Management of Nutcracker syndrome; a multicentric case series study among Egyptian population

Background Nutcracker syndrome (NCS) is an uncommon vascular compression disorder caused by extrinsic compression of the left renal vein (LRV), resulting in renal venous hypertension. This study evaluates the clinical presentation, diagnostic workup, management strategies, and clinical outcomes of patients with NCS treated across multiple vascular referral centers in Egypt. Methods A retrospective multicenter case series was conducted between January 2018 and December 2023. Diagnosis was established using clinical findings supported by duplex ultrasonography, computed tomography venography and magnetic resonance venography. Results Fourteen patients underwent intervention for symptomatic NCS. Clinical presentation included hematuria, flank pain, varicocele, pelvic congestion symptoms, and low back pain. Both anterior and posterior anatomical variants were identified, including one patient with a circum-aortic left renal vein and one patient with concomitant superior mesenteric artery syndrome requiring combined surgical treatment. Open surgery was the predominant treatment strategy, with left renal vein transposition performed in most patients, while selected patients underwent left gonadal vein transposition or endovascular LRV stenting. Technical success was achieved in all interventions. Early postoperative complications were infrequent and consisted mainly of transient ileus and one superficial wound infection. During follow-up, most patients experienced complete or substantial resolution of symptoms with durable clinical improvement. One patient developed LRV occlusion after transposition with persistent intermittent symptoms, whereas no major procedure-related mortality or life-threatening complications were observed. Conclusions Left renal vein transposition remains a durable and effective surgical option, whereas endovascular stenting represents a valuable minimally invasive alternative in carefully selected patients.