The optimal management strategy of nutcracker syndrome is debated, especially in the setting of concurrent pelvic congestion syndrome. In this article, we describe our treatment algorithm as illustrated by four different case scenarios. In our experience, renocaval pressure gradients are often inconclusive, but evaluation of the left renal vein waveform as well as a "test PTA" with evidence of a waist in the balloon can be helpful in unmasking a relevant stenosis. We consider nutcracker syndrome not to be a contraindication for ovarian vein embolization. Decision for simultaneous or sequential stenting should be based on angiographic findings and clinical course.