Posterior Nutcracker Syndrome with Left Renal Vein Duplication

In females, persistently elevated venous pressure in the gonadal vein may eventually lead to reflux and collateral vessel forma-tion, manifesting as lower abdominal or pelvic pain that radiates to the posteromedial thigh and buttock.3'5'6 Hypertension alone is not a typical clinical manifestation.7 Usually, hypertension is accompanied or pre-ceded by abdominal pain, hematu-ria, and other signs, including ortho-static proteinuria, chronic fatigue, pelvic congestion and, in males, formation of a left-sided varicocele. Passage of blood clots along the left ureter may result in ureteral colic and manifest as left flank pain.5 Doppler ultrasonography, CTA, magnetic resonance angiography, and renal venography are estab-lished modalities for evaluation of these cases. Imaging reveals retroaortic left renal vein and its abrupt narrowing point between the abdominal aorta and vertebral column, as well as secondary effects such as collateral vessel forma-tion (eg, gonadal vein).1'3'4 Associated radiologic abnormalities, including cross-fused renal ectopia and other vascular anomalies such as renal arte-riovenous malformation, aneurysm, or left renal vein duplication may also be seen on CT, as in our case.1'3 Symptomatic treatment is based on clinical presentation and severity of left renal vein hypertension.