Diagnostic and Treatment Approach in Case of Aorta Mesenteric Clamp


aorta mesenteric clamp
anatomical and physiological features
diagnostic and treatment algorithm


The article presents anatomical and physiological features of the aorta mesenteric clamp. Diagnostic and treatment features of the pathology were analyzed in order to improve operating procedures. Unfortunately, few published literature data are not the result of multicenter randomized research and indicate the fact that consensus on diagnostic algorithms and therapeutic approach is absent.


Lopatkin NA, Morozov AK, Zhitnikova LN. Stenoz pochechnoi veny. Moscow; c1984. 144p.

Sahalevych AI. Patohenetychne obhruntuvannia metodiv khirurhichnoho likuvannia livostoronnioho varykotsele. Thesis. 2002.

Spiridonov AA, Strakhov SN, Pryadko SI. Khirurgicheskaya korrektsiya regionarnoy venoznoy pochechnoy gipertenzii (plastika levoy pochechnoy veny i testikulo-ileokalnyye anastomozy). Angiolog. isosud. khir. 1996;3:11-25

Strakhov SN, Burkov IV. Pochechnaya flebogipertenziya I mezhvenoznyye anastomozy pri varikotsele. Angiolog. isosud. khir. 2008;1:85-91.

Strakhov SN, Pryadko SI, Bondar ZM, Kosyreva NB. Varianty arkhitektoniki, gemodinamiki levoy pochechnoy I yaichnikovoy ven I vybo rpatogeneticheski obosnovannogo metoda khirurgicheskogo lecheniya levostoronnego varikotsele. Annaly khirurgii, 2014;3:32-40.

Ahmed K, Sampath R, Khan MS. Current trends in the diagnosis and management of renal nutcracker syndrome: A review. Eur. J. Vasc. Endovasc. Surg. 2006;31:410416. DOI: https://doi.org/10.1016/j.ejvs.2005.05.045

Altugan FS, Ekim M, Fitöz S et al. Nutcracker syndrome with urolithiasis. J Pediatr Urol. 2010;6:519-521. DOI: https://doi.org/10.1016/j.jpurol.2010.05.014 [PMid:20594917]

Arima M, Hosokawa S, Ogino T et al. Ultrasonographically demonstrated nutcracker phenomenon: alternative to angiography. Int Urol Nephrol. 1990;22:3-6. DOI: https://doi.org/10.1007/BF02550429

Ariyoshi A, Nasage K. Renal haematuria caused by "nutcracker" phenomenon: a more logical surgical management. Urology. 1990;35(2):168-170. DOI: https://doi.org/10.1016/0090-4295(90)80069-Y

Barnes RW, Fleisher HL, Redman JF, Smith JW, Harshfield DL, Ferris EJ. Mesoaortic compression of the left renal vein ( the so-called nutcracker syndrome) repair by a new stenting procedure. J Vasc Surg. 1988;8(4):415-421. DOI: https://doi.org/10.1016/0741-5214(88)90104-8

Beinart C, Sniderman KW, Saddekni S et al. Left renal vein hypertension: a cause of occult hematuria. Radiology. 1982;145:647-650. DOI: https://doi.org/10.1148/radiology.145.3.7146391

Bjarnason H. Commentary on "renal vein stenting via the right internal jugular vein approach with a provocative valsalva maneuver may reduce the risk of stent migration". Perspect Vasc Surg Endovasc Ther. 2011;23:272-273. DOI: https://doi.org/10.1177/1531003511429332 [PMid:22138209]

Chait A, Matasar KW, Fabian CE et al. Vascular impressions on ureters. Am J Roentgenol Radium Ther Nucl Med. 1971;111:729-749. DOI: https://doi.org/10.2214/ajr.111.4.729 [PMid:5103904]

Chen S, Zhang H, Shi H et al. Endovascular stenting for treatment of nutcracker syndrome: report of 61 cases with long-term follow-up. J Urol. 2011;186:570-575. DOI: https://doi.org/10.1016/j.juro.2011.03.135

Chen S, Zhang H, Tian L et al. Endovascular management of Nutcracker syndrome after migration of laparoscopically places extravascular stents. Am J Kidney Dis. 2012; 60: 322-326. DOI: https://doi.org/10.1053/j.ajkd.2012.04.022 [PMid:22717342]

Chen W, Chu J, Yang JY et al. Endovascular stent placement for the treatment of nutcracker phenomenon in three pediatric patients. J Vasc Interv Radiol. 2005:16(11):1529-1533. DOI: https://doi.org/10.1097/01.RVI.0000178259.87608.EC

Chuang CK, Chu SH, Lai PC. The nutcracker syndrome managed by autotransplantation. J Urol. 1997:157(5):1833-1834. DOI: https://doi.org/10.1016/S0022-5347(01)64872-9

Chung BI, Gill IS. Laparoscopic splenorenal venous bypass for nutcracker syndrome. J Vasc Surg. 2009;49:1319-1323. DOI: https://doi.org/10.1016/j.jvs.2008.11.062

Coolsaet BL. Ureteric pathology in relation to right and left gonadal veins. Urology. 1978;12(1):40-49. DOI: https://doi.org/10.1016/0090-4295(78)90365-5

Daily R, Matteo J, Loper T et al. Nutcracker syndrome: symptoms of syncope and hypotension improved following endovascular stenting. Vascular. 2012;20:337-341. DOI: https://doi.org/10.1258/vasc.2011.cr0320

De Schepper A. Nutcracker phenomenon of the renal vein causing left renal vein pathology. J Belg Rad. 1972;55:507-511. [PMid:4660828]

Ekim M, Ozçakar ZB, Fitoz S et al. The "nutcracker phenomenon" with orthostatic proteinuria: case reports. Clin Nephrol. 2006;65:280-283. DOI: https://doi.org/10.5414/CNP65280 [PMid:16629228]

El Sadr AR, Mina A. Anatomical and surgical aspects in the operative management of varicoceles. Urol Cut Rev. 1950;54:257-262. [PMid:15443180]

El-Sadr AR. Mina E. Anatomical and surgical aspects in the operative management of varicocele. Urol. Cutaneous. Rev. 1950;54:257-262. [PMid:15443180]

Fong JK, Poh AC, Tan AG, Taneja R. Imaging findings and clinical features of abdominal vascular compression syndromes. AJR Am. J. Roentgenol. 2014;203:29-36. DOI: https://doi.org/10.2214/AJR.13.11598

Gorospe EC, Aigbe MO. Nutcracker syndrome: a rare cause of hematuria. Scientific World Journal. 2006;6:745-746. DOI: https://doi.org/10.1100/tsw.2006.144 [PMid:16816885 PMCid:PMC5917173]

Grant JCB. Method of Anatomy. Baltimore, MD: Williams and Wilkins. c1937. 158p.

Grimm LJ, Engstrom BI, Nelson RC, Kim CY. Incidental detection of nutcracker phenomenon on multidetector CT in an asymptomatic population: Prevalence and associated findings. J Comput Assist Tomogr. 2013;37:415-418. DOI: https://doi.org/10.1097/RCT.0b013e3182873235

Ha TS, Lee EJ. ACE inhibition can improve orthostatic proteinuria associated with nutcracker syndrome. Pediatr Nephrol. 2006;21:1765-1768. DOI: https://doi.org/10.1007/s00467-006-0206-3 [PMid:16902785]

Hartung O, Azghari A, Barthelemy P et al. Laparoscopic transposition of the left renal vein into the inferior vena cava for nutcracker syndrome. J Vasc Surg. 2010;52:738-741. DOI: https://doi.org/10.1016/j.jvs.2010.04.018

Hartung O, Grisoli D, Boufi M et al. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: lessons learned from the first five cases. J Vasc Surg. 2005;42(2):275-280. DOI: https://doi.org/10.1016/j.jvs.2005.03.052

He Y, Wu Z, Chen S, Tian L, Li D, Li M, Jin W, Zhang H. Nutcracker syndrome - How well do we know it? Urology. 2014;83:12-17. DOI: https://doi.org/10.1016/j.urology.2013.08.033

Hohenfellner M, D'Elia G, Hampel C et al. Transposition of the left renal vein for treatment of the nutcracker phenomenon: long-term follow-up. Urology. 2002;59:354-357. DOI: https://doi.org/10.1016/S0090-4295(01)01537-0

Hohenfellner M, Steinbach F, Schultz-Lampel D et al. The nutcracker syndrome: new aspects of pathophysiology, diagnosis and treatment. J Urol. 1991;146:685-688. DOI: https://doi.org/10.1016/S0022-5347(17)37893-X

Lau JLT, Lo R, Chan FL, Wong KK. The posterior nutcracker. Haematuria secondary to retroaortic left renal vein. Urology. 1986;28:437-438. DOI: https://doi.org/10.1016/0090-4295(86)90085-3

Kibbe MR, Ujiki M, Goodwin AL, Eskandari M, Yao J, Matsumura J. Iliac vein compression in an asymptomatic patient population. J Vasc Surg. 2004;39:937-943. DOI: https://doi.org/10.1016/j.jvs.2003.12.032

Kim KW, Cho JY, Kim SH et al. Diagnostic value of computed tomographic findings of nutcracker syndrome: correlation with renal venography and renocaval pressure gradients. Eur J Radiol. 2011;80:648-654. DOI: https://doi.org/10.1016/j.ejrad.2010.08.044

Kim SH, Cho SW, Kim HD et al. Nutcracker syndrome: Diagnosis with Doppler US. Radiology. 1996;198:93-97. DOI: https://doi.org/10.1148/radiology.198.1.8539413

Kim SJ, Kim CW, Kim S et al. Long-term follow-up after endovascular stent placement for treatment of nutcracker syndrome. J Vasc Interv Radiol. 2005;16(3):428-431. DOI: https://doi.org/10.1097/01.RVI.0000149904.26242.54 [PMid:15758146]

Sharper KRL, Jackson JE, Williams J. The nutcracker syndrome: an uncommon cause of haematuria. BJU. 1994;74:144-146. DOI: https://doi.org/10.1111/j.1464-410X.1994.tb16575.x

Kurklinsky A, Shepherd R. A case of combined nutcracker and May-Thurner Syndromes in an adult with resolution of hemodynamic findings. Presented at: XVI World Meeting of the International Union of Phlebology. August 31-September 4, 2009; Principality of Monaco, France. GE3.7-10.

Kurklinsky AK, Rooke TW. Nutcracker phenomenon and nutcracker syndrome. Mayo Clin. Proc. 2010;85:552-559. DOI: https://doi.org/10.4065/mcp.2009.0586

Ma Z, Liu X, Ning Y. Nutcracker phenomenon in combination with glomerular nephritis in isolated hematuria patients. Int Urol Nephrol. 2013;45:809-816. DOI: https://doi.org/10.1007/s11255-012-0265-2 [PMid:22956462]

MacMahon HE, Latorraca R. Essential renal hematuria. J Urol. 1954;71:667-676. DOI: https://doi.org/10.1016/S0022-5347(17)67843-1

Mahmood SK, Oliveira GR, Rosovsky RP. An easily missed diagnosis: flank pain and nutcracker syndrome. BMJ Case Rep. 2013;37:415-418. DOI: https://doi.org/10.1136/bcr-2013-009447

Maleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Interv Radiol. 2000;11(7):859-864. DOI: https://doi.org/10.1016/S1051-0443(07)61801-6

Mazzoni MB, Kottanatu L, Simonetti GD et al. Renal vein obstruction and orthostatic proteinuria: a review. Nephrol Dial Transplant. 2011;26:562-565. DOI: https://doi.org/10.1093/ndt/gfq444

McDermott S, Oliveira G, Ergul E, Brazeau N, Wicky S, Oklu R. May-Thurner syndrome: Can it be diagnosed by a single MR venography study? Diagn Interv Radiol. 2013;19:44-48. DOI: https://doi.org/10.4261/1305-3825.DIR.5939-12.1

Menard MT. Nutcracker syndrome: When should it be treated and how? Perspect. Vasc Surg Endovasc Ther. 2009;21:117-124. DOI: https://doi.org/10.1177/1531003509338402

Neste MG, Narasimham DL, Belcher KK. Endovascular stent placement as a treatment for renal venous hypertension. J Vasc Interv Radiol. 1996;7:859. DOI: https://doi.org/10.1016/S1051-0443(96)70861-8

Ozkurt H, Cenker MM, Bas N et al. Measurement of the distance and angle between the aorta and superior mesenteric artery: normal values in different BMI categories. Surg Radiol Anat. 2007;29:595-599. DOI: https://doi.org/10.1007/s00276-007-0238-9

Park SJ, Lim JW, Cho BS et al. Nutcracker syndrome in children with orthostatic proteinuria: diagnosis on the basis of Doppler sonography. J Ultrasound Med. 2002;21:39-45. DOI: https://doi.org/10.7863/jum.2002.21.1.39 [PMid:11794401]

Pascarella L, Penn A, Schmid-Schonbein GW. Venous hypertension and the inflammatory cascade: major manifestations and trigger mechanisms. Angiology. 2005;56:3-10. DOI: https://doi.org/10.1177/00033197050560i102 [PMid:16193224]

Pastershank SP. Left renal vein obstruction by a superior mesenteric artery. J Can Assoc Radiol. 1974;25(1):52-54. [PMid:4823206]

Patrick T. Hange, Nikhil Gupta et al. Journal of Clinical Medicine. 2018;7(5):107. DOI: https://doi.org/10.3390/jcm7050107 [PMid:29738433 PMCid:PMC5977146]

Polguj M, Topol M, Majos A. An unusual case of left venous renal entrapment syndrome: A new type of nutcracker phenomenon? Surg Radiol Anat. 2013;35:263-267. DOI: https://doi.org/10.1007/s00276-012-1027-7

Poyraz AK, Firdolas F, Onur MR et al. Evaluation of left renal vein entrapment using multidetector computed tomography. Acta Radiol. 2013;54:144-148. DOI: https://doi.org/10.1258/ar.2012.120355

Praveen Kumar M, Suseelamma D, Saritha S et al. Multiple renal vascular variations. Open Access Scientific Reports. 2012;1:334.

Pytel A. Renal fornical hemorrhages: Their pathogenesis and treatment. J Urol. 1960;83:783-789.

Radisic MV, Feldman D, Diaz C et al. Unexplained hematuria during pregnancy: right-sided nutcracker phenomenon. Int Urol Nephrol. 2007;39:709-711. DOI: https://doi.org/10.1007/s11255-006-9101-x

Reed NR, Kalra M, Bower TC et al. Left renal vein transposition for nutcracker syndrome. J Vasc Surg. 2009;49:386-393. DOI: https://doi.org/10.1016/j.jvs.2008.09.051

Rudloff U, Holmes RJ, Prem, JT, Faust GR, Moldwin R, Siegel D. Mesoaortic Compression of the Left Renal Vein (Nutcracker Syndrome): Case Reports and Review of the Literature. Ann Vasc Surg. 2006;20:120-129. DOI: https://doi.org/10.1007/s10016-005-5016-8

Shaper KR, Jackson JE, Williams G. The nutcracker syndrome: an uncommom case of haematuria. Br J Urol. 1994;74(2):144-146. DOI: https://doi.org/10.1111/j.1464-410X.1994.tb16575.x [PMid:7921928]

Schoekeir AA, el-Diasty TA, Ghoeneim MA. The nutcracker syndrome: new methods of diagnosis and treatment. Br J Urol.1994;74(2):139-143. DOI: https://doi.org/10.1111/j.1464-410X.1994.tb16574.x

Scholbach T. From the nutcracker-phenomenon of the left renal vein to the midline congestion syndrome as a cause of migraine, headache, back and abdominal pain and functional disorders of pelvic organs. Med Hypotheses. 2007;68:1318-1327. DOI: https://doi.org/10.1016/j.mehy.2006.10.040

Scultetus AH, Villavicencio JL, Gillespie DL. The nutcracker syndrome: its role in the pelvic venous disorders. J Vasc Surg. 2001;34(5):812-819. DOI: https://doi.org/10.1067/mva.2001.118802

Shin JI, LeeJS, Kim MJ. The prevalence, physical characteristics and diagnosis of nutcracker syndrome. Eur J Vasc Endovasc Surg. 2006;32(3):335-336. DOI: https://doi.org/10.1016/j.ejvs.2006.04.030

Shin JI, Park JM, Lee JS et al. Effect of renal Doppler ultrasound on the detection of nutcracker syndrome in children with hematuria. Eur J Pediatr. 2007;166:399-404. DOI: https://doi.org/10.1007/s00431-006-0252-7

Shin JI, Park JM, Shin YH et al. Superimposition of nutcracker syndrome in a hematuric child with Henoch-Schönlein purpura. Int J Clin Pract. 2005;59:1472-1475. DOI: https://doi.org/10.1111/j.1742-1241.2005.00590.x

Skeik N, Gloviczk P, Macedo TA. Posterior nutcracker syndrome. Vasc Endovascular Surg. 2011;45:749-755. DOI: https://doi.org/10.1177/1538574411419376

Takahashi Y, Ohta S, Sano A et al. Does severe nutcracker phenomenon cause pediatric chronic fatigue? Clin Nephrol. 2000;53:174-181. [PMid:10749295]

Takahashi Y, Sano A, Matsuo M. An ultrasonographic classification for diverse clinical symptoms of pediatric nutcracker phenomenon. Clin Nephrol. 2005;64:47-54. DOI: https://doi.org/10.5414/CNP64047 [PMid:16047645]

Takebayashi S, Ueki T, Ikeda N et al. Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography. Am J Roentgenol. 1999; 172: 39-43. DOI: https://doi.org/10.2214/ajr.172.1.9888735

Takezawa K, Nakazawa S, Yoneda S et al. Renal autotransplantation for the treatment of nutcracker phenomenon which caused varicocele rupture: a case report. Hinyokika Kiyo. 2011;57:213-216. [PMid:21646854]

Thompson PN, Darling RC, Chang BB, Shah DM, Leather RP. A case of nutcracker syndrome: treatment by mesoaortic transposition. J Vasc Surg. 1992;16(4):663-665. DOI: https://doi.org/10.1016/0741-5214(92)90176-9

Velasquez CA, Saeyeldin A, Zafar MA, Brownstein AJ, Erben Y. A systematic review on management of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 2018;6:271-278. DOI: https://doi.org/10.1016/j.jvsv.2017.11.005

Venkatachalam S, Bumpus K, Kapadia SR, Gray B, Lyden S, Shishehbor MH. The nutcracker syndrome. Ann Vasc Surg. 2011;25:1154-1164. DOI: https://doi.org/10.1016/j.avsg.2011.01.002

Wei SM, Chen ZD, Zhou M. Intravenous stent placement for treatment of nutcracker syndrome. J Urol. 2003;170:1934-1935. DOI: https://doi.org/10.1097/01.ju.0000089872.39883.a3 [PMid:14532811]

Wendel RG, Crawford ED, Hehman KN. The "nutcracker" phenomenon: an unusual cause for renal varicosities with haematuria. J Urol. 1980;123(5):761-763. DOI: https://doi.org/10.1016/S0022-5347(17)56121-2

Wolfish NM, McLaine PN, Martin D. Renal vein entrapment syndrome: frequency and diagnosis-a lesson in conservatism. Clin Nephrol. 1986;26:96-100. [PMid:3530569]

Xu D, Gao Y, Chen J. Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome. J Vasc Surg. 2013;57:1429-1431. DOI: https://doi.org/10.1016/j.jvs.2012.10.092

Zhang H, Li M, Jin W et al. The left renal entrapment syndrome: diagnosis and treatment. Ann Vasc Surg. 2007;21:198-203. DOI: https://doi.org/10.1016/j.avsg.2006.10.021

Zheng ZL, Tong ZY, Mou Y et al. Investigations on diagnostic standards of nutcracker syndrome with ultrasonic examination. Chin J Ultrasonography. 2004;13:363-365.

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.


Download data is not yet available.