORTANCE

The left renal vein (LRV) is affected by a venous compression syndrome called Nutcracker syndrome (NCS). This syndrome is characterized by extrinsic compression of the LRV, which usually occurs between aorta and superior mesenteric artery. It is a rare and under-diagnosed condition, more prevalent in females and that, if left untreated, can lead to severe problems. There are no clear guidelines regarding management. Therefore, the authors report this rare case and its symptoms in male patient and they display current management options.

CASE PRESENTATION

NCS was observed during computer tomography in a male patient presented with persistent left flank pain and associated haematuria. Ultrasound for left scrotum demonstrated left moderate-sized varicocele. The left varicocele testis unit was 1.6 mm and during the Valsalva manoeuvre in the supine position the testis unit was 2 mm. LRV compression between abdominal aorta and superior mesenteric artery was identified by computer tomography imaging and therefore, diagnosis of NCS was confirmed.

CLINICAL DISCUSSION

The actual prevalence is unclear, and incidence rates have been observed to fluctuate among age group and more prevalent in women. Main symptoms include haematuria, left flank discomfort, varicocele in men, proteinuria and anaemia. Depending on severity of symptoms, management might range from conservative care to surgery.

CONCLUSION

This treatment strategy was effective in reducing the symptoms of the patients. In young patients, conservative treatment is advised for a fair amount of time. However, more studies on how much the authors should wait before considering surgery is important.

Anterior and Posterior Nutcracker Syndrome Combined with May-Thurner Syndrome: First Report of This Unique Case

BACKGROUND

Anterior nutcracker syndrome is defined as the compression of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta, whereas posterior nutcracker syndrome refers to the compression of the retroaortic LRV between the aorta and the vertebral column-the presence of the circumaortic left renal vein may predispose to "combined nutcracker syndrome". May-Thurner syndrome consists of obstruction of the left common iliac vein caused by the crossing right common iliac artery. We report a unique case of combined nutcracker syndrome associated with May-Thurner syndrome.

CASE PRESENTATION

A 39-year-old Caucasian female came to our radiology unit for triple-negative breast cancer computed tomography (CT) staging. She complained of pain in hermid-back and low-back regions and intermittent abdominal pain in the left flank region. Multidetector computed tomography (MDCT) incidentally revealed a circumaortic left renal vein draining to the inferior vena cava, with bulbous dilatation of both the antero-superior and posterior-inferior branches, which was associated with pathological serpiginous dilation of the left ovarian vein with varicose pelvic veins. Axial CT imaging of the pelvis also showed compression of the left common iliac vein by the overlying right common iliac artery consistent with May-Thurner syndrome without signs of venous thrombosis.

CONCLUSION

Contrast-enhanced CT is the best imaging modality for suspected vascular compression syndromes. CT findings showed a combination of anterior and posterior nutcracker syndrome in the left circumaortic renal vein, associated with May-Thurner syndrome, which has not previously been described in the literature.

CT Evaluation of the Findings of Nutcracker Syndrome in Patients with Bladder Cancer after Radical Cystectomy and Ileal Neobladder Formation: A Correlation with Hematuria

Purpose

Patients with bladder cancer may show hematuria after radical cystectomy with ileal neobladder formation, causing anxiety regarding tumor recurrence. Here, we aim to show that the nutcracker syndrome (NCS) can be a cause of hematuria post-operation, and is a common, rather than a rare syndrome.

Materials and Methods

A retrospective review of contrast-enhanced abdominopelvic CT (CE-APCT) and urine analysis (UA) findings of 255 patients with bladder cancer who underwent radical cystectomy and ileal neobladder formation between 2011 and 2016 was performed. In the CE-APCT review, the left renal vein flow patterns were evaluated to determine the presence of NCS findings. In the UA review, patients were classified according to the percentage of UA tests with positive hematuria among the total number of UA tests.

Results

CT findings of NCS were present in 31.9% of the 135 patients. In the positive hematuria group, there were 26% more patients with NCS findings than those without.

Conclusion

NCS findings are prevalent even for bladder cancer patients after surgery, and there is a strong correlation between NCS findings and hematuria. Furthermore, the prevalence of NCS findings is much higher than urinary tract recurrence after the surgery.

Diagnostic Clues in Pediatric Nutcracker Syndrome: From Two Clinical Cases to Current Literature Analysis

Nutcracker syndrome (NCS) is a rare pediatric disease caused by left kidney vein compression. Besides the "Triade's symptoms", including hematuria, proteinuria, and flank pain, a wide spectrum of clinical manifestations has been reported. As the significant hemodynamic changes secondary to the dilatation of the left renal vein, serious consequences such as renal vein thrombosis and severe anemia might occur in these children. NCS diagnosis includes a variety of invasive and non-invasive imaging tools, but cutoff values need to be further validated. A conservative treatment represents the most common therapeutic approach for these patients, but operative options are available in selected cases. To complicate matters, a standard diagnostic and treatment algorithm is currently lacking and scientific pediatric evidence in this field is still poor and limited. In this perspective, early recognition of NCS is crucial but challenging for pediatricians. Therefore, a better knowledge of the disease is recommended. Starting from two different clinical presentations of NCS, we aimed to provide a comprehensive overview of the disease in children.

Nutcracker syndrome in children: Appearance, diagnostics, and treatment - A systematic review

BACKGROUND

The nutcracker syndrome (NCS) is defined by compression of the left renal vein (LVR) and may present with a wide variety of symptoms. Due to its rarity in pediatric patients, incidence, diagnostics and performed therapy regimen are widely undefined. To this date, there are only case reports and small collectives of pediatric patients described but comprehensive research is lacking.

METHODS

A systematic literature research on pediatric NCS was carried out on Medline and Scopus databases according to PRISMA principles using predefined search terms and inclusion criteria. The PROSPERO registered review (CRD42021237415) identified patients' characteristics regarding age, sex, clinical symptoms, applied diagnostic methods and treatment options.

RESULTS

In total 47 articles were included. Overall, 423 children (218 boys and 205 girls) with diagnosed NCS were included in the analysis. Mean age was 12.0 (boys 12.9, girls 12.0) years. Hematuria was most common presentation (55.5%), followed by proteinuria (49.9%). Classical flank pain was only detected in 19.1% of patients. Sonographic evaluation was the most commonly used diagnostic tool (99%). Invasive diagnostic studies were performed in 97 children. 86.8% patients were treated conservatively and 94.9% showed complete resolution (42.8%) or at least improvement (52.2%) of symptoms. Type of operative treatment comprised of open surgery with transposition of LRV, endovascular stenting and laparoscopy.

CONCLUSIONS

Overall, data quality regarding NCS in children is poor. However, conservative approach in pediatric patients is recommended and should be regarded first treatment option. Diagnostic and treatment should follow a defined algorithm when NCS is suspected. Sufficient observation and follow-up must be assured in all patients to get significant results in this heterogenous syndrome.

LEVEL OF EVIDENCE

V-IV.

Interventional Management of a Rare Combination of Nutcracker and Wilkie Syndromes

Nutcracker and Wilkie syndromes are rare mesoaortic compression entities, and their association is even less common. Data on interventional treatment of these pathologies are still scarce, but results from limited case series are encouraging. We report the case of a previously healthy 45-year-old woman diagnosed with nutcracker and Wilkie syndromes who presented with macroscopic hematuria, intermittent pain in the left flank and hypogastric region, postprandial nausea, and unexplained significant weight loss. A successful endovascular approach with stent implantation in the left renal vein was performed, but the stent migrated toward the left kidney, and this acute complication was managed through an interventional strategy as well. At the three-month follow-up, the patient described a marked improvement in all symptoms, except for the macroscopic hematuria. As it was our strong belief that the approach was efficient, we further investigated the “hematuria”, which eventually led to the diagnosis of endometrial carcinoma. A hysterectomy and bilateral adnexectomy were planned, and chemoradiotherapy was initiated with the goal of preoperative tumor reduction. To our knowledge, this is the first reported case in which both Wilkie and nutcracker syndromes were effectively treated by stent implantation in the left renal vein, complicated with very early stent migration due to inadequate apposition to the less compliant venous lumen. The treatment of the duodenal compression was indirectly included in the stenting of the left renal vein, as reclaiming the venous lumen widened the aortomesenteric angle. The aim of this review is to discuss our center’s transcatheter experience with these rare disorders and explore the literature in order to establish the benefits and limitations of such an approach.

Left renal vein entrapment in postural proteinuria: the diagnostic utility of the aortomesenteric angle

Nutcracker syndrome related to the left kidney vein compression is a cause of orthostatic proteinuria during childhood. Some studies have shown that the ratios between maximum velocities and anterior-posterior diameters of hilar and aortomesenteric segments of the left kidney vein between upright and supine positions must be more than 4 in order to make a Nutcracker syndrome diagnosis. Our aim was to investigate whether the use of a decrease in aortomesenteric angle between upright and supine positions in the presence of isolated orthostatic proteinuria can be a criterion for the diagnosis of Nutcracker syndrome. Relevant patient information, which included demographic data, clinical examination findings, laboratory data, urinary system ultrasound, and kidney color flow Doppler ultrasound results, were prospectively collected. Thirty-nine pediatric patients with orthostatic proteinuria were included in the study. Left kidney vein compression findings were demonstrated in 31 patients. The ratio of maximum velocities of hilar and aortomesenteric segments of the left kidney vein between upright and supine positions was above 4 in only 7 of our patients. Ratio of aortomesenteric angle between upright and supine positions was significantly decreased for patients with left kidney vein compression findings.  Conclusion: The use of a decrease in the ratio of aortomesenteric angle between upright and supine positions in the presence of orthostatic proteinuria, instead of the ratios for maximum velocities and anterior-posterior diameters of hilar and aortomesenteric segments, can be more helpful for the diagnosis of Nutcracker syndrome in the differential diagnosis of orthostatic proteinuria. What is Known: • Proteinuria may be a sign of an impending kidney disease • Nutcracker syndrome is a cause of orthostatic proteinuria. What is New: • Ratio of aortomesenteric angle between upright and supine positions > 0.6 can be used for Nutcracker syndrome diagnosis.

The Journey and Barriers to Treatment of Patients with Renal Nutcracker Syndrome

OBJECTIVES

To better understand renal nutcracker syndrome (NCS) from a patients' perspective starting at presentation and followed through to diagnosis and management METHODS: This descriptive study was conducted on a national level via a self-selected online survey distributed via river sampling by a post on the Facebook Page 'Renal Nutcracker Syndrome Support Group'.

RESULTS

Of the 22 responses collected, 95.5% were female and 91% self-identified as White. 43% experienced symptoms as teenagers and 62% were diagnosed as young adults. Prior to receiving a definitive diagnosis, over half of the respondents were worked up for kidney stones (57%) and ovarian cysts (48%) and saw at least ten to fifteen providers. Nearly 80% experienced constant pain throughout the day. Pain management included prescription oral pain relievers (38%), prescription patches (29%), and physical therapy (19%). Surgical procedures included nephrectomy with auto transplant (38%), left renal vein transposition (10%), and laparoscopic extravascular stent placement (10%). Respondents had high healthcare utilization for management of NCS. Nearly 30% were unable to work and had filed for disability.

CONCLUSIONS

Awareness of NCS should increase among healthcare providers of all specialties to improve quality of care to those living with NCS. It is crucial to keep NCS within the differential diagnosis in patients presenting with gross hematuria and unusual abdominal and/or flank pain.

Endovascular treatment of a patient with nutcracker syndrome and pelvic varices involving anterior and posterior renal veins

We have reported a case of a 36-year-old woman with flank and pelvic pain and hematuria. She had posterior nutcracker syndrome and pelvic varices involving one anterior and three posterior renal veins (including one major vein). We used a complete endovascular approach, which included stent implantation in the major posterior renal vein and left gonadal vein embolization. During a 12-month follow-up period, the patient had had no symptoms and good computed tomography results. Endovascular treatment represents a safe and successful option for patients with nutcracker syndrome and pelvic varices involving the anterior and posterior renal veins.

Spontaneous rupture of the ovarian vein in association with nutcracker syndrome: a case report

Background

Nutcracker syndrome is a condition in which the left renal vein is pinched between the abdominal aorta and the superior mesenteric artery, resulting in an increase in renal vein pressure and certain symptoms. We report a very rare case of retroperitoneal hematoma caused by the rupture of varicose veins of the left ovary.

Case presentation

A 77-year-old Japanese woman, para 7, experienced sudden left lower abdominal pain. She had no history of trauma or treatment complications. Computed tomography revealed a left retroperitoneal hematoma, but her abdominal pain subsided quickly; thus, urgent treatment was not required. We then scheduled her for an assessment regarding the cause of her bleeding. However, 6 days after the pain onset, abdominal pain symptoms recurred, confirming hematoma regrowth. Magnetic resonance imaging and three-dimensional computed tomography revealed an abnormal vascular network from the left side of the uterus to the left adnexa. Subsequent angiography revealed that the retroperitoneal bleeding originated from rupture of the distended left ovarian vein, which caused blood reflux from the left renal vein to the left ovarian vein. Although angiography confirmed a passage between the left renal vein and inferior vena cava, computed tomography showed obvious stenosis in the left renal vein. In accordance with these findings, we diagnosed the cause of the distention and rupture of the left ovarian vein as nutcracker syndrome. She underwent embolization of the left ovarian vein as hemostasis treatment, and had a good course thereafter.

Conclusions

This is the first report of a spontaneous rupture of the left ovarian vein caused by nutcracker syndrome. Nutcracker syndrome is not yet well known to clinicians and should be considered as part of the differential diagnosis when an abnormal vascular network in the pelvis is found.

Role of multiparametric ultrasound in testicular focal lesions and diffuse pathology evaluation, with particular regard to elastography: Review of literature

BACKGROUND

Ultrasound is the main requested technique for the assessment of traumatic, vascular, neoplastic, and inflammatory testicular pathology. Moreover, the role of ultrasound has broadened over the years along with the introduction of new techniques, such as contrast enhanced ultrasound and ultrasound elastography.

OBJECTIVE

An updated representation of the pre-existing Literature evidence for multiparametric ultrasound imaging with particular regard to elastography, in the evaluation of focal and diffuse testicular pathologies, has been presented.

METHODS

The search was performed in PubMed, Cochrane, EMBASE, Web of Science and Scopus databases from the earliest available article (1977) until January 2021. Based on the evidence of the Literature, the current role of US imaging for focal and diffuse testicular pathologies has been reported and illustrated, with emphasis on examination technique, classification, and pitfalls.

RESULTS

Multiparametric Ultrasound has a recognized role for testicle focal and diffuse disease. Elastography is nowadays recognized as an essential part of the multiparametric ultrasound examination. However, in the setting of testicular pathology this method showed some promising results in the setting of varicocoele and for focal lesions characterization. In the remaining field its role is still under debate.

DISCUSSION

B-mode ultrasound and color Doppler ultrasound have been for a long time the diagnostic gold standard for testicular pathologies. The introduction of both contrast enhanced ultrasound and elastography in the last two decades has brought to the emergence of the multiparametric ultrasound concept. These methods are currently able to increase diagnostic confidence especially for testicular lesions characterization, with different relevance depending on the pathology under consideration.

CONCLUSION

Multiparametric ultrasound testis assessment, with specific regard to elastography is nowadays recommended for focal and diffuse disease evaluation. Further and larger studies are however needed to validate these results and to understand if the role of elastography in testicular pathology may be broadened.