Concurrent Superior Mesenteric Artery and Nutcracker Syndromes: A Case Report

TL;DR

A 16-year-old male with rare dual vascular compression disorders was successfully treated with surgery for one condition and monitored for the other.

Contribution

This case report presents the rare concurrent occurrence of superior mesenteric artery and nutcracker syndromes in a single patient.

Findings

Aortomesenteric angle and distance measurements confirmed SMAS in a patient with gastrointestinal symptoms.

Compression of the left renal vein and collateral venous pathways indicated concomitant NCS.

Surgical intervention resolved SMAS symptoms, while asymptomatic NCS was managed conservatively.

Abstract

Superior mesenteric artery syndrome (SMAS) and nutcracker syndrome (NCS) are rare vascular compression disorders caused by entrapment of the third portion of the duodenum and the left renal vein, respectively, between the abdominal aorta and the superior mesenteric artery (SMA). While both conditions share a common pathophysiological mechanism, their simultaneous occurrence remains exceptionally rare. We report the case of a 16-year-old male patient who presented with persistent epigastric pain, nausea, and bilious vomiting. Clinical history revealed recent unquantified weight loss, with a body mass index (BMI) of 17.5 kg/m². Contrast-enhanced computed tomography (CECT) demonstrated a markedly reduced aortomesenteric angle (14.3°) and distance (3.9 mm), consistent with SMAS, along with compression of the left renal vein, upstream dilation, and collateral venous pathways, supporting the diagnosis of concomitant NCS. Due to the severity of duodenal obstruction and failure of conservative management, the patient underwent a transmesocolic anisoperistaltic gastrojejunostomy. Postoperative recovery was uneventful, with complete resolution of gastrointestinal symptoms and satisfactory nutritional improvement at the three-month follow-up. As NCS was asymptomatic, it was managed conservatively with scheduled clinical and radiological surveillance. This case highlights the importance of comprehensive cross-sectional imaging in identifying dual vascular compression syndromes and emphasizes the need for individualized treatment strategies based on symptomatology and anatomical findings.

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