Nutcracker syndrome: when should it be treated and how?

Nutcracker syndrome refers to compression of the left renal vein by the superior mesenteric artery and aorta. Patients typically present with left flank pain and associated symptoms of pelvic congestion. Hematuria is frequently present, and vulvar or lower extremity varices are seen in a subset of patients. Clinical suspicion of the syndrome is confirmed by duplex scanning, computerized tomography, or magnetic resonance imaging. Documentation of a hemodynamically significant pressure gradient across the point of compression during venographic assessment in patients with appropriate symptom severity is important prior to undertaking treatment. A variety of surgical procedures have been described to achieve venous decompression, the most popular being that of transposition of the left renal vein to the more distal inferior vena cava. Long-term data on the success of surgical treatment is scarce. More recently, endovascular stenting of the left renal vein has been used.