[Transposition of the Superior Mesenteric Artery at the Infrarenal Segment of the Aorta in "Nut Cracker Syndrome"].

The nut cracker syndrome (NCS) can be considered as an under-diagnosed disease, which the patients have usually suffered from for a prolonged time prior to correct diagnosis and subsequent initiation of adequate therapy. There are several possible therapies, the most promising - transposition of the superior mesenteric artery (SMA) - from the perspective of its aetiopathogenesis - has rarely been used.Based on selective references from the scientific medical literature and our own clinical experiences in vascular medicine, the important characteristics of the "nut cracker" phenomenon and syndrome are described.A topic-related narrative review has been based on a literature search in PubMed using the key words "Nut cracker syndrome", "May-Turner syndrome", "Wilkie syndrome", "aorto-mesenteric angle", "pelvic congestion syndrome".There are diverse symptoms in NCS, which is unspecific; however, in particular, the combination of signs and symptoms associated with a suspicious pathological urine finding may indicate NCS. Duplex ultrasonography and CT-scan are very accurate diagnostic procedures and include an adequate search for simultaneously occurring vascular anomalies. Taken together, clinical findings and laboratory parameters may lead to a patient-specific and graduated therapeutic plan, in which transposition of SMA is a causal, effective and safe procedure, particularly when there are combined vascular anomalies, e.g., the combination of NCS with May-Turner syndrome in young patients.The nutcracker syndrome as venous congestion of the kidney may be a "hard nut". Modern medicine aims at achieving evidence for the best approach by case reports and retrospective cohort studies and can - in the meanwhile - provide a verified diagnostic work-up. In addition, is a therapeutic algorithm comprising a spectrum of highly effective measures, particularly for young patients, who frequently exhibit additional vascular anomalies.