Left Vein Research Articles

Life-threatening presentation of an acute cerebellar ischemic stroke secondary to a protein C deficiency.

Acute cerebellar ischemic stroke is a rare disease in children. Typically, patients present with ataxia and cranial nerve palsy. Rarely, some patients show a severe intracranial hypertension syndrome with a life-threatening clinical presentation. We report a case of a 2-year-old male child who was admitted for deterioration of his consciousness level and vomiting. Cerebral imaging revealed a right cerebellar and brainstem infarction with an obstructive hydrocephalus and a tonsillar herniation. Angiography identified an occlusion of the right anterior inferior cerebellar artery. The child was referred to a neurosurgeon for the treatment of acute hydrocephalus and posterior fossa craniectomy. Etiological investigations revealed a protein C deficiency. Initially, the patient was maintained under fluid restriction and received mannitol several times as he had clinical and radiological signs of intracranial hypertension. He was also kept on mechanical ventilation and monitored. However, the evolution was complicated by the occurrence of a thrombosis of the vena cava and the renal vein.

Imipramine in dogs: A pharmacokinetic study following oral administration under fasted and fed conditions

This study investigates the pharmacokinetics (PK) of imipramine, a tricyclic antidepressant used in human psychiatric disorders and increasingly considered in veterinary medicine. Despite its longstanding use in canines, prior research on imipramine's PK in dogs is lacking. This study aimed to determine the PK of imipramine in dogs in regards to feeding conditions, and to ascertain whether desipramine (active metabolite) is formed or not. In this study, six male Labrador dogs underwent oral administration (1.5 mg/kg) of imipramine tablets (10 mg each; Tofranil®, Novartis) in both fasted and fed conditions. Dogs were randomly allocated to one of two treatment groups, employing an open, single-dose, two-treatment, two-phase, cross-over design, with a washout period of one week. Blood was drawn from the left cephalic vein to heparinized tubes at 0, 0.25, 0.5, 0.75, 1, 1.5, 2, 4, 6, 8, 10, 24, and 48 h. Plasma concentrations were quantified using a validated HPLC method, and the data were analyzed using PKanalix™ software with a non-compartmental approach.Concentrations of imipramine remained quantifiable up to 1.5 hr after administration under both conditions. Desipramine, in both feeding states, was detectable for a short duration, but not quantifiable. No significant differences were observed in the PK parameters of imipramine between the fasting and fed states. The rapid attainment of maximum concentration (Cmax) occurred within 0.25 h, indicating a swift absorption rate. Notably, the terminal half-life in dogs was remarkably short at 0.25 h, prompting a re-evaluation of dosing strategies. Considering the recommended therapeutic plasma concentrations in humans, the administered dose might result in effective levels for a brief period of time. Future research should explore intravenous administration, multiple-dose studies, and metabolic investigations to further elucidate imipramine's PK in dogs.

SURGICAL MANAGEMENT OF RENAL CELL CARCINOMA WITH INFERIOR VENA CAVA THROMBOSIS: A CLINICAL CASE

Kidney cancer with inferior vena cava thrombosis represents a complex condition that requires meticulous surgical treatment. The most common malignant kidney tumor in adults is renal cell carcinoma. The incidence of renal cell carcinoma has increased recently due to the enhanced resolution of imaging techniques. Most cases are discovered incidentally. Renal cell carcinoma's ability to spread to vascular systems without developing metastases is a significant feature. Venous involvement can manifest as a tumor thrombus in the renal vein on the affected side, potentially extending to the right atrium or the inferior vena cava. The risk of having a tumor thrombus in the renal vein or inferior vena cava ranges from 2-10%, with the right side being more frequently affected. The level of tumor thrombus extension can reach the hepatic veins and even the right atrium. This condition thus requires a multidisciplinary approach and a rational surgical strategy, focusing on achieving favorable outcomes in such complex cases.

Paradoxical cerebral embolism three decades after mustard surgery in a patient with complete transposition of the great arteries: a case report.

Atrial switch procedures such as the Mustard operation were previously popular for the complete transposition of the great arteries (i.e. dextro-transposition of the great arteries [d-TGA]). Patients with d-TGA who underwent atrial switch procedures approximately three decades ago have now entered adulthood. A female patient in her 30s with d-TGA had a paradoxical embolic stroke following the initiation of a low-dose oestrogen plus progesterone oral pill for dysmenorrhoea. She underwent Mustard surgery when she was 2 years old. Following a series of procedures including implantation of a permanent pacemaker that was required because of sinus node dysfunction, she had reached adulthood, was living by herself and working independently. One month after taking the low-dose oestrogen plus progesterone oral pill, venous thrombosis occurred in the left soleus and left peroneal veins; and she experienced an acute ischaemic stroke in the right middle cerebral artery area. Transoesophageal echocardiography revealed that the shunt was present only during the Valsalva manoeuvre. Based on the examinations, the patient was diagnosed with juvenile ischaemic stroke as a result of a paradoxical embolism. These findings suggest that paradoxical cerebral embolism can occur as a late complication in patients with d-TGA who underwent the Mustard operation as children.

On the Origin of Abdominal Venous Leiomyosarcomas: The Role of the Sex-Hormone Drainage Pathways.

We hypothesized that abdominal venous leiomyosarcoma (AV-LMS) disproportionately originates in veins of the sex-hormone drainage pathway (SHDP). Our purpose was to classify the anatomical origin of AV-LMS in a large cohort using imaging and explore prognostic implications. A retrospective review of imaging of all patients presenting with abdominal non-uterine LMS at a single tertiary oncology center was performed. Inclusion criteria were a biopsy-proven LMS of non-uterine abdominal/pelvic origin with pretreatment enhanced computed tomography (CT)/magnetic resonance imaging (MRI). Patients with uterine LMS or prior radiation were excluded. LMS site of origin was assigned by one expert radiologist and indeterminate sites were reviewed with a second external expert radiologist. Locations of inferior vena cava (IVC) tumors were subclassified based on a modification of prior literature. SHDP was defined as originating from ovarian/testicular vein, distal left renal vein, adrenal vein or mid-IVC (IIA). One hundred fifty-five (155) patients were included (92/152 (61%) female) with distant metastases found at presentation in 23/155 (14.8%). Most common organs of origins were veins (84/152, 55.3%), gastrointestinal (24, 15.8%), genital (11, 7.2%) and paratesticular/spermatic cord (11, 7.2%). For venous LMS, the adrenal (both sexes), mid-IVC (IVC IIA, females) and ovarian veins had the highest relative predilection for abdominal non-uterine LMS. Eighty-four (84/152, 55.3%) of tumors were SHDP. On multivariable analysis, both size and SHDP were significant predictors of distant metastases at presentation (P = 0.01), while sex, age, organ system/site and grade were not. For both sexes, tumors arising from SHDP constitute the majority of AV-LMS and may impart a significantly lower risk of metastatic disease at presentation. Among veins, the adrenal veins had the highest predilection for LMS.

Activating Transcription Factor 6 Mediates Inflammation in Experimental Varicocele-Induced Epididymal Epithelial Cells.

Varicocele is a dilatation of the internal spermatic vein and it is generally recognized as one cause of male infertility. This study aimed to analyze the roles of activating transcription factor 6 (ATF-6) in experimental varicocele-induced epididymal epithelial cells. Experimental left varicocele was established in rats through partial left renal vein ligation. At 8weeks after surgery, the left epididymal damage was observed using H&E and TUNEL staining. The expressions of neutral α-glucosidase (NAG), ATF-6, tumor necrosis factor (TNF)-α, and phospho-nuclear factor (p-NF)-κB p65 (S536) in the left epididymis were measured by immunohistochemistry. ATF-6 silence in rat epididymal epithelial cells was established by ATF-6 siRNA transfection. The cells were treated with hypoxia for 24h, and cell viability was measured by CCK-8, levels of NAG, TNF-α, and interleukin (IL)-8 in cells were measured by ELISA, levels of p-NF-κB p65 (S536)/NF-κB p65 protein in cells were measured by Western blotting. The results showed that the experimental left varicocele induced hypertrophy and apoptosis of epididymal epithelial cells (p<0.05), and decreased the expressions of NAG in the epididymal epithelial cells compared with the sham-operated control rats (p<0.01). Meanwhile, the expressions of ATF-6, TNF-α, and p-NF-κB p65 (S536) were increased in the epididymal epithelial cells after the experimental left varicocele compared with the sham-operated control rats (p<0.05). In the hypoxia-treated cells, ATF-6 silence increased the cell viability and decreased the levels of TNF-α, IL-8, and p-NF-κB p65 (S536) compared with the control cells (p<0.05). The ATF-6 pathway was activated in a rat's left varicocele-induced epididymal damage. Inhibition of the ATF-6 pathway might be a possible novel therapeutic approach for left varicocele-induced epididymal damage.

JAK2 Mutation Assessment in Thrombotic Events at Unusual Anatomical Sites: Insights from a High-Altitude Cohort.

Thrombosis stands as a significant contributor to both morbidity and mortality in individuals afflicted with myeloproliferative neoplasms. This retrospective study investigated the association between JAK2 mutations and venous thrombosis at unusual sites, and in young individuals with ischemic stroke, residing at high altitudes in the Aseer region, Saudi Arabia. Data were collected from two high-altitude referral hospitals over three years (2020-2022). Records of all JAK2 mutation tests were reviewed. Those requested as part of evaluation of thrombosis events, without known myeloproliferative neoplasms (MPNs) were analysed. Among the 208 JAK2 tests, 40 (19.2%) were linked to thrombotic event evaluations. The cohort, with a median age of 41, included 17 (42.7%) males and 23 females, with 57.5% having completely normal complete blood counts (CBC). Thrombotic events were divided between splanchnic vein thrombosis (36.6%) and cerebral thrombosis (34.1%), while the remaining cases involved unprovoked deep vein thromboses/pulmonary embolisms and portal vein thrombosis. Only 2 (5%) participants tested positive for JAK2 mutations: a 17-year-old male diagnosed concurrently with polycythemia vera after renal vein thrombosis and a 31-year-old woman with hepatic vein thrombosis and a normal CBC. This study reveals that JAK2 mutations are infrequently found in high-altitude patients with unprovoked DVT, PE, or atypical thrombosis. While JAK2 testing is notably relevant for splanchnic vein thrombosis, its routine use for other thrombotic events, particularly with normal CBC results, remains uncertain. Given the study's limitations, further prospective research with larger cohorts is needed to refine guidelines for JAK2 mutation testing in various thrombotic contexts.

Kidney transplant artery and vein stenting: 15-year follow-up

BackgroundWe would like to present an unusual case of simultaneous stenosis of renal graft artery and vein diagnosed four months after transplantation. both treated by stent placement. Our aim is to point at the fact that renal graft venous stenosis is very rarely reported in the literature and – as it is not easy to diagnose by routine US - it could be overlooked. If early detected it can be treated by stent placement.Case presentationWe present a case of 36-old-male with renal failure who received a kidney graft from deceased donor. The patient experienced delayed graft function. No rejection was found in the biopsy. Four months after transplantation the kidney function deteriorated to sCr 280 µmol/l. Graft artery stenosis together with graft vein stenosis was revealed. Both lesions were dilated with stent placement, the graft function returned to 230 µmol/l and became stable for 10 years. Ten years after stent placement graft function deteriorated to 300 µmol/l. An in stent restenosis of arterial stent was detected. It was successfully dilated by the balloon, the graft function returned to 230 µmol/l and stays stable for another 5 years.ConclusionsAn unusual simultaneous transplanted kidney artery and vein stenosis treated by stent placement is presented. The patient had stable graft function for 15 years after the procedure with one re-intervention on arterial stent.

Clinical case of successful thrombolysis in a newborn with thrombosis of the left renal vein

Thrombosis occurring in the neonatal period is a nosology with a large number of complications, often leading to disability and death. This article highlights the successful treatment of a newborn child with renal vein thrombosis using systemic thrombolysis. A clinical case of successful systemic thrombolysis in a full-term boy in the early neonatal period with thrombosis of the left renal vein and transition of the floating part of the thrombus to the inferior vena cava is presented. A child aged 3 days was admitted to the neonatal intensive care unit from a maternity hospital, where thrombosis was suspected. Gross hematuria was observed. Laboratory data revealed thrombocytopenia and increased levels of fibrinogen and D-dimer. Ultrasound showed a sharp increase in the volume of the left kidney, a diffuse change in its parenchyma, a sharp depletion of blood flow, and accumulation of fluid in the perinephric tissue on the left, and a thrombus was observed in the lumen of the left renal vein with the presence of a floating part extending into the inferior vena cava. Thrombolytic therapy with the drug alteplase was started in combination with an infusion of unfractionated heparin. Doses were selected based on coagulogram parameters. On day 2 of therapy, hematuria resolved. On day 4 of therapy, the alteplase infusion was completed, and heparin therapy was continued. On day 13, the child was switched to a low-molecular-weight-heparin therapy. Dynamic ultrasound revealed size reduction, recanalization and further thrombus lysis, and normalization of intrarenal blood flow and kidney size. No renal dysfunction was recorded during observation. The child was transferred to the further care unit at aged 14 days and was discharged home at the age of 25 days in satisfactory condition on ongoing anticoagulant therapy under outpatient supervision of a hematologist. During follow-up observation at aged 1.5 months of life, no clinical, laboratory, and ultrasound indicators of renal function disorders were noted. Currently, there are no approved recommendations and protocols for individual thrombosis in newborns, although this particular age group is due to the vulnerability of hemostasis to the development of a thrombotic process.

Testicular Pain Following Laparoscopic Donor Nephrectomy: An Underreported Complication.

Introduction: Testicular pain (TP) after laparoscopic donor nephrectomy (LDN) is a relatively underreported complication. This study aimed to investigate the incidence, characteristics, and factors associated with ipsilateral TP after left-sided LDN. Materials and Methods: This study prospectively collected baseline data and surgical details for all patients who underwent left-sided LDN during the study period. Each patient underwent scrotal ultrasonography 1 month postoperation. Donors were categorized by the level of gonadal vein ligation (level 1 at the renal vein confluence and level 2 at or below the iliac vessel crossing) and the presence or absence of TP. The characteristics of pain and demographics were compared across the groups. Results: Among 61 male patients who underwent left-sided LDN between March 2017 and December 2018, 54.1% (33/61) experienced ipsilateral TP. TP was more frequent in level 2 donors (64.3%) than in level 1 (45.5%), but the difference was not statistically significant (p = 0.141). Most TP occurred within a week (60.6%), was mild (75.8%), and resolved within 3 months (63.7%). The incidence of varicocele and hydrocele was 32.8% and 34.4%, respectively. The occurrence of TP was not significantly associated with the presence of varicocele or hydrocele and other factors. Conclusion: More than half of the male donors who underwent LDN experienced TP. The findings emphasize the importance of discussing this potential complication during preoperative counseling. This study found no significant association between TP and the level of gonadal vein ligation or the presence of varicocele, warranting further investigation into the cause of TP.

Monocentric prospective study to valid multidisciplinary diagnostic and therapeutic approach for Nutcracker syndrome.

Background: Nutcracker syndrome (NCS) is defined as left renal vein (LRV) compression by the superior mesenteric artery. NCS diagnosis is rendered complex by confounding symptoms. The study objective was to perform a prospective observational analysis of the diagnostic and therapeutic criteria of the patients with suspected NCS. When NCS diagnosis was confirmed, transposition of the LRV was carried out by mini-invasive robotic surgery (MIRS). Method: All patients addressed to the vascular surgery department for suspicion of NCS between January 2022 and June 2023 were included in the study. Patients were subsequently assessed by means of a computed tomography scan, dynamic duplex ultrasound and phlebography associated with an occlusion test of the left gonadic vein (LGV). Diagnostic criteria included aorto-mesenteric angle, LGV diameter and reflux, velocity ratios and diameters and the reno-caval gradient. Result: Thirty two patients aged 37 ± 14years had suspicion of NCS. Twenty presented an aorto-mesenteric angle below 20°, twenty three had a LGV diameter greater than 5mm and twenty two of the latter patients also had LGV reflux. A significant reno-caval gradient greater than 5mmHg was found in ten cases, thereby consolidating NCS diagnosis. Overall, thirteen patients neither presented NCS or pelvic varicosities; eight had pelvic congestion syndrome without NCS and were successfully treated by embolization. Eleven patients with confirmed NCS underwent LRV transposition in the inferior vena cava (IVC). Eight of the latter patients received a complementary pelvic varicosity embolization 2days later. Two months post-operation 100% of transposed LRV were permeable as assessed by duplex ultrasound controls and all of these patients reported an improvement of symptoms. Conclusion: An innovative multidisciplinary decisional algorithm establishes certitude in NCS diagnosis which can subsequently be treated radically by MIRS.

A rare combined variation of left renal vasculature in a human cadaver: embryological basis and clinical significance.

Classically, a single renal artery supplies, and a single renal vein drains each kidney. The morphology and variations in the renal vascular structures are of great importance when performing any type of renal surgery. The present case describes a rare combination of renal vasculature variation in a formalin-fixed, Chinese male cadaver. In this case, the left kidney is drained by a main renal vein (MRV) and an inferior renal vein (IRV), the latter might be the remnant of the left dorsal renal vein during the embryonic period. Two sets of renal arteries are present in this case, possibly due to persistent mesonephric arteries during embryonic development. Describing such anatomical variations is not only of academic interest but also important to help radiologists with the correct interpretation of image examinations and for surgeons to be prepared in advance.

Nephronsparing surgery for retroperitoneal sarcomas

Objective: to clarify the indications for the use of nephron-sparing technologies in surgical treatment of patients with retroperitoneal sarcomas. Material and Methods. The study included 64 patients with primary retroperitoneal sarcomas with kidney and renal pedicle invasion, who underwent surgical treatment in the Thoracic-abdominal Department of the P.A. Herzen Moscow Oncology Research Institute from 2010 to 2021. Twenty-one patients underwent nephrectomies, and 43 patients underwent nephron-sparing surgery. The morphological profile of sarcomas, age and gender of the patients, feasibility of using nephron-sparing technologies, postoperative complications, and long-term outcomes in patients of both groups were analyzed. Results. Forty-three patients with primary retroperitoneal sarcomas with invasion of the renal parenchyma, ureter, and renal pedicle underwent nephron-sparing surgery (precision mobilization of the kidney, ureter and vascular structures of the kidney from tumor tissue, kidney resection, ureteral stenting, resection of the renal vein orifices, resection of the ureters, and kidney autotransplantation). Postoperative complications were observed in 19.0 % of nephrectomy group patients (4 pts: II, IIIB, IV and V types according to Clavien–Dindo) and in 30.2 % of nephron-sparing group patients (15 pts: types II – 8, IIIA – 1, IIIB – 3, IV – 1). No statistical differences in the relapse-free period and survival time between two groups were observed. The 1-, 3- and 5-year survival rates were 84.1 %, 65.9 %, and 51.4 %, respectively. Multifactorial analysis showed that mortality increased significantly in patients over 64 years of age and was associated with both disease recurrence and concomitant pathology (p=0.009). There was also a trend toward decreased survival in patients with leiomyosarcoma (p=0.066). Conclusion. In retroperitoneal sarcomas, tumor resection with preservation of organs and structures not directly invaded by the tumor is the optimal surgical strategy. Nephron-sparing technologies do not worsen both immediate and long-term treatment outcomes. For leiomyosarcoma, tumor resection with nephrectomy is the most suitable approach.

Concomitant circumaortic and retro-aortic left renal veins associated with fenestrated renal artery.

Variations of the left renal vein can be in the form of circumaortic vein or renal collar, retro-aortic vein, additional renal vein, or multiple primary tributaries. We report a unique complex venous pattern of concomitant circumaortic and retro-aortic left renal veins associated with a fenestrated left renal artery. Two renal veins, anterior and posterior to the renal artery, originated from the renal hilum. The anterior vein was further divided into two branches. One branch passed through the fenestrated renal artery to continue as the anterior limb of the circumaortic vein. It received the suprarenal and gonadal veins and drained into the inferior vena cava. The other branch coursed posterior to the fenestrated renal artery and joined the posterior renal vein. The posterior renal vein was divided into two branches: one forming the posterior limb of the circumaortic vein, and the other continued obliquely downwards as the retro-aortic vein. Variations in the left renal vein have been implicated in several clinical conditions, such as varicocele and pelvic varices. It also plays a crucial role in renal transplantation, as the left kidney is often used as the donor organ. Even though many reports have been published on circumaortic and retro-aortic veins, the complex venous pattern associated with a fenestrated renal artery has not been reported previously.

Differentiation of solid and friable tumour thrombus in patients with renal cell carcinoma: The role of MRI apparent diffusion coefficient

PurposeInferior vena cava (IVC) involvement by renal cell carcinoma (RCC) is associated with a higher disease stage and is considered a risk factor for poor prognosis. This study aimed to investigate the role of the apparent diffusion coefficient (ADC) of MRI 3D texture analysis in the differentiation of solid and friable tumour thrombus in patients with RCC. Materials and methodsThe study involved 27 patients with RCC with tumour thrombus in the renal vein or IVC, surgically treated with nephrectomy and thrombectomy and in whom preoperatively abdominal MRI including the DWI sequence was conducted. For 3D texture analysis, the ADC map was used, and the first-order radiomic features were calculated from the whole volume of the thrombus. All tumour thrombi were histologically classified as solid or friable. ResultsThe solid and friable thrombus was detected in 51.9 ​% and 48.1 ​% of patients, respectively. No differences in mean values of range, 90th percentile, interquartile range, kurtosis, uniformity and variance were found between groups. Equal sensitivity and specificity (93 ​% and 69 ​%, respectively) of ADC mean, median and entropy in differentiation between solid and friable tumour thrombus, with the highest AUC for entropy (0.808), were observed. Applying the skewness threshold value of 0.09 allowed us to achieve a sensitivity of 86 ​% and a specificity of 92 ​%. ConclusionsIn patients with RCC and tumour thrombus in the renal vein or IVC, the 3D texture analysis based on ADC-map allows for precise differentiation of a solid from a friable thrombus.

Point of care ultrasound and shock: The value in bedside diagnosis and hemodynamic assessment in undifferentiated shock patients

Point of care ultrasound (POCUS) was introduced as a tool for critical care assessment in the 1990s and has since grown to be a tool for quantitative and qualitative data. Adopted initially by the emergency medicine community, it has recently been integrated into medical education for numerous specialties. It remains a valuable adjunct in the initial evaluation of patients as a widely available portable resource and provides real-time imaging. In patients who present in undifferentiated shock, visualization of the heart and lungs using POCUS can help delineate the cause of the clinical decompensation. Cardiac evaluation can look for right and left ventricular dysfunction, estimate left ventricle ejection fraction, evaluate for cardiac tamponade, and detect new wall motion abnormalities. Assessment of the lungs can add additional insight into underlying pathology. In patients who suffer cardiac arrest, POCUS can help identify any potentially reversible causes. It can also be used for hemodynamic assessment to aid in the resuscitation of patients with shock by evaluating of the inferior vena cava, hepatic, and renal veins. Here we provide a resource to describe not only the numerous benefits of POCUS in assessing and monitoring critically ill patients, but also the imaging findings of life-threatening diagnoses.

Tumor Characteristics Associated With Preoperatively Detectable Tumor-Informed Circulating Tumor DNA in Patients With Renal Masses Suspicious for Renal Cell Carcinoma.

Understanding the specific tumor characteristics associated with detectable circulating tumor DNA (ctDNA) in patients with renal cell carcinoma (RCC) is critical for informing future studies aiming to establish the clinical utility of such testing. We characterized the pathologic and clinical features associated with preoperatively detectable ctDNA in patients with renal masses suspicious for RCC. Consecutive patients who underwent partial or radical nephrectomy for nonmetastatic suspected RCC (cT1b-T3) during 2022-2023 had prospectively collected tumor-informed ctDNA analyses conducted preoperatively and postoperatively. Descriptive statistics and univariate analyses were used to describe the study findings. Sixty-nine patients with a median age of 62 years (IQR, 51-70) and a median follow-up time of 7 months (IQR, 3-11) had 205 ctDNA samples collected for analysis. Thirty-nine (61%) had preoperative detectable ctDNA of 64 patients. Postoperative ctDNA status was available for 47 patients, and three (6%) had detectable ctDNA. Two had inferior vena cava (IVC) involvement, and one developed metastatic disease. Subgroup analysis of solely malignant RCC (n = 65) revealed that patients with preoperative detectable ctDNA had a higher pathologic stage (P = .001), larger tumors (7 v 4.5 cm; P = .001), higher tumor complexity (P = .022), and increased rates of tumor grades 3-4 (P = .038). All patients with gross renal vein or IVC involvement (n = 9) and those with lymphovascular invasion (n = 6) on pathology had detectable preoperative ctDNA. On univariate analysis, high tumor complexity, larger tumors, and tumor grades 3-4 were found to be predictors of preoperatively detectable ctDNA status. Preoperative ctDNA was detectable in 61% of patients with nonmetastatic RCC, and it correlated with clinically relevant features. Clinical trials should consider incorporating both preoperative and postoperative ctDNA analyses to augment prediction of disease recurrence and to refine treatment decision making.

The Ligament of Marshall: Far From Vestigial!

BackgroundThe ligament of Marshall (LOM) is a vestigial fold of the left atrium that contains the remnant left cardinal vein, muscle bundles, and nerve fibers. Despite its description as an embryologic remnant, the LOM carries significant clinical importance as an important focus for atrial fibrillation propagation as well as a therapeutic target. MethodsIn this review, we discuss the embryologic origins of the LOM, its physiology and importance in atrial fibrillation pathogenesis, as well as the role of targeting and ablating the LOM surgically during concomitant cardiac surgery including lung transplantation. ResultsThe LOM, particularly its distal segment, is an important focus for atrial fibrillation as both a primary trigger as well as an accessory bundle for signal propagation. It is a key target for electrophysiologic therapies including radiofrequency and alcohol-based ablative strategies. The LOM is also a crucial target for surgical ablation while addressing the left atrial lesion sets. This is often performed concomitantly with other cardiac surgical operations and may play an important role in reducing the risk of postoperative atrial fibrillation after lung transplantation. ConclusionsFar from just a vestigial structure, the ligament of Marshall remains an important focus for paroxysmal atrial fibrillation and is a potent therapeutic target for both electrophysiologic and surgical approaches.

Left-Sided Inferior Vena Cava: A Retrospective Study and Literature Review

ObjectiveThe primary goal of this research is to delve into the clinical and pathological facets of the left-sided inferior vena cava (IVC), and to catalogue and condense its radiological and clinical attributes, thereby furnishing valuable references for pertinent clinical diagnosis and therapeutic procedures. MethodsWe collated and scrutinized the general clinical features, radiological characteristics, and diagnostic and therapeutic strategies of 30 patients diagnosed with left-sided IVC in our hospital from July 2014 through February 2024. ResultsA majority of patients were asymptomatic and were only identified during diagnostic procedures for other ailments. CT scans revealed anomalies in the anatomical configuration of the left-sided IVC. The radiological presentations primarily showcased the right common iliac vein traversing the lumbar vertebrae to amalgamate with the left common iliac vein, forming the IVC. The IVC ascended on the left side of the abdominal aorta, accepted the left renal vein, and then transitioned to the right side of the abdominal aorta. In three instances, the IVC was witnessed ascending on the left side of the abdominal aorta, permeating through the diaphragm, converging with the azygos vein and abdominal aorta, and making its way into the right atrium. In these cases, the hepatic segment of the IVC was missing, and there was an absence of the IVC inferior to the hepatic vein, a condition we refer to as complete left-sided IVC. ConclusionLeft-sided IVC is predominantly asymptomatic but carries significant anatomical implications during abdominal, retroperitoneal surgeries, and vascular interventions. Precise identification and management of this anomaly can mitigate surgical risks and enhance patient prognosis.

Renal autotransplant as a definitive treatment for nutcracker syndrome: A multicenter retrospective study

ObjectiveNutcracker syndrome is a rare condition that involves mechanical compression of the left renal vein, leading to chronic and debilitating left flank pain. The etiology of the pain is misdiagnosed frequently, and patients usually require long-term opioid use to manage their pain. Multiple therapeutic options for nutcracker syndrome have been described in the literature but the reports are limited by small numbers of patients, and the lack of convincing data demonstrating consistently improved outcomes. Here we report the largest series to date of patients undergoing renal autotransplantation for the treatment of nutcracker syndrome. MethodsWe performed a multicenter retrospective cohort review of patients 105 patients with nutcracker syndrome who underwent renal autotransplantation as a primary or salvage therapy. ResultsDuring the overall study period, 93.1% of patients treated with autotransplantation had durable, complete flank pain relief at 12 months with both open and robotic surgical approach. After autotransplantation, a statistically significant decrease in the percentage of patients using opioids from 48.6% to 17.0% was demonstrated at 12 months. In those patients using opioids before autotransplantation, a statistically significant decrease in morphine milligram equivalents was demonstrated from an alarming 68.9 ± 15.0 per day to 25.0 ± 11.02 morphine milligram equivalents per day. ConclusionsOur findings suggest that renal autotransplantation, as a primary treatment or a salvage treatment, in patients with nutcracker syndrome provides durable pain relief and a marked decrease in chronic opioid use regardless of surgical approach.