Non-invasive imaging diagnosis of left renal vein compression causing hematuria. Part 2. CT

Left renal veins of 77 patients were examined by computed tomography (CT) to evaluate its usefulness in determining the left renal vein compression which is causing renal bleeding. From CT image, left renal vein compression was observed in 6 (86%) of the 7 cases which had been classified as idiopathic renal bleeding, in 9 (21%) of the 42 cases which had urinary tract diseases causing hematuria, and in 3 (11%) of the 28 cases which did not have hematuria. In 15 of the 18 cases of left renal vein compression, left renal vein was compressed between the superior mesenteric artery and the abdominal aorta, showing so-called nutcracker phenomenon. In the remaining 3 cases, however, the superior mesenteric artery provided sharp delineation from the abdominal aorta. The superior mesenteric artery and the abdominal aorta made the mean angle of 35.5 degree in patients with normal left renal vein, the mean angle of 45.4 degrees in those with left renal vein compression without nutcracker phenomenon, and the mean angle of 11.9 degrees in those with nutcracker phenomenon. CT was superior to ultrasonography, in revealing left renal vein compression.     

左肾静脉下移术治疗左肾静脉压迫综合征(附3例报告)

目的 探讨改进治疗左肾静脉压迫综合征（即胡桃夹综合征-NCS）的手术方法。方珐对3例明确诊断为左肾静脉压迫综合征的患者采用左肾静脉下移与下腔静脉端侧吻合术。结果术中肾动脉阻断时间分别为20min、21min及16min。肉眼血尿消失时间分别在术后第3天、第5天及第4天，镜下血尿消失时间分别在术后第5天、第7天及第6天。随访4—6月，血尿均未复发。结论左肾静脉下移与下腔静脉行端侧吻合治疗左肾静脉压迫综合征，疗效满意。     

The posterior "nutcracker": hematuria secondary to retroaortic left renal vein

Retroaortic left renal vein is an uncommon variant in the renal venous system. Recently a patient with such anomaly presented to us with hematuria.     

Posterior nutcracker syndrome with left renal vein duplication: An uncommon cause of hematuria

INTRODUCTIONPosterior Nutcracker syndrome (NCS) is a rare anomaly in which the left renal vein passes behind the aorta which compresses it against the vertebral column, restricting the venous drainage of the left kidney.PRESENTATION OF CASEA 46 year-old lady presented with intermittent painless hematuria for 6 years. Urinalysis showed microscopic hematuria. An abdominal CT scan showed left renal vein duplication with the retroaortic branch trapped between the vertebral column and the aorta at the level of the aortic bifurcation, suggestive of posterior NCS. There were multiple small cortical cysts, sand-like stones in the left kidney and duplication of both right and left renal arteries.DISCUSSIONPosterior NCS in a patient with a duplicated left renal vein may not show all the clinical features of a typical NCS as the elevated pressure due to compression is dissipated through the pre-aortic branch of the duplicated renal vein. CT Angiography can be helpful in such a patient with multiple abnormalities. Management can range from simple surveillance to nephrectomy depending on the symptoms and renocaval pressure gradient.CONCLUSIONAlthough posterior NCS is a rare anomaly of the left renal vein, it should be considered in the differential diagnosis of haematuria.     

Pre-aortic left renal vein compression syndrome (Magoss and Walshe syndrome)

A case of a pre-aortic left renal vein compression by the aorta is reported. The clinical presentation was characterized by the left flank pain varying with body position. Renal venography was crucial for the diagnosis of this lesion. The left renal vein was successfully decompressed by ovarian vein-vena cava shunt surgery. The patient's left flank pain subsided after the surgery. This is the first reported case of a left renal vein compression syndrome by the aorta following the nephrotic syndrome.     

Large bronchial cyst causing compression of the left atrium.

We describe here a case with a large bronchogenic cyst treated by surgical resection, who presented with evidence of left atrial overload on electrocardiogram (ECG). The 50-year-old male patient presented with the chief complaint of heaviness in the chest on exertion. An ECG revealed evidence of left atrial overload, and echocardiography and imaging revealed a mass having a maximum diameter of 9 cm on the cranial aspect of the left atrium, caudal to the tracheal bifurcation. The patient was treated by surgical resection of the cystic mass via right anterolateral thoracotomy. His postoperative course was satisfactory and the patient was relieved of his main symptom.     

腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的疗效分析

目的 探讨腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者8例,男5例,女3例.年龄13 ～31岁,平均27岁.血尿病史3 ～46个月,均合并蛋白尿.8例彩色多普勒超声检查:左肾静脉狭窄段内径1.0～3.0 mm,平均2.4mm;扩张段内径5.3 ～ 14.9 mm,平均9.1 mm.扩张段与狭窄段比值均＞3.8例CT三维血管重建检查:左肾静脉受压明显,血流速度0.52 ～1.15 m/s,平均0.75 m/s;腹主动脉与肠系膜上动脉夹角9.3.～23.8.,平均18.6°.膀胱镜检查6例,均可见左侧输尿管口喷血.8例均行腹腔镜下左肾静脉外支架固定术治疗,术中将长5～8 cm直径1 cm的带外支撑环的e-PTFE人造血管固定于下腔静脉与肾门之间的左肾静脉外,以抵抗肠系膜上动脉的压迫,减轻肾静脉受压. 结果 8例患者手术顺利.手术时间55 ～140 min,平均63 min.术中出血量10 ～ 30 ml,平均14 ml.术中术后未发生外科并发症.术后恢复顺利,住院5～7 d,平均6d出院.术后随访3～20个月,血尿消失后未复发7例,7例尿常规检查正常.1例仍间断出现镜下血尿.8例彩色多普勒超声复查显示左肾静脉狭窄段内径6.5～8.7 mm,平均7.4 mm;扩张段与狭窄段比值1.1 ～1.4,平均1.3;流速0.23 ～0.42 m/s,平均0.31 m/s;腹主动脉与肠系膜上动脉夹角为51°～65°,平均57°. 结论 腹腔镜下人造血管外支架固定术是治疗左肾静脉压迫综合征的一种新术式,术中需暂时阻断肾动脉,无需离断左肾静脉或肠系膜上动脉等血管,设计巧妙,创伤小,恢复快,疗效满意.     

Spontaneous aorto-left renal vein fistula: the "abdominal pain, hematuria, silent left kidney" syndrome

Spontaneous aorto-left renal vein fistula (ALRVF) is a rare occurrence; with this case, only 16 have been reported to date. Common features in patients with ALRVF include abdominal pain (81%), hematuria (100%), impaired renal function (85%), and nonvisualization of the left kidney (100%). Less common but also present in the majority of cases are a left sided bruit (73%), pulsatile abdominal mass (63%), and proteinuria (50%). Also important, 94% have a retroaortic left renal vein, unlike the six cases of traumatic ALRVF that have been reported. This magnifies the diagnostic value of contrast abdominal computed tomographic scanning, which demonstrates not only the anomalous location of the left renal vein but also the abdominal aortic aneurysm and poor enhancement of the left kidney. These findings rule out the possibility of the "nutcracker syndrome" (left renal vein compression between aorta and superior mesenteric artery). Although confirming the presence of a fistula by early caval opacification, aortography does not always distinguish ALRVF from the more common aortocaval fistula. This can be accomplished by Duplex scanning with deep probes and even preferably color coding of velocity signals. With such precise preoperative localization, surgical repair is relatively easy and safe.     

Division of the left renal vein. Guidelines and consequences.

Ligation and division of the left renal vein is a reasonable safe procedure in selected patients when exposure of the perirenal aorta is crucial. This manipulation is possible because of extensive venous collateralization from the left kidney in man. Measurement of the venous stump pressure before ligation is recommended to assess the degree of collateralization, and the upper limit within which the vein may be divided safely is probably in the neighborhood of 60 cm of water. Reanastomosis of the vein is not necessary for preservation of renal function, although transient left renal dysfunction may occur. Examination of the urine and careful monitoring of renal function should be routine in the postoperative period. Intravenous urography and left spermatic venography later in the postoperative course can indicate the ultimate degree of function of the left kidney and the pathways of venous collateralization. Preservation of normal function and venous architecture at the renal hilum should be the rule.     

Noninvasive radiological diagnosis of renal vein thrombosis in renal transplantation.

Thrombosis of the allograft renal vein is a rare complication of renal transplantation. Of 557 consecutive renal transplants performed between January 1, 1985 and November 30, 1989, 3 cases occurred for an over-all incidence of 0.4%. In 2 cases the diagnosis was made preoperatively with renal scintigraphy and duplex Doppler sonography. No graft was salvaged, despite timely diagnosis in 2 patients. We conclude that the diagnosis of renal vein thrombosis in the renal allograft recipient should be suspected clinically and by the radiographic findings of absent perfusion on renal scintigraphy, and the detection of an arterial signal, albeit abnormal, on duplex Doppler sonography. When diagnosed, nephrectomy appears to be the only treatment.     

Transposition of the left renal vein in nutcracker syndrome.

Mesoaortic compression of left renal vein produces left renal vein hypertension resulting in left flank pain, hematuria and pelvic-ureteral varices. This is called the nutcracker syndrome. The nutcracker syndrome has been treated in various ways. We recently experienced two cases of patients with nutcracker syndrome. We treated the patients with transposition of their left renal vein.