Surgical management of Nutcracker syndrome caused by a middle mesenteric artery in an adolescent

Nutcracker syndrome is a rare condition usually caused by compression of the left renal vein between the aorta and superior mesenteric artery. The middle mesenteric artery (MMA) is an exceptional anatomical variant, reported in only 27 cases, most often incidentally. We describe an 18-year-old patient with chronic left flank pain and left varicocele. Computed tomography angiography confirmed compression of the left renal vein by the MMA (compression ratio, 3.0; angle. 14°). Surgical division, transposition, and orthotopic reimplantation were performed successfully. Recognition of rare vascular variants such as the MMA is crucial for accurate diagnosis and appropriate surgical management.