Left IVC has been well-described and occurs in 0.2%-0.5 % of the general population ⁶. In most cases via the left renal vein or more inferiorly, and crossover is usually anterior to the aorta ^6,7. In this study, we present a case of LIVC associated with nutcracker phenomenon.

The patient was evaluated by abdominal ultrasound and CT examinations. Abdominal ultrasound revealed a 16 cm x 11 cm x 11 cm heterogeneous/hyperechoic mass in the left lobe of the liver. The biliary tree was not dilated. Noncontrast and contrast-enhanced abdominal and pelvic CT scans showed the mass had invaded the celiac truncus and the head of the pancreas and, the liver was not cirrhotic. A Tru-cut biopsy was performed, and the microscopic findings suggested a metastatic neoplasm originating from an adenocarcinoma.

Multiplanar contrast-enhanced CT of the abdomen also showed the interposition of the IVC (Figure 1). At the level of the renal hila; the left vena cava passes either in front of the aorta or runs to right as a left renal vein and becomes stenosed and the distal portion of the left renal vein was dilated. The criterion for diagnosis of nutcracker phenomenon is accepted the ratio of anteroposterior diameter of the stenosed segment (between the aorta and SMA) to the left renal vein near the hilum is more than 1/5 (8). In our case, the ratio of stenosed segment of the left renal vein (between the aorta and SMA) and dilated segment of the left renal vein near the hilum of the anteroposterior diameters was measured the approximetly 2mm/12mm. Consecutive axial CT images showed compression of the left renal vein between the aorta and the superior mesenteric artery (SMA) (Figure 2).

Click Here to Zoom

Figure 1: At the level of the renal hila, coronal contrastenhanced CT image shows an interposition of the IVC (aa: abdominal aorta, Livc: left inferior vena cava, arrow: the narrow part of the left renal vein, zigzag arrow: superior mesenteric artery, arrowheads: suprarenal inferior vena cava)

Click Here to Zoom

Figure 2A, B, C, D, and E: Consecutive axial CT images shows compression of the left renal vein between the aorta and superior mesenteric artery. The left vena cava passes either in front of the aorta or runs to right as a left renal vein in the arterial phases (aa:abdominal aorta, ivc:inferior vena cava, black arrows: narrow segment of left renal vein, double arrows: left renal vein, Livc: left inferior vena cava, black arrowhead: superior mesenteric artery).

Owing to her poor clinical state, she did not operate. Twenty days later, the patient died.

Usual clinical presentation of the nutcracker phenomenon may include flank pain or abdominal back pain only 1-3. Our patient presented with abdominal pain and hematuria. Due to poor health condition with metastatic liver disease, she was not evaluated for nutcracker phenomenon.

In the fifth week of gestation, 3 pairs of major veins differentiate: the vitelline veins, the umbilical veins, and the cardinal veins. From a division of the cardinal veins, the subcardinal veins and the lower portion of the IVC form ⁶. The subcardinal system is composed of paired veins on either side of the developing abdominal aorta. The left subcardinal vein typically regresses to form the left gonadal vein and the left renal vein ^6,7. If this left subcardinal venous system does not regress and the left renal vein remains, an LIVC, also called a transposed IVC is formed. The most common variations are duplicate IVC, retroaortic renal veins, and circumaortic venous rings ^6,7. However, LIVCs are rare, with a reported incidence of only 0.2%-0.5% ^6,7.

The left IVC is of no importance unless a surgical operation is being considered. Its surgical implications can be important because it may complicate the surgery of aneurysms of the abdominal aorta.

To the best of our knowledge, this is the first reported case of an association between of LIVC and the nutcracker phenomenon. We believe that LIVC and the nutcracker phenomenon may occur more frequently than has been reported owing to their anatomic relationship.

1) Cuellar I Calabria H, Quiroga et al. A. Nutcracker or left renal vein compression phenomenon: multidetector computed tomography findings and clinical significance. Eur Radiol. 2005 15:1745-1751.

2) Chang CT, Hung CC, Ng KK, et al Nutcracker syndrome and left unilateral haematuria. Nephrol Dial Transplant. 2005; 20: 460-

3) Kaneko K, Kiya K, Nishimura K, et al. Nutcracker phenomenon demonstrated by three-dimensional computed tomography. Pediatr Nephrol. 2001; 16: 745-747.

4) Ekim M, Bakkaloglu SA, Tumer N, et al Orthostatic proteinuria as a result of venous compression (nutcracker phenomenon) a hypothesis testable with modern imaging techniques. Nephrol Dial Transplant. 1999; 14:826-827.

5) Kaneko K, Ohtomo Y, Yamashiro Y, et al Magnetic resonance angiography in nutcracker phenomenon. Clin Nephrol. 1999; 51: 259-260.

6) Minniti S, Visentini S, Procacci C. Congenital anomalies of the venae cavae: embryological origin, imaging features and report of three new variants. Eur Radiol. 2002; 12: 2040-2055.

7) Nishibe T, Sato M, Kondo Y, et al Abdominal aortic aneurysm with left-sided inferior vena cava. Report of a case. Int Angiol. 2004; 23: 400-402.

8) Cho BS, Choi YM, Kang HH, et al Diagnosis of nut-cracker phenomenon using renal Doppler ultrasound in orthostatic proteinuria. Nephrol Dial Transplant. 2001 Aug; 16: 1620-1625.