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Nutcracker syndrome (NCS) is caused by compression of the left renal
vein (LRV) between the abdominal aorta and superior mesenteric artery
(SMA), resulting in several urological
symptoms[1].
A 36-year-old male with Marfan-like features, who had developed type B
aortic dissection 3 months prior, presented with sudden gross hematuria.
Computer tomography (CT) revealed obstruction of the LRV sandwiched
between the dissecting aneurysm of abdominal aorta and the SMA,
so-called “nutcracker phenomenon” (A ). Abrupt narrowing of
the LRV at the aortomesenteric (AM) portion (beak sign) (B ) as
well as the great ratios of the diameter of the LRV between at the AM
portion (2.1mm) and the hilar portion (11.8mm) were identified,
resulting in a diagnosis of NCS[2]. Gross
hematuria remained persistent, thus our team decided to perform surgical
intervention. Obstruction of the LRV was released after the graft
replacement of thoracoabdominal aorta (C ) and hematuria was
promptly relieved. Three-dimensional CT illustrated the preoperative
abnormally acute angle between the SMA and aorta (D, 17
degrees) was clearly widened (E , 40 degrees) after the
operation.
This is the first report of NCS caused by a dissecting aneurysm of the
thoracoabdominal aorta and its successful surgical management. NCS
should be considered as a differential diagnosis for unexplained
hematuria in patients with chronic aortic dissection.