Left Renal Venography Research Articles

Reply to the correspondence letter by Park et al. “Renal Doppler ultrasonography in the diagnosis of nutcracker syndrome”

We appreciate the interest of and comments by Park et al. Nutcracker syndrome is certainly an under-recognized cause of hematuria in children. It was noted that left renal venography is the most accurate modality to identify nutcracker syndrome, and it was concluded that renal Doppler ultrasonography should be considered as an initial screening tool in children with hematuria. We agree with this opinion; however, we would like to make additional comments. We described nutcracker syndrome as an uncommon but under-recognized cause of hematuria in children. Yang et al. also consider nutcracker syndrome as a rare clinical condition [3]. Our case report is an attempt for physicians to consider this diagnosis, especially in the emergency department, when evaluating children with hematuria, especially hematuria associated with abdominal pain. We agree with the opinion of ultrasonography being the initial investigation in children with isolated hematuria. However, in the emergency department when patients present with undifferentiated abdominal pain, other alternative diagnoses should be considered. Computed tomography (CT) scans are helpful in identifying and excluding other causes of acute abdominal pain. Reports from emergency departments indicate the use of CT scan for the diagnosis of nutcracker syndrome [2]. The diagnostic value of CT scan is well established in the evaluation of nutcracker syndrome and is well correlated with renal venography and renocaval pressure gradient [1]. An important limitation of the use of ultrasound is that it is operator-dependent and may not be feasible in the emergency departments at all times.

Incapacitating Pelvic Congestion Syndrome in a Patient With a History of May–Thurner Syndrome and Left Ovarian Vein Embolization

The aim of this article is to report a rare case of unresolved incapacitating pelvic congestion syndrome (PCS) in a patient with a history of May-Thurner syndrome previously treated with stenting and left ovarian vein embolization. Additionally, this article highlights the role of pelvic venography in patients with PCS and reviews the coexistence. A 32-year-old woman was referred to us for the evaluation of recurrent pelvic pain and dyspareunia requiring analgesics. Initially, she developed left lower-extremity deep vein thrombosis a few months after her first pregnancy. On further workup, she was diagnosed with May-Thurner syndrome and underwent left common iliac and left external iliac vein stenting. Furthermore, left ovarian vein coil embolization was performed for symptoms suggesting PCS at the same outside facility. The patient was referred to us for persistent pelvic pain approximately 1 year after she underwent left ovarian vein coil embolization. A diagnosis of incompletely resolved PCS was considered. Iliocaval venogram demonstrated patent left common iliac and external iliac venous stents in situ. Subsequent right ovarian venogram revealed a patent, but grossly dilated, right ovarian vein with retrograde flow and cross-pelvic collaterals confirming grade III PCS. Right ovarian vein coil embolization was performed, with excellent patient outcome. In the setting of a combined diagnosis of PCS and May-Thurner syndrome, persistent incapacitating PCS after initial iliac stenting should be followed with a complete pelvic venous evaluation including ovarian and left renal venography to rule out residual pelvic congestion secondary to any coexisting ovarian vein incompetencies or nutcracker syndrome.

Hemodynamic Investigation of the Left Renal Vein in Pediatric Varicocele: Doppler US, Venography, and Pressure Measurements

To evaluate prospectively the hemodynamic state of the left renal vein with Doppler ultrasonography (US) and venography in pediatric patients with varicocele to assess the "nutcracker phenomenon." The institutional review board considered this study ethically sound, and parental informed consent was obtained for all subjects. Doppler US of the left renal vein was performed in 27 consecutive boys with varicocele (age range, 7-15 years; mean, 11.9 years) and in 20 boys without varicocele as control subjects (age range, 7-17 years; mean, 11.4 years). Doppler US was used to evaluate left renal vein diameters and peak velocities in the proximal left renal vein near the renal hilum and in the left renal vein between the aorta and superior mesenteric artery (aortomesenteric portion). The diameter ratios and peak velocity ratios between two sites were obtained. For statistical comparison of results, the t test was used. Left renal venography and renocaval pressure measurement were performed in 13 patients with varicocele. The Fisher exact test was used to evaluate the associations between the nutcracker phenomenon (renocaval pressure gradient >/=3 mm Hg) and the development of collateral veins. The diameters of the proximal left renal vein and the peak velocities in the aortomesenteric portion of the left renal vein were significantly different between the varicocele group and the control group (P < .001). The diameter ratios (5.7 +/- 1.8 [standard deviation]) and peak velocity ratios (5.2 +/- 2.6) in patients with varicocele were significantly higher than those in control subjects (3.5 +/- 1.0 and 3.1 +/- 0.8, respectively) (P < .005). According to findings at left renal venography (n = 13), 10 patients (77%) met the criteria for the nutcracker phenomenon. The nutcracker phenomenon was significantly associated with the development of collateral veins (P = .035). Doppler US and venography of the left renal vein can show hemodynamic changes of the left renal vein and depict the presence of the nutcracker phenomenon in pediatric varicocele.

Varicocele: A review of radiological and anatomical features in relation to surgical treatment

The patterns of venous drainage of the testis and scrotum have been evaluated in patients with varicocele by a variety of radiological procedures, including left renal venography, and at the time of operation by ascending venography and retrograde injection of contrast medium into prominent varicosities. These studies have allowed classification of the system of veins involved in the condition into several groups, including involvement of the internal spermatic vein alone, pure cremasteric varicocele, mixed internal spermatic and cremasteric varicosities in one or both systems with valvular incompetence or mere dilatation without apparent incompetence of valves. As a result, an anatomical approach to the surgical management of varicocele is suggested which attempts to place the operative treatment on a more rational basis appropriate to each case.

Incidence and implications of a left inferior vena cava on IVC filter placement

Abstract Objective: To assess the prevalence and ability to detect a left inferior vena cava (IVC) during venography prior to filter placement and its implications for device implantation. Materials and Methods : Over 58 months, patients referred for an IVC filter were prospectively evaluated for a left IVC by performing cavography injecting into the left iliac vein, left renal venography, or CT scan correlation. Additionally, cavograms of patients receiving filters over the four previous years were reviewed to assess the adequacy of detecting these anomalies based on the degree of opacification of the left iliac vein in relation to the position of the catheter tip. Results: Prospective evaluation for a left IVC was adequate in 477 of 503 patients. Retrospective evaluation using CT scans was possible in another 14. Left IVCs were detected in 5 patients (1%). Three patients with duplications were managed with either 2 filters, a suprarenal filter, or a bird′s nest filter straddling both cavas. Two patients with isolated left IVCs received a single filter. Of 62 retrospectively reviewed cavograms, the left iliac vein was inadequately opacified in 69% when the catheter was in the low IVC (53 patients) and 71% when it was in the right iliac vein (7 patients). Conclusions: Low caval or right iliac vein injections infrequently provide sufficient reflux into the left iliac vein to assess for a left IVC. Left iliac vein catheterization is easy and will readily provide this information. Modifications in filter placement technique may be necessary when caval anomalies are present.

Intravenous Stent Placement for Treatment of the Nutcracker Syndrome

The nutcracker syndrome was first reported in 1972 by de Schepper.1 It is a rare cause of hematuria. We placed a stent in the left renal vein to treat a recent case of the nutcracker syndrome. CASE REPORT A 37-year-old man presented with intermittent gross hematuria 4 years in duration. Physical examination revealed no abnormal findings. Laboratory tests were within normal range except for microscopic hematuria. Ultrasonography of the urinary tract and excretory urography were normal. Cystoscopy showed gross bleeding from the left ureteral orifice. Angiographic computerized tomography (CT) of the abdomen demonstrated that the left renal vein was compressed between the abdominal aorta and superior mesenteric artery (SMA), and had become stenosed. The distal portion of the left renal vein was dilated (fig. 1, A). Sagittal magnetic resonance angiography revealed that the angle between the abdominal aorta and SMA was only 21 degrees (normal 90) and the left renal vein exhibited oblate form due to compression (fig. 1, B). Left renal venography showed obstruction of left renal venous outflow, and intrarenal and perihilar varices (fig. 2, A). On the basis of these findings, we diagnosed the nutcracker syndrome. We used a venous endoprosthetic stent (Wallstent, Boston Scientific Corp., Natick, Massachusetts) for treatment. The stent was composed of thin stainless steel wire, which was bent into a cylindrical mesh structure. It was placed into the left renal vein via the left transfemoral vein. After stent placement left renal venography demonstrated that blood outflow was unobstructed (fig. 2, B). The patient received antiplatelet therapy postoperatively. Six days later the hematuria resolved. The patient has been free of hematuria for more than 3 months.

Diagnosis of the Nutcracker Syndrome With Color Doppler Sonography: Correlation With Flow Patterns on Retrograde Left Renal Venography

Shigeo Takebayashi1 Teiichiroh Ueki2 Naoya Ikeda2 Atsushi Fujikawa2 OBJECTIVE. Our objective was to confirm flow patterns of the left renal vein and assess the usefulness of color Doppler sonography in the diagnosis of the renal vein entrapment. or nutcracker, syndrome. SUBJECTS AND METHODS. Forty-four patients with hematuria of unknown origin underwent color Doppler sonography, renal arteriography, retrograde left renal venography. and renocaval pressure measurement. The flow patterns were classified according to the presence or absence of distended left renal veins on sonograms and collateral veins on retrograde venograms. The sensitivity and specificity of color Doppler sonography for revealing the nutcracker syndrome were assessed by analyzing pressure gradients in combination with the venograms. which were used as the gold standard. RESULTS. Twenty-one nondistended left renal veins were seen, including 19 (43%) without collateral veins or hypertension and two (5%) with collateral veins but without hypertension (long-term nutcracker syndrome). The 23 distended left renal veins included seven without collateral veins or hypertension and one with hypertension but without collateral veins (early nutcracker syndrome). The remaining 15 distended left renal veins with collateral veins included I I (25%) with borderline hypertension (partially compensatory status of the syndrome) and four (9%) with hypertension (noncompensatory status of the syndrome). The sensitivity and specificity of color Doppler sonography for revealing the nutcracker syndrome were 78% and lO()%, respectively, when color flow in collateral veins was included in the diagnostic criteria. CONCLUSION. The nutcracker syndrome can exist in either nondistended or distended left renal veins. However, normal flow also can exist in distended left renal veins. The ability of color Doppler sonography to reveal color flow in collateral veins is useful for the noninvasive diagnosis of the nutcracker syndrome.

Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography.

Our objective was to confirm flow patterns of the left renal vein and assess the usefulness of color Doppler sonography in the diagnosis of the renal vein entrapment, or nutcracker, syndrome. Forty-four patients with hematuria of unknown origin underwent color Doppler sonography, renal arteriography, retrograde left renal venography, and renocaval pressure measurement. The flow patterns were classified according to the presence or absence of distended left renal veins on sonograms and collateral veins on retrograde venograms. The sensitivity and specificity of color Doppler sonography for revealing the nutcracker syndrome were assessed by analyzing pressure gradients in combination with the venograms, which were used as the gold standard. Twenty-one nondistended left renal veins were seen, including 19 (43%) without collateral veins or hypertension and two (5%) with collateral veins but without hypertension (long-term nutcracker syndrome). The 23 distended left renal veins included seven without collateral veins or hypertension and one with hypertension but without collateral veins (early nutcracker syndrome). The remaining 15 distended left renal veins with collateral veins included 11 (25%) with borderline hypertension (partially compensatory status of the syndrome) and four (9%) with hypertension (noncompensatory status of the syndrome). The sensitivity and specificity of color Doppler sonography for revealing the nutcracker syndrome were 78% and 100%, respectively, when color flow in collateral veins was included in the diagnostic criteria. The nutcracker syndrome can exist in either nondistended or distended left renal veins. However, normal flow also can exist in distended left renal veins. The ability of color Doppler sonography to reveal color flow in collateral veins is useful for the noninvasive diagnosis of the nutcracker syndrome.

Left renal vein entrapment syndrome in two girls with orthostatic proteinuria

Left renal vein entrapment was documented by bilateral ureteral catheterization and imaging studies as a cause of orthostatic proteinuria in two girls. Renal ultrasonography showed compression of the left renal vein between the aorta and the superior mesenteric artery (Nutcracker phenomenon). Abnormal collateral veins and high pressure gradients between the left renal vein and the inferior vena cava were found on left renal venography and pressure tracing, respectively. The left kidney was documented as the source of postural proteinuria by bilateral ureteral catheterization. Our observations suggest renal congestion due to left renal vein entrapment was the cause of orthostatic proteinuria.

Embolization of the internal spermatic vein in varicocele: significance of venous pressure.

Embolization of the left internal spermatic vein using spring-coils was performed in 20 patients with varicocele following pressure measurement of the left renal vein and inferior vena cava. During the follow-up of 16-24 months, there was no recurrence in 16 patients with pressure difference less than 3 mmHg; however, there were two recurrences in 4 patients with pressure difference greater than 4 mmHg and opacified adrenal or ureteral veins on venography. We conclude that a significant pressure difference between left renal vein and inferior vena cava, and opacification of adrenal or ureteral veins on left renal venography may be poor prognostic signs of recurrence of varicocele following embolization.

Varicocele in Children: “To Treat or Not to Treat”—Venographic and Manometric Studies

The management of varicocele is still controversial in spite of its high incidence (15%) in prepubertal boys and young adults and although it is believed to represent a major contributing factor to male subfertility. Fifty boys between 6 and 14 years of age were operated on for left varicocele, and a long segment of the left internal spermatic vein was excised. Thirty-four of them underwent preoperative retrograde left renal venography and pressure readings in both renal veins and inferior vena cava. In all 50 patients, intraoperative antegrade (via internal spermatic vein) left renal venography was performed. This examination revealed impaired renal venous drainage in 38 patients (group A) and normal venous return through the left renal vein in 12 patients (group B). In all 34 patients (from both groups) on whom retrograde venography was performed, there was marked renospermatic reflux. The pressure readings in the left renal vein were significantly increased in group A only. Our data strongly suggest that left varicocele is caused by renospermatic venous reflux and that this condition is probably irreversible. The reflux in group A is explained by the impaired venous drainage through the left renal vein. In group B, it is our impression that the reflux is a result of a congenitally valveless left internal spermatic vein. If varicocele is indeed a major cause for infertility, then our data logically point toward surgery.

A case of Renal Vein Thorombosis Associated with Nephrotic Syndrome

Renal vein thrombosis is usually a complication of multiple underlying renal disease rather than primary process. High incidence of renal vein thrombosis in patients with nephrotic syndrome, which suggest the nephrotic syndrome play a paramount role in the genesis of renal vein thrombosis or thromboembolic phenomena. But these are likely to relationship of egg and chicken, and then we cannot determine what is primary of these. Recently authors experienced a case that was questioned renal vein thrombosis with nephrotic-syndrome clinically, laboratory and preliminary radiologically, and this case is confirmed by selective left renal venography. Here we report a case of renal vein thrombosis with nephrotic syndrome which successfully managed with oral anticoagulants and reviewed literatures.

Varicocele in children: “To treat or not to treat” — Venographic and manometric studies

The management of varicocele is still controversial in spite of its high incidence (15%) in prepubertal boys and young adults and although it is believed to represent a major contributing factor to male subfertility. Fifty boys between 6 and 14 years of age were operated on for left varicocele, and a long segment of the left internal spermatic vein was excised. Thirty-four of them underwent preoperative retrograde left renal venography and pressure readings in both renal veins and inferior vena cava. In all 50 patients, intraoperative antegrade (via internal spermatic vein) left renal venography was performed. This examination revealed impaired renal venous drainage in 38 patients (group A) and normal venous return through the left renal vein in 12 patients (group B). In all 34 patients (from both groups) on whom retrograde venography was performed, there was marked renospermatic reflux. The pressure readings in the left renal vein were significantly increased in group A only. Our data strongly suggest that left varicocele is caused by renospermatic venous reflux and that this condition is probably irreversible. The reflux in group A is explained by the impaired venous drainage through the left renal vein. In group B, it is our impression that the reflux is a result of a congenitally valveless left internal spermatic vein. If varicocele is indeed a major cause for infertility, then our data logically point toward surgery.

Doppler flow studies, venography and thermography in the evaluation of varicoceles of fertile and subfertile men.

The varicoceles of 39 men of proven fertility and 57 husbands of infertile marriages were assessed by the Doppler technique and classified according to venous activity. Retrograde left renal venography in 17 subjects showed that Doppler grading was unable to distinguish between 7 patients with competent internal spermatic veins and 10 with internal spermatic vein reflux. Patients whose varicoceles were associated with internal spermatic vein reflux had a significant reduction in sperm density and these may be implicated as a cause of male infertility. The remaining varicoceles were probably the result of incompetence of other venous tributaries of the spermatic cord and were associated with higher sperm densities. The Doppler was able to identify accurately those varicoceles with significant elevation of scrotal temperature as determined by computer assisted infra-red scrotal thermography. The sperm densities of these patients were similar to the values found in patients with normal scrotal temperatures. The varicoceles of infertile men were found to have a greater incidence of spontaneous venous activity than the varicoceles of fertile men and this suggests that any reduction of fertility caused by elevation of scrotal temperature may be via an effect other than a reduction in sperm density.