Abstract
Introduction:
Nutcracker syndrome is a rare vascular compression disorder characterized by entrapment of the left renal vein, most commonly between the aorta and the superior mesenteric artery. 1 This anatomical compression results in impaired renal venous outflow, leading to clinical manifestations related to renal ischemia and pelvic venous congestion. 2 Endovascular interventions constitute the first-line treatment approach, whereas surgical options such as left renal vein bypass or autotransplantation are reserved for refractory or severe cases. 3
Materials and Methods:
We present the case of a 44-year-old female with a long-standing history of pain in the left flank, pelvis, and left lower extremity. CT imaging revealed a reduced aorto-mesenteric angle of 22 degrees and a narrowed aorto-mesenteric distance of just 5 millimeters, confirming compression of the left renal vein at its passage, along with post-stenotic dilatation. The patient underwent two left gonadal vein embolizations, but there was no clinical improvement.
Results:
Renal autotransplantation was chosen as the surgical treatment for this case. The first stage consisted of a laparoscopic nephrectomy, during which meticulous dissection and isolation of the renal vessels and ureter were performed. The kidney was then extracted and prepared for autotransplantation with cold perfusion using Custodiol solution. Excess perinephric fat, small vessels, and lymphatics were ligated to enhance graft quality and reduce postoperative complications. In the second stage, the graft was implanted into the right iliac fossa, with vascular anastomoses to the external iliac artery and vein using end-to-side techniques. Ureteral reimplantation was performed via the Lich-Gregoir technique, and a double-J stent was inserted to ensure urinary drainage. Immediate graft reperfusion was achieved intraoperatively. The patient reported complete resolution of symptoms at the 3-month follow-up.
Conclusion:
Renal autotransplantation is a safe, effective, and reliable surgical intervention for severe nutcracker syndrome, providing definitive anatomical correction and significant clinical improvement.
Declaration of conflicting interest:
The authors have no conflicts of interest to declare that are relevant to the content of this article.
Patient consent:
Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.
The authors declare no commercial associations or conflicts of interest related to this video in the past 2 years.
Funding information:
The authors did not receive support from any organization for the submitted work.
Runtime of video:
7 mins 01 sec.