CASE 11332 Published on 02.12.2013

Atypical presentation of nutcracker syndrome in renal arteriovenous malformation: MDCT imaging findings

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

Zeyneb Yuceler1, Mecit Kantarci1, Kamuran Kalkan2, Serdar Sevimli2, Yesim Kizrak1, Hayri Ogul1, Berhan Pirimoglu1

Ataturk universitesi 25090 Erzurum, Turkey; Email:akkanrad@hotmail.com
1:Atatürk University, School of Medicine, Department of Radiology, Erzurum, Turkey
2:Atatürk University, School of Medicine, Department of Cardiology, Erzurum, Turkey
Patient

35 years, female

Categories
Area of Interest Abdomen ; Imaging Technique CT, Catheter arteriography
Clinical History
A 35-year-old woman referred for evaluation of flank pain, haematuria and hypertension. Physical examination was unremarkable except her blood pressure of 150/90 mmHg. Laboratory investigations showed microscopic haematuria on urinalysis.
Imaging Findings
On renal Doppler ultrasound (US) right kidney's size was small related to left. Renal computed tomography (CT) angiography revealed vascular-attenuation mass located in the renal sinus which is close to vena cava inferior and right renal artery. Additionally CT demonstrated nutcracker syndrome accompanied by distal dilatation and mesoaortic narrowing of left renal vein [Fig. 1a, b]. Conventional renal angiography revealed arteriovenous malformation (AVM) with its numerous tortuous vessels communicating with renal artery [Fig. 2]. The patient underwent interventional arterial embolization. After three months clinical follow-up her blood pressure and urinalysis were normal. 
Discussion
Renal arteriovenous malformation (AVM) is composed of multiple irregular tortuous varixlike vessels without elastic component [1]. The incidence is less than 0.04% of population and one-quarter of all renal vascular anomalies [2]. Clinical symptoms include haematuria, hypertension and rarely signs due to high cardiac output [3]. Contrast enhanced computed tomography is useful for detecting renal AVM and it can be seen as a vascular-attenuation mass located in the renal sinus, also on delayed phases it has the same attenuation as inferior vena cava [1]. Additionally ipsilateral renal atrophy can be seen due to vascular shunting. Angiography is the gold standard for confirming renal AVM [2]. Embolization is a successful treatment in most of the cases [3]. Compression of the left renal vein mostly between the superior mesenteric artery and aorta associated with urinary symptoms (haematuria and flank pain) is determined as Nutcracker syndrome [4, 5]. Imaging findings are distal dilatation and mesoaortic narrowing of left renal vein [1]. In this report we present a patient with renal AVM causing dilatation of left renal vein and compression of it between superior mesenteric artery and aorta as nutcracker syndrome due to increased venous pressure and impaired blood outflow.
Differential Diagnosis List
Renal arteriovenous malformation
Renal arteriovenous fistula
Fibromuscular dysplasia
Final Diagnosis
Renal arteriovenous malformation
Case information
URL: https://www.eurorad.org/case/11332
DOI: 10.1594/EURORAD/CASE.11332
ISSN: 1563-4086