Presentation
Left testicular pain. No complaint of abdominal pain or loin pain.
Patient Data
A few dilated veins are noted at the left pampiniform plexus, their largest diameter (5 mm), and they show reflux with Valsalva (grade III refluxing varicocele).
Complementary SMA Doppler revealed:
Decreased aortic-SMA angle measuring about 26 degrees (normally 38 to 65 degrees).
Compressed left renal vein with AP diameter of the compressed part about 2.2 mm.
Proximally dilated left renal vein with AP diameter of the pre-compressed part about 11.2 mm.
The compression ratio measures about 5.
Case Discussion
The left renal vein normally passes between the SMA anteriorly and the abdominal aorta posteriorly. The nutcracker syndrome is a compression of the left renal vein between the SMA and abdominal aorta due to a decreased aortic-SMA angle.
This pressure interferes with blood flow and results in dilatation of left renal vein proximal to the compression.
The left testicular vein drains into the left renal vein. Hence, it will also become dilated and congested.
Two diagnostic features support nutcracker syndrome:
Narrowed aortic-SMA angle (normally 38 to 65 degrees).
Left renal vein compression ratio (pre-compressed AP diameter : compressed AP diameter); ratio above 2.25 is highly sensitive and specific for nutcracker syndrome.
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