Superior Mesenteric Artery Syndrome Complicated by Nutcracker Syndrome: Diagnostic and Therapeutic Challenges

Vascular compression syndromes result from compression of blood vessels by anatomical structures, impairing arterial or venous flow. Superior mesenteric artery (SMA) syndrome causes duodenal obstruction due to a narrowed aortomesenteric angle and a shortened distance. Nutcracker syndrome (NCS) involves compression of the left renal vein (LRV) between the SMA and aorta. Both conditions are rare, with concurrent cases infrequently reported. SMA syndrome has a notably low incidence, while the true prevalence of NCS is not well defined. Overlapping, nonspecific symptoms often delay diagnosis and increase morbidity. We report a 42-year-old woman presenting with two months of worsening abdominal pain, early satiety, nausea, diarrhea, and unintentional weight loss. Physical exam showed left-sided tenderness; laboratory results were unremarkable. Initial imaging, including upper GI series and gastric emptying study, was inconclusive. Symptoms improved with dietary changes but recurred on resuming normal intake, suggesting a structural cause. Computed tomography findings revealed a reduced aortomesenteric angle of 28° and a distance of 3.5 mm with duodenal narrowing, greater than 50% compression of the LRV, dilation of the gonadal veins, and pelvic varices, consistent with concurrent SMA syndrome and NCS. The patient was counseled on conservative management, including nutritional rehabilitation, with surgical options including duodenojejunostomy and renal vein procedures for refractory cases. Close follow-up was planned to monitor response and assess surgical need. This case underscores the importance of clinical suspicion for vascular compression syndromes and the value of advanced imaging when routine tests are inconclusive.