ANSWER: Nutcracker syndrome
EXPLANATION:
The first row, axial contrast-enhanced CT scan of the abdomen provided demonstrates compression of the left renal vein sandwiched between the superior mesenteric artery (SMA) and the abdominal aorta (blue arrow), causing a renal venous outflow obstruction and subsequent venous hypertension.
Intrarenal and/or perirenal varices (yellow arrow) increase the clinical suspicion (which are also visualized on subsequent coronal and sagittal reformats). The findings are compatible with Nutcracker syndrome.
Secondary features include left pelvic varices/varicoceles. Symptoms include left flank pain with possible hematuria. Treatment incudes PTA with stent or surgery.
WRONG ANSWERS:
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SMA syndrome: extrinsic compression of the 3rd portion of the duodenum, which is sandwiched between the SMA and abdominal aorta.
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May-Thurner syndrome: extrinsic compression of the proximal left common iliac vein by the overlying right common iliac artery against the vertebral body (usually L5). Presents with unilateral (LLE) edema.
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MAL syndrome: narrowing of the proximal celiac artery by the median arcuate ligament attached to the diaphragm, which is accentuated on end-expiration and classically presents with symptoms similar to bowel ischemia.
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Paget-Schroetter syndrome - extrinsic compression of the subclavian/axillary vein by prominent anterior scalene muscle at the level of the costocervical junction.
REFERENCES:
Walker, T. Gregory. “Nutcracker Syndrome.” STATdx, Elsevier, 2020.
