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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.