Posterior nutcracker syndrome managed with gonadal vein transposition in a 22-year-old woman: a case report

Introduction: Nutcracker syndrome refers to a condition in which the left renal vein is anatomically entrapped. A rare variant of this syndrome, posterior nutcracker syndrome, occurs when the retroaortic renal vein is compressed between the aorta and the vertebral body. Case presentation: A 22-year-old woman from a rural town in Ethiopia presented with left flank abdominal pain that had persisted for 4 months. Her vital signs were normal, though she had a slightly low body mass index of 18.75 kg/m 2 . During the physical examination, mild tenderness was noted over the left flank. Urinalysis revealed hematuria, and a computed tomography angiogram of the abdomen and pelvis confirmed left renal vein compression between the aorta and the vertebral column. The patient subsequently underwent left ovarian (Gonadal) vein transposition and an end-to-side anastomosis to the inferior vena cava. She experienced a smooth postoperative recovery and was discharged. Discussion: Posterior nutcracker syndrome is a rare cause of hematuria and chronic flank pain. Computed tomography angiography plays a central role in diagnosis by demonstrating left renal vein compression and collateral venous pathways. Surgical intervention is indicated in symptomatic patients with persistent or disabling symptoms. Gonadal vein transposition is effective in decompressing the left renal venous system. Conclusion: Posterior nutcracker syndrome is a rare vascular condition that may present with unexplained hematuria and chronic flank pain. Gonadal vein transposition is a potential treatment for selected patients with persistent symptoms, but longer follow-up and objective postoperative imaging are needed to determine long-term outcomes.