肝细胞癌合并门静脉癌栓、继发门静脉海绵样变多层螺旋CT表现

目的探讨肝细胞癌合并门静脉癌栓、继发门静脉海绵样变的多层螺旋CT表现。方法收集31例经病理证实为肝细胞癌合并门脉癌栓继发门静脉海绵样变的多层螺旋CT资料,与手术病理相对照,回顾分析其栓塞部位、CT表现及侧支循环开放情况。结果栓塞部位：门静脉主干及左、右支栓塞23例,其中4例合并肠系膜上静脉和（或）脾静脉、下腔静脉栓塞,1例合并胆囊浸润;门静脉主干及左支栓塞1例;f1静脉主干及右支栓塞5例,其中2例合并肝右静脉和（或）下腔静脉栓塞;门静脉主干及肠系膜上静脉栓塞1例;单纯右支栓塞1例。CT表现：平扫癌栓均为等密度;增强扫描动脉期明显不均匀强化,门静脉期强化程度减退呈等密度,相应血管内可见充盈缺损。侧支循环开放与血管扩张情况：肝门胆管周围侧支开放31例（100％）,胆囊窝周围侧支开放19例（61．29％）,胃底、胃小弯区侧支开放21例（67．74％）,食管下段侧支开放7例（22．58％）,脾静脉扩张15例（48．38％）。结论HCC并门静脉癌栓继发门静脉海绵样变的多排螺旋CT表现具有一定的特征性,可为I临床提供准确的参考信息,有助于该病的诊断。     

磁共振、彩色多普勒及间接门脉数字减影血管造影在门静脉系统显像中的对照研究

目的 评价磁共振血管成像（MRA）、彩色多普勒血流显像（CDFI）及间接门脉数字减影血管造影（DSA）在门静脉高压症门脉系统及门体侧支循环显像中的应用和三者优缺点比较。方法 32例该症病人接受了MRA检查,20例病人分别行CDFI和DSA检查。结果 MRA对胃左静脉侧支（LGV）、胃短静脉侧支（SGV）、开放脐静脉侧支（UV）、自发脾肾静脉分流侧支、胃后静脉侧支（PGV）及腹膜后交通侧支的检出率分别为93.75%、87.5%、6.25%、15.62%、37.5%和28.13%,其中1例合并门脉主干（MPV）栓塞;CDFI对LGV、SGV、UV诸侧支的显示率分别为80％、5％、10％,1例合并脾静脉栓塞,另1例合并MPV海绵样变;间接门脉DSA对前述侧支的显示率分别为80％、45％及25％。结论 MRA能更全面、准确地了解门脉系统及门体侧支循环的建立情况。     

左肾静脉移位术治疗胡桃夹综合征五例

2003年2月至2007年11月我们采用左肾静脉下移与下腔静脉端侧吻合术治疗5例胡桃夹综合征患者，其中男4例，女1例，年龄13-41岁，病程2个月～3年，主要症状为反复血尿和不同程度蛋白尿，合并左侧精索静脉曲张2例，术前均采用彩色多普勒超声、血管造影和（或）CT三维血管重建确诊为腹主动脉与肠系膜上动脉夹角处左肾静脉明显受压，肾静脉近端扩张。手术方法：采用经腹入路，在左肾血管水平腹主动脉前方切开后腹膜，分离左肾动、静脉，从上至下依次结扎左肾上腺、睾丸（卵巢）及腰静脉，充分游离左肾静脉，Bulldog阻断左肾动静脉后（图1），迅速在左。     

MSCTA肠系膜下动脉成像的临床应用

目的探讨多层螺旋CT血管造影（MSCTA）在肠系膜下动脉（IMA）成像中的临床应用价值。方法选择因直肠或左半结肠癌和血管性病变行MSCTA检查的患者75例，采用容积再现（VR）血管生长技术（AV）进行血管重建，观察肿瘤供血动脉及IMA狭窄或闭塞后的侧支循环情况。结果35例直肠癌患者中，显示肿瘤供血动脉：直肠上动脉35、直肠下动脉29例、骶正中动脉6例、乙状结肠动脉4例；7例乙状结肠癌由乙状结肠动脉供血；3例直肠乙状结肠交界区癌中，1例乙状结肠动脉供血，2例乙状结肠动脉和直肠上动脉供血；2例降结肠癌由左结肠动脉供血；5例脾曲癌由左结肠动脉升支和中结肠动脉左支供血。23例IMA狭窄或闭塞患者均有Riolan动脉弓侧支循环形成。结论MSCTA能清楚显示IMA参与肿瘤供血及准确评价其狭窄或闭塞后侧支循环形成情况。     

MSCTA在诊断肾静脉变异中的价值

分析多层螺旋CT血管造影（MSCTA）对肾静脉（RV）变异的诊断价值。方法回顾性分析352例行腹部MSCTA检查患者,采用容积再现（VR）“血管生长”技术进行RV重建。结果352例共检出RV变异36例,检出率10.2%。双侧RV变异2例;右肾RV变异11例;左侧肾RV变异23例,包括主动脉周围型RV变异12例（3.4%）,完全性主动脉后位型RV变异6例（1.7%）;其他5例（1.4%）。结论MSCTA能清楚显示肾静脉变异,为临床提供解剖学资料。     

原位自体肾移植联合下腔静脉切除重建在腹膜后肿瘤中的应用

目的 探讨原位自体肾移植联合下腔静脉（inferior vena cava,IVC）切除重建在腹膜后肿瘤中的应用及临床疗效。方法 回顾性分析1例复杂腹膜后肿瘤患者的临床资料。腹部CT检查提示肿瘤起源于IVC,侵及肝后IVC及双侧肾静脉主干。术中超声探查可见IVC及双肾静脉主干内机化血栓形成。阻断左侧肾静脉后,术中行超声探查及超声造影（contrast-enhanced ultrasound,CEUS）前后对比未见明显血流动力学改变。结果 术中完整切除左肾静脉并缝扎断端,取出右肾静脉内机化血栓后,成功行原位自体右肾移植联合IVC切除重建。患者术后恢复良好,复查CT检查提示重建的人工IVC通畅,双肾血管彩色多普勒超声检查提示血流灌注良好,未见回流障碍。术后予以口服利伐沙班抗凝治疗,患者于术后19 d出院,术后病理学检查结果提示为IVC平滑肌肉瘤（inferior vena cava leiomyosarcoma,IVCL）。结论 原位自体肾移植联合IVC切除重建治疗复杂腹膜后肿瘤是安全可行的,左侧肾静脉可视术中情况予以结扎离断,但需联合术中超声（造影）综合评判决定。     

机械吸栓联合导管接触性溶栓治疗肾静脉血栓形成1例

<正>肾静脉血栓形成(renal venous thrombosis,RVT)是指肾静脉主干和/或其分支内血栓形成,导致肾静脉全部或部分阻塞而引起的一系列病理改变及临床表现的肾血管性疾病。RVT漏诊率及误诊率较高^[1],如未及时诊治,RVT可脱落造成肺栓塞,甚至死亡。急性RVT可表现为腰肋或腹部疼痛,肾功能异常,病侧肾增大,镜下或肉眼血尿,发热及外周血白细胞计数增多等^[2]。抗凝与溶栓是RVT治疗的基础,但通过血管腔内介入方法治疗RVT相关的报道较少。本文报道1例机械吸栓联合导管接触性溶栓治疗RVT患者,总结相关诊疗经验,现报道如下。     

多层螺旋CT血管成像诊断颈动脉海绵窦瘘

目的探讨颈动脉海绵窦瘘(CCF)的解剖病理基础及螺旋CT血管成像(MSCTA)表现,提高MSCTA对CCF的诊断能力。方法12例经DSA证实的CCF均进行了螺旋CT平扫、增强扫描及血管成像重建。结果CCF的MSCT及CTA表现为:海绵窦扩大及眼上静脉扩张12例,并与颈内动脉同时显影;其他属支静脉扩张6例;对侧海绵窦扩大4例,与DSA检查结果一致。患侧眼球突出12例。颅底、眶壁骨折5例。眼球壁模糊、增厚5例。脑挫伤、出血4例。眼外肌增粗1例。结论螺旋CT及其血管成像诊断CCF简单、快捷、准确、可靠,特别是在外伤性CCF中,是首选的检查及诊断方法。     

16层螺旋CT血管造影及三维重建技术在活体供肾动脉解剖学评估中的应用

目的 探讨16层螺旋CT血管造影在活体供肾动脉解剖学评估中的应用价值。方法 36名亲属活体供肾者在肾切取前进行肾动脉16层螺旋CT血管造影及血管三维成像，血管三维成像方法包括容积再现技术（VR）、最大密度投影（MIP）、表面遮盖成像（SSD）、血管内镜技术（CTVE）、多平面重建（MPR）及曲面重建（CPR）。结果 横断面CT及MPR显示所有供者的双肾大小、形态及位置均正常，肾实质密度正常，呈均匀强化。VR、MIP、CPR显示双肾动脉粗细、形态均正常；29例双肾均为单一肾动脉，2例双肾有2支肾动脉，2例左肾为2支肾动脉，3例右肾为2支肾动脉，上述结果均在术中得到证实。11例VR及MIP同时较好地显示双侧肾小盏、肾盂及输尿管上段。SSD均能很好显示肾动脉主干的起源、大小、形态及与周围的解剖关系。CTVE能较好显示腹主动脉、双肾动脉开口及肾动脉血管内腔。结论 16层螺旋CT血管造影可作为活体肾移植术前了解供肾血管及形态的有效方法。     

门脉高压症侧支开放率及脐静脉开放时离断术前后门脉系统的血流动力学变化

彩色多普勒血流显像（ＣＤＦＩ）及前列腺素Ｅ１（ＰＧＥ１）间接门脉数字减影血管造影（ＤＳＡ），可详细了解门脉高压症门脉系统的血流动力学及影像学变化，前者对胃左静脉（ＬＧＶ）、开放脐静脉（ＵＶ）及自发脾肾静脉分流侧支的显示率分别为７７．５％、１２．５％及８５％，后者对ＬＧＶ、胃短静脉（ＳＧＶ）及ＵＶ的显示率分别为７８．３％、３９．１％及３０．４％，两者结合应用，优缺点可以互补。ＬＧＶ、ＳＧＶ是曲张静脉破裂出血的根源，应彻底离断。ＵＶ开放时，离断术后门脉主干流量及ＵＶ的这肝血流量均增加，行离断术为佳．自发脾肾静脉分流侧支出现率最高，当其丰富时，行离断术或胃左静脉腔静脉分流术为佳。     

腹膜后肿瘤手术并下腔静脉及肾静脉切除与重建

目的探讨复杂腹膜后肿瘤手术切除时对腹腔大血管的处理方法，以提高肿瘤切除率。方法总结了１９９０年～１９９７年手术切除腹膜后肿瘤２１９例中的１１例合并下腔静脉（ＩＶＣ）或肾静脉（ＲＶ）切除的经验。其中ＲＶ下ＩＶＣ切除５例，肝下ＩＶＣ及右肾切除３例，肝下ＲＶ上ＩＶＣ切除１例，左ＲＶ大部切除与左输卵管静脉吻合２例（１例合并ＩＶＣ切除）。结果随访半年本组无１例死亡，血尿素氮、肌酐及肾脏Ｂ超检查均在正常范围。结论（１）左ＲＶ有较多属支和恒定吻合干与周围静脉相连，可于左ＲＶ近心端结扎，如需切除部份ＲＶ，则至少保留一个ＲＶ属支（通常为左性腺静脉）以维持循环；（２）ＩＶＣ切除一般不需行血管重建，但如肾静脉血流受阻，则应行血管重建，至少保证一个肾脏血液回流。     

Bilateral renal vein thrombosis in a twin newborn without known risk factors

Neonatal renal vein thrombosis (RVT) is associated with neonatal stress, catheters and genetic prothrombotic risk factors. In an unusual case of bilateral RVT a twin newborn showed initial good adaptation at birth (weight 2,720 g). The placenta was monochorionic, diamnionic. The infant (gestational week 37) exhibited a severe macrohematuria within 24 hours after birth. Sonography of the kidneys showed a dense cortical parenchyma, loss of cortico-medullary differentiation and negative diastolic flow in both renal arteries and veins, while no thrombus in the main renal veins could be detected. No prothrombotic blood parameters and positive infection serology were detected. Because of acute renal failure peritoneal dialysis was necessary for 6 weeks. The patient was treated by heparinization for 5 days. Interestingly, it was kidney biopsy which confirmed the diagnosis of RVT in addition to the clinical presentation, whereas sonography was unspecific. Histology exhibited the picture of an ischemic contracted kidney with numerous siderophages. At present (age 19 months), the patient suffers from chronic renal failure (calculated glomerular filtration rate according to Schwartz 12 ml/min/1.73 m2). In conclusion, our case teaches that, despite the lack of a clinically obvious shock event, absence of known risk factors and indirect ultrasound findings, renal vein thrombosis should be considered in a macrohematuric newborn with renal failure. For clinical suspicion of RVT correct therapy was initiated, however, the diagnosis remained unclear until a renal biopsy was performed.     

Hemodynamics of the varicocele. Part I. Correlation among the clinical, phlebographic and scintigraphic findings

To determine whether the varicocele results from collateral circulation partially replacing an obstructed left renal vein, we developed a scintigraphic technique that provides not only information about the velocity of retrograde flow in the testicular veins but also quantitative information about the size of the varicocele. The reliability of this method was assessed by comparison with the results of phlebography and the clinical diagnosis in 104 patients. Furthermore, the diameter of the left testicular vein was determined on the phlebogram. Good correlation was found among the velocity of the retrograde flow in the left testicular vein, the size of the varicocele and the diameter of the left testicular vein.     

Noninvasive diagnosis of renal vein thrombosis by digital subtraction venography

The definitive diagnosis of renal vein thrombosis (RVT) depends upon the demonstration of a persistent filling defect or defects within the renal vein by renal venography or selective renal angiography during the venous phase. We describe here the utilization of digital subtraction venography to diagnose RVT in a young nephrotic male patient. We injected 40 cm3 of contrast substance in a foot vein, having 4-second delayed films over the inferior vena cava and renal veins. We demonstrated a retrograde propagation of the dye into the right renal vein indicating intrarenal venous thrombosis. 'Renal vein thrombosis and digital venography'.     

Evaluation of 100 laparoscopic varicocele operations with preservation of testicular artery and ligation of collateral vein in children and adolescents

OBJECTIVES: To introduce a useful technique for identifying any collateral veins during laparoscopic varicocele operation and to evaluate our long-term results with this technique after 100 cases. METHODS: A new method was used to detect an incidental collateral vein. During surgery the patient was placed in anti-Trendelenburg position after introducing laparoscopic instruments until the dilated scrotal varicose filled up with blood. The main spermatic vein was then grasped atraumatically and the blood was pressed out manually from the scrotum. During this manoeuvre any existing collateral vein/veins became dilated and could be easily identified. The dilated spermatic vein and also any collateral vessel were first prepared then clipped. RESULTS: Out of the 100 patients, collateral veins were detected and ligated in 19 cases. In 15 cases a single collateral, in 4 cases two collaterals, and in the remaining 81 children no collateral veins were found. The testicular artery was identified in all operations as a pulsatile vessel. At a mean of 24 months (range 6-60 months) follow-up recurrence occurred in one patient and in five children hydrocele developed postoperatively. Testicular atrophy and severe intra- or postoperative complication did not occur in any patient of this series. CONCLUSION: The identification of incidental collateral vein by this method and preservation of the testicular artery resulted in a very good success rate in children and adolescents treated by laparoscopic varicocele operation.     

Idiopathic retroperitoneal fibrosis with large vessel thrombosis

A 53-year-old female was hospitalized for evaluation of swelling in the bilateral lower extremities. A computed tomography (CT) scan of the abdomen revealed bilateral hydronephrosis and features consistent with retroperitoneal fibrosis. Transfemoral venography and magnetic resonance angiography (MRA) showed thrombosis of both the left common iliac vein and inferior vena cava, and filling of numerous collateral veins in the retroperitoneal area. A diagnosis of idiopathic retroperitoneal fibrosis with central venous thrombosis was made. Ureteral stenting, medication with corticosteroids and subsequent warfarin were started, resulting in marked improvement of renal function and the lower extremities. Diagnosis and follow-up of deep venous thrombosis can be aided by MRA. Administration of steroids with anticoagulation was considered to be successful in the case presenting with deep venous thrombosis caused by retroperitoneal fibrosis.     

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. Received October 5, 1995; received in revised form June 27, 1996; accepted July 22, 1996     

Bilateral Renal Vein Thrombosis Secondary to Membraneous Glomerulonephritis: Successful Treatment with Thrombolytic Therapy

Renal vein thrombosis (RVT) is a rare phenomenon. Bilateral RVT is even less common. RVT has been reported as idiopathic or in association with puerperium, hypercoagulable states, membraneous glomerulonephritis (MGn), renal transplantation, malignancy, and renal vein instrumentation or trauma. Due to its rarity, the literature describing RVT consists mainly of isolated case reports and there are no consistent recommendations regarding diagnosis and treatment of this vascular emergency. We present a case of bilateral RVT associated with MGn. A 45-year-old man complaining of nonspecific abdominal pain of 2 days’ duration was found to have bilateral RVT upon computed tomographic evaluation. He was successfully treated with emergent endovascular mechanical thrombectomy in conjunction with chemical thrombolysis and subsequently therapeutically anticoagulated. A renal biopsy demonstrated MGn, and the patient was placed on an appropriate medical regimen. He is well approximately 18 months later, with preserved renal function. Despite a multitude of potential causative mechanisms, all RVT patients should undergo a thorough workup for underlying hypercoagulable disorder and underlying benign or malignant renal causes. Treatment is aimed at prompt relief of venous obstruction and preservation of renal parenchymal function. Interventional radiological procedures, including thrombolysis and thrombectomy, have proven to be valuable in the treatment of RVT. Surgical options include thrombectomy and nephrectomy.     

活体供肾术前评估中16层螺旋CT的价值

目的：评价16层螺旋CT三维重建在活体供肾血管、肾实质、泌尿系统评估中的实际应用价值.方法：回顾2004年以来41例活体肾移植供体临床资料,术前均行16层螺旋CT扫描,采集肾动脉期、静脉期以及排泄期的影像数据,采用MIP、VR、MPR和CRP等三维图像后处理技术,评估供体肾动脉、肾静脉、泌尿集合系统和肾实质情况,与术中所见相对照.结果：41例供肾动脉显示,34例双肾单支动脉供血,其中2例左肾动脉、3例右肾动脉分支较早;4例右肾见一支副肾动脉,3例左肾见一支副肾动脉;术中证实有1例右副肾动脉,1例左肾动脉早期分支未能在影像中显示清楚,准确率95.1%.41例供肾静脉显示,37例双肾静脉为单支,4例右侧双支肾静脉;术中证实5例右侧双支肾静脉未能在影像中显示,准确率87.8%;泌尿集合系统显影满意,1例左侧双肾盂双输尿管畸形.结论：16层螺旋CT三维重建能准确显示供体肾脏血管、泌尿集合系统、肾实质解剖及可能的病理情况,给临床肾移植术前评估提供有价值的帮助,可作为供体术前检查的首选方法.