Renal Capsular Veins Research Articles

High aldosterone levels in the renal capsular vein from the left aldosterone-producing adenoma on adrenal venous sampling.

A 42-year-old female patient was referred to our hospital with hypertension and hypokalemia and was diagnosed with primary aldosteronism. Dynamic contrast-enhanced computed tomography images revealed a 13-mm nodule on the lateral segment of the left adrenal gland and a fine venous connection between the nodule and the prominent renal capsular vein running nearby. The venograms in the left lateral tributary with a microcatheter confirmed alternative drainage to the left renal capsular vein during adrenal venous sampling, and the left renal capsular vein sampling was added. The patient was diagnosed with a left aldosterone-producing adenoma (APA) using the lateralization index (48.3) and a higher plasma aldosterone concentration (PAC) of the left lateral tributary (66 700 pg/mL) than other tributary samples after adrenocorticotropic hormone stimulation. Furthermore, markedly higher PAC (224 000 pg/mL) was observed in the left renal capsular vein blood than in the left adrenal central vein (45 000 pg/mL) and tributaries, confirming the diagnosis. Laparoscopic left partial adrenalectomy and following histopathological analysis revealed a CYP11B2-positive adrenocortical adenoma. Complete clinical and biochemical success for primary aldosteronism was achieved after 6 months. Direct evidence of APA blood venous drainage into the renal capsular vein has been demonstrated. Sampling from an alternative drainage pathway could be beneficial for APA diagnosis if such APA blood drainage is assumed. Aldosterone-producing adenomas may drain blood into an alternative pathway but for the adrenal vein. The presence of alternative venous drainage could be assumed by contrast-enhanced computed tomography or venogram during adrenal venous sampling. Sampling in the alternative drainage veins and demonstrating elevated aldosterone levels could help in diagnosing aldosterone-producing adenoma.

Composition of Perinephric Fat and Fuhrman Grade in Clear Cell Renal Cell Carcinoma: The Role of Peritumoral Collateral Vessels

Background: The aim of this study was to investigate whether the presence of peritumoral collateral vessels could be indicative of a high Fuhrman grade (e.g., III and IV) in clear cell renal cell carcinoma (ccRCC). Methods: Between November 2019 and February 2020, a total of 267 ccRCC patients with histology-proven diagnoses were retrospectively analyzed and screened. Imaging analysis was performed on computed tomography (CT) images to assess the presence of peritumoral collateral vessels and understand the potential association with high Fuhrman grades. These vessels are defined as dilated and macroscopically visible peritumoral renal capsular veins. Results: A total of 190 ccRCC patients were included in the study, considering the exclusion criteria. In patients with peritumoral collateral vessels, there was a statistically significant greater presence of ccRCC with a high Fuhrman grade both among the total cohort of patients regardless gender (n = 190) (p < 0.001) as well as among ccRCC male patients only (n = 127) (p < 0.005). Conclusion: Here, we show a novel association between peritumoral collateral vessels and ccRCC with high Fuhrman grades in male patients. The presence of peritumoral collateral vessels in perinephric adipose tissue can be indicative of more aggressive ccRCC.

Non-stimulated adrenal venous sampling using Dyna computed tomography in patients with primary aldosteronism.

In this retrospective study, we aimed to examine the effect of applying Dyna computed tomography (CT) on the success rate of adrenal venous sampling (AVS) without adrenocorticotropic hormone stimulation. A total of 100 consecutive patients with primary aldosteronism who underwent AVS between May 2012 and July 2015 were enrolled. In all the cases, Dyna CT was used in AVS to validate catheter position in the right adrenal vein. A selectivity index (cortisoladrenal vein /cortisolinferior vena cava) of ≥2.0 of both adrenal veins were required for successful AVS. Dyna CT indicated misplaced catheters in 16 patients; of these patients, 75% (12/16) eventually had successful right AVS after catheter repositioning. The success rate of initial sampling at the right adrenal vein was 76% (76/100), which increased to 88% (88/100) after Dyna CT was applied (p < 0.001). The most common inadvertently catheterised vessels detected using Dyna CT were the accessory hepatic veins (56.3%, 9/16), followed by the renal capsular veins (37.5%, 6/16). The overall success rate of non-stimulated AVS using Dyna CT was 87% (87/100). Thus, the application of Dyna CT further increased the success rate of non-stimulated AVS.

PS 17-01 USEFUL APPLICATION OF COMPUTED TOMOGRAPHY DURING ARTERIOGRAPHY FOR A CASE OF ALDOSTERONE-PRODUCING ADENOMA WITHOUT A SIGN OF OVERPRODUCTION OF ALDOSTERONE IN ADRENAL VENOUS SAMPLING.

Objective: We sometimes experience a case of aldosterone-producing adenoma (APA) without a sign of overproduction of aldosterone in adrenal venous sampling (AVS). One of the reasons is that APA can form ectopic drainage veins besides the authentic adrenal central veins. We tried to utilize computed tomography (CT) during arteriography for identification of such drainage veins in a case of APA. Design and method: A 56-year-old Japanese male was treated for hypertension with amlodipine (5 mg/day) for the past 6 years. In April 2015, primary aldosteronism (PA) was suspected because a laboratory examination showed hypokalemia (2.6 mEq/L). Endocrinological evaluations indicated hyperaldosteronism with high aldosterone renin ratio (ARR): plasma aldosterone concentration (PAC) 272 pg/ml, plasma renin activity (PRA) 0.2 ng/ml/hr and ARR 1360. Abdominal CT suggested APA of 8 mm in diameter at the left adrenal gland. AVS was performed to confirm overproduction of aldosterone from APA; however, the overproduction was not identified in both sides of adrenal central veins, in spite of successful cannulation. We performed CT during arteriography to identify outflow from the adenoma in consideration of ectopic drainage veins. Results: The left renal capsular vein and a small branch to the left renal vein were clearly visualized as drainage veins from the adenoma. AVS was again conducted from these drainage veins and we successfully confirmed overproduction of aldosterone from them. He was diagnosed as left APA and laparoscopic adrenalectomy was performed. After the operation, the blood levels of PAC and PRA became normal and his blood pressure and hypokalemia also normalized. Conclusions: There are several reports that demonstrate ectopic drainage veins from adrenal adenoma (JAMA Surg. 148:378, 2013). Identification of aldosterone overproduction in APA with ectopic drainage veins is not easy for conventional AVS procedure. CT during arteriography is indicated to be useful for identification of ectopic drainage veins in such case of APA.

CT during Arteriography to Visualize the Right Adrenal Vein for Adrenal Venous Sampling

The present report describes 6 cases of adrenal venous sampling (AVS) in patients who underwent computed tomography (CT) during arteriography because cannulation of right adrenal veins was otherwise difficult. CT was performed during arteriography to obtain information on the location and direction of the right adrenal vein. Two right adrenal veins were visualized in 1 case. The right central adrenal vein was not visualized in 1 case owing to an injury from a previous unsuccessful AVS procedure, but the right renal capsular vein was well visualized. CT during arteriography could contribute to a high AVS success rate.

Retro-aortic, left inferior renal capsular vein.

In our case report, abdominal multi-detector computed tomography was used for the pre-operative anatomy evaluation in a living kidney donor. The early phase of the test revealed normal kidneys in the donor. The vascular phase detected a venous variant on the left side: An inferior renal capsular vein, which had a loop and a retro-aortic course. This preoperative knowledge was crucial for the laparoscopic nephrectomy as a surgical procedure for harvesting kidney from the living donor.

Right Adrenal Venography Findings correlated with C-arm CT for Selection During C-arm CT-assisted Adrenal Vein Sampling in Primary Aldosteronism

This study was designed to evaluate retrospectively the efficacy of C-arm CT to confirm right adrenal vein catheterization during adrenal vein sampling (AVS) and to correlate adrenal venography findings with C-arm CT and/or biochemical results for right adrenal vein selection. Forty-two consecutive primary aldosteronism patients (M:F = 21:21; age: 29-70 years) underwent C-arm CT assisted sequential AVS. After catheterization of right adrenal vein, C-arm CT was performed to confirm catheter position. Catheter was repositioned when right adrenal gland was not opacified. Radiological images, medical records, and biochemical results were reviewed for technical/biochemical success rates and complications. Right adrenal venography findings of pinnate pattern, visualization of renal capsular vein, and retroperitoneal vein other than renal capsular vein were correlated with C-arm CT and/or biochemical results for right adrenal vein selection. Both the technical and biochemical success of AVS was achieved in 40 patients (95.2%). C-arm CT failed due to catheter instability in one, and adrenal/vena cava cortisol gradient was <3 in one patient. Catheter was repositioned in four patients (9.5%) according to C-arm CT findings. Right adrenal venography finding of renal capsular vein significantly correlated with C-arm CT and/or biochemical results (100%) for right adrenal vein selection (p = 0.011, χ(2) test), whereas pinnate pattern (p = 0.099) and other retroperitoneal veins (p = 0.347) did not. There was no procedure-related complication. C-arm CT increases confidence of right adrenal vein catheterization during AVS. Visualization of renal capsular vein on adrenal venography suggests right adrenal vein catheterization and C-arm CT may not be required.

Impact of Accessory Hepatic Veins on Adrenal Vein Sampling for Identification of Surgically Curable Primary Aldosteronism

Adrenal vein sampling is the gold standard for identification of surgically curable primary aldosteronism, but its accuracy might be hindered by blood dilution from accessory vein blood. We prospectively investigated the presence of accessory veins draining into adrenal veins and their effect on the selectivity index (SI) in 74 consecutive patients undergoing adrenal vein sampling. On the right side, the venous anatomic pattern could be conclusively determined in 91.8% of the cases: we detected hepatic accessory veins in 12.1%, no accessory veins in 42.4%, and renal capsular veins in 45.5%. On the left side there was a phrenico-adrenal trunk in 89.4% and renal capsular accessory veins in 10.6% of the cases. On both sides, renal capsular and phrenic accessory veins did not affect the SI. At variance, on the right side, hepatic accessory veins were associated with SI values approximately 3-fold lower than that found when such accessory veins were absent (median: 3.10 [range: 0.80 to 84.2] versus median: 1.10 [range: 0.70 to 2.20]; P=0.01). However, superselective adrenal catheterization resulted into higher SI values (median: 23.88; range: 4.80 to 84.20) in these cases. Thus, hepatic accessory veins sharing egress into the inferior vena cava with the right adrenal vein occurred in approximately 12% of the patients and imply a low SI, likely because of adrenal blood dilution by hepatic blood carrying a low cortisol concentration. In the presence of this anatomic variation, superselective catheterization of the right adrenal vein should be undertaken to determine the lateralization of aldosterone secretion.

Portosystemic shunt on CT during arterial portography: prevalence in patients with and without liver cirrhosis

To review various portosystemic shunts (PS) and to evaluate their prevalence by CT during arterial portography (CTAP) using a multidetector-row CT (MDCT). CTAP of 116 patients (liver cirrhosis 70 patients, non-liver cirrhosis 46 patients) was retrospectively reviewed. CTAP was performed with the catheter placed in the superior mesenteric artery using MDCT. Axial CT images of 0.625- and 3.75- or 2.5-mm thickness were obtained. Multiplanar reformation images and maximum intensity projection images were subjected to review. A part of the veins in the ileocecal region drained into the right renal vein or the inferior vena cava (IVC) via the right gonadal vein in 57 patients (81%). A part of the veins of the ascending colon drained via the right renal capsular vein into the IVC in 37 patients (53%). In 46 patients without liver cirrhosis, the right gonadal and right renal capsular veins were opacified on CTAP in 22 patients (48%) and 20 patients (43%), respectively. Portosystemic shunts in retroperitoneum were frequently recognized on CTAP images in patients with liver cirrhosis. The right gonadal vein and the right renal capsular vein were the most frequent routes of the portosystemic shunts. They may exist in physiological condition.

Gonadal vein recruitment in renal cell carcinoma: Incidence, pathogenesis and clinical significance

Objective: Gonadal vein recruitment by collateral veins in patients with renal cell carcinoma is not routinely searched for during abdominal computed tomography. We performed a retrospective view to determine the incidence of gonadal vein recruitment for collateral venous drainage in patients with renal cell carcinoma and we discuss its potential importance. Patients and methods: Abdominal CT examinations were available for 58 of 95 patients with renal cell carcinoma identified during a 3-year-period. The presence of collateral veins and recruitment of the ipsilateral gonadal vein was recorded and correlated with the estimated blood loss at surgery. Results: Eighteen of 58 tumours were small (less than 5 cm). Multiple (greater than three) collateral renal capsular veins were noted in 26 of 58 patients and few (less than three) were noted in 11. Recruitment of the gonadal vein (range 4–18 mm, mean 8 mm) was seen in 18 of 58 patients (31%) who all had multiple collaterals. Gonadal vein recruitment was only seen in patients with tumours greater than 5 cm. Mean estimated blood loss at surgery was significantly different ( P < 0.001) in 18 of 58 patients (mean, 1078 ml) with gonadal vein recruitment compared to 40 of 58 patients (mean 304 ml) without distinct visualization of the gonadal vein and compared to 22 of 40 patients with large tumours (mean 368 ml). Conclusion: Gonadal vein recruitment signifies well-developed arteriovenous shunting and high flow collateral venous drainage pathways and may be used as an index of tumour vascularity. This finding may have clinical potential in triaging patients toward pre-operative renal embolization.

Detailed Anatomy of the Internal Spermatic Vein and the Ovarian Vein. Human Cadaver Study and Operative Spermatic Venography: Clinical Aspects

The exact anatomical course of the spermatic vein and the ovarian vein (gonadal) has not been described in detail previously. To determine the precise anatomy of the gonadal veins an autopsy study of 70 fresh human cadavers (40 men, 10 women, 10 male stillborns and 10 female stillborns) was performed by making a resin cast of both gonadal veins which then was carefully dissected. The study showed absence of valves in the spermatic vein, cross-communications between the right and left spermatic veins, and communication between the spermatic and renal capsular veins, spermatic and ipsilateral ureteral veins, and spermatic ipsilateral colonic veins. For clarification of the presence of valves intraoperative antegrade spermatic venography was done in 6 men with and 5 without varicocele. In both groups valves were not detected. These observations regarding the anatomy of the spermatic vein and the ovarian vein may help to explain related clinical conditions.

Anatomy of the Venous Drainage of the Human Testis: Testicular Vein Cast, Microdissection and Radiographic Demonstration

The venous drainage of the testis was identified and described in an autopsy, radiographic and operative series of 30, 28 and 7 adult males, respectively. Testicular vein cast--right and left--was prepared in autopsy specimens to identify the course, tributaries and communications of the testicular vein. Intraoperative spermatic venography was done in 17 men with and in 11 men without varicocele. The retrograde spermatic venography showed the precise anatomy of the pampiniform plexus. Antegrade spermatic venography was done to identify the valves. During cystectomy in 7 adult men, the whole tree of the spermatic vein was taken and microdissected. Our findings show that the venous drainage of the testis cannot be looked upon as it is in the standard anatomy; on the contrary, it deviates from the description in the text. We demonstrated that the venous drainage of the testis is via the pampiniform plexus, which is primarily drained by the testicular and external pudendal veins. The testicular vein--midway between the internal inguinal ring and the lower pole of the kidney--divides into the medial and lateral branch to form a delta. The medial branch communicates with the ureteral and contralateral veins; there, it terminates in the left renal vein or inferior vena cava on the right side. The lateral branch communicates with colonic and renal capsular veins and terminates in the perinephric space. There is no cross-communication between the left and right testicular venous systems in the scrotal, retropubic or pelvic areas. The only cross-communication is in the abdomen, and is seen in only 50% of men. The testicular vein has no valves.

Persistent varicocele following high ligation of the internal spermatic vein. Phlebography and vaso-occlusion with ethibloc

The importance of phlebography and vaso-occlusion using ethibloc in diagnosis and treatment of the persistent varicocele following ligation ("Bernardis' technique") is demonstrated. We performed 280 surgical ligations of the internal spermatic vein. In 30 patients persistence of the varicocele was found. In 9 patients following phlebography embolisation of a long segment including smaller collaterals was performed using ethibloc. The other 21 patients were treated surgically because of unusual draining of the collaterals into renal capsular veins, into the hemiazygos vein and into renal segmental veins. In all cases following embolisation complete resolution of the varicocele was observed within 3 months.

Selective adrenal phlebography.

Catheterization of the adrenal veins is potentially a useful clinical tool since it permits not only detailed visualization of the inner glandular vasculature but also sampling of effluent hormones. Bucht (1) , was the first investigator to study the left adrenal vein angiographically in man; since that time there have been surprisingly few subsequent articles (2, 3) on this subject. We have developed a technic for catheterizing with facility both adrenal veins in man. On the basis of three years experience, we now feel that adrenal phlebography does indeed have wide clinical application. Anatomy The intraglandular venous circulation is complex and incompletely understood (4, 5). The cortex and medulla are drained in series by sinusoids, venules, and muscular veins which join to form the central vein. This then becomes the adrenal vein as it exits on the ventral groove of the gland. It should be noted that the main venous branches are cuffed by invaginated folds of cortex and that even the central vein is surrounded by a thin layer of cortex. At the corticomedullary junction, there is a rich plexus of sinusoids which is drained independently into the medullary veins by relatively few channels. The adrenal capsular plexus is drained by the many venae comitantes, which accompany the small capsular ramifications of the adrenal arteries into renal capsular veins, lumbar veins, phrenic veins, and others. Direct intervenous anastomotic connections linking the central vein with capsular veins and their branches have also been frequently observed. Our own injection studies with oily and aqueous contrast media confirm these findings (Fig. 1). Although it is assumed that under normal conditions the major adrenal output of medullary and cortical hormones drains into the central vein, it is also reasonable to suggest that the capsular veins represent an excellent alternative pathway in times of stress or in disease. Well developed eccentric longitudinal muscle bundles characteristically present in the central vein and its larger tributaries are presumed to play a dominant role in the control and expulsion of glandular hormones. The right adrenal vein is very short and enters usually in a cephalad direction into the right posterolateral border of the inferior vena cava at the level of T12 or upper border of L1. The left adrenal vein after joining the left phrenic vein empties into the superior border of the left renal vein opposite the gonadal vein. Exceptions to this standard anatomy textbook description have recently been emphasized by Gagnon (6) and Johnstone (7). These authors found not only examples of multiple adrenal veins but also instances in which the right vein emptied into the renal or hepatic vein and the left into lumbar and renal veins and even into the portal system.

Adrenal venography.

Evaluation of adrenal gland abnormalities remains one of the difficult areas in roentgen diagnosis. An adrenal lesion must be large to be detected on plain abdominal films. Retroperitoneal air study reveals only the shape and size of the gland and is subject to misinterpretation. Arteriography can demonstrate the presence of some adrenal tumors, particularly vascular tumors such as pheochromocytomas (2), but adrenal adenomas and adrenal hyperplasia do not have an abundance of newly formed vessels and therefore are usually poorly demonstrated by arteriography. Moreover, the multiple origin of adrenal arteries from the inferior phrenic artery, the aorta, and the renal arteries (12) makes selective arteriography of the adrenal gland impossible. Kahn (8) has performed selective catheterization of the inferior phrenic arteries but states that it is technically difficult. Winkler and he (15) have also obtained better filling of adrenal arteries at celiac and renal angiography by injecting contrast medium following the administration of adrenalin. A new approach to adrenal diagnosis was suggested in 1962 by Starer (14) and also by Bucht (3). These investigators demonstrated adrenal adenomas by a retrograde injection of contrast medium into the left adrenal vein. Both, however, concluded that the method had little future because of the difficulty they encountered in catheterizing the right adrenal vein. Masoni (10) has described a method for catheterizing the right adrenal vein but did not perform venography of the gland. Because of the shortcomings of the other roentgen approaches to adrenal diagnosis, a further appraisal of adrenal venography seems justified. Our experience with the technic in 45 patients forms the basis of this report. Anatomy When compared with the multiple and varied origin of adrenal arteries, the venous drainage of the gland is singular and regular (1). This is particularly true of the left gland, from which the intra-adrenal and adrenal capsular veins collect into a single vein, which exits at the lower pole of the gland. Just below the gland, the left adrenal vein usually receives the left inferior phrenic vein and a renal capsular vein. The confluence of the three then enters the superior surface of the mid-left renal vein. On the right the venous drainage of the gland is less constant, but a complete anatomic study of the relative frequency of occurrence of the variations is not available. It is generally stated that in the majority of persons a single vein drains the right gland and directly enters the right posterolateral aspect of the inferior vena cava 2 to 4 cm above the right renal vein (1). In some persons a single right adrenal vein has a common origin with or drains into an hepatic vein. Occasionally, two or three right adrenal veins may be present, draining into the inferior vena cava, hepatic veins, or rarely into the right renal vein (6, 7).