Varicocele and Nutcracker Syndrome

Objective. Varicocele is a vascular lesion commonly associated with infertility. Its etiology is only partly understood; hence, the purpose of the study was to establish its correlation with intrinsic anatomic differences and nutcracker syndrome. Methods. A total of 93 patients with varicocele and 76 patients without varicocele were enrolled. The diagnosis of varicocele was based on physical examination, followed by sonographic evaluation of the hilar portion and aortomesenteric portion (AMP) of the left renal vein (LRV). The anteroposterior diameter in millimeters and peak flow in centimeters per second in each region were measured. Results. A total of 28 patients with the nutcracker syndrome were identified in the study group (30.10%), and 2 were identified in the control group (2.63%). The mean diameters of the hilar portion and AMP of the LRV were significantly different in varicocele‐affected patients compared with the control group (P < .0001 for both). The mean peak velocities in the hilar portion and AMP were significantly different in patients with varicocele (P < .0001). Patients with varicocele and nutcracker syndrome did not have a significant difference in either the hilar or AMP diameter compared with patients with varicocele without nutcracker syndrome. They had a significant difference in both the hilar and AMP peak flow velocity (P = .0001 for both). Conclusions. Our findings indicate that nutcracker syndrome is a frequent finding in varicocele‐affected patients and should be routinely excluded as a possible cause of varicocele. In addition, intrinsic anatomic differences in the AMP and hilar portion of the LRV could be directly responsible for the onset of varicocele.     

影像学诊断胡桃夹综合征进展

胡桃夹综合征（NCS）是由于左肾静脉在腹主动脉和肠系膜上动脉之间受压而引起一系列临床症状的综合征,包括血尿、蛋白尿、侧腹痛、生殖静脉曲张等。影像学检查如多普勒超声、CTA、MRA、血管腔内超声（intravascular ultrasound,IVUS）及肾静脉造影对诊断NCS具有重要作用。本文对NCS的影像学表现和诊断标准进行综述。     

精索静脉血流速度与内径比值在精索静脉曲张诊断中的意义

目的探讨精索静脉血流速度与内径比值（V／D）对精索静脉曲张的诊断价值。方法对63例临床确诊为精索静脉曲张的患者（VC组）及50例健康受检者（对照组）应用彩色多普勒超声检查观察左侧精索静脉的发病情况，并记录相关数据，进行统计学分析。结果VC组精索静脉内径较对照组明显增宽，V／D比值较对照组明显减小，均存在明显的统计学差异（P〈0．05）；血流速度在两组之间不存在统计学差异（P〉0．05）。结论精索静脉血流速度与内径比值作为评价精索静脉曲张患者精索静脉血流动力学参数的一项重要指标，对精索静脉曲张的诊断有重要意义。     

The influence of left renal vein entrapment on outcome after surgical varicocele repair: a color Doppler sonographic demonstration.

OBJECTIVE: To evaluate the impact of left renal vein entrapment on outcome after surgical varicocele repair using color Doppler sonography. METHODS: Eighty-four men had varicoceles on color Doppler sonography (2 right sided, 74 left sided, and 8 bilateral), which were diagnosed on the basis of a venous diameter of 3 mm or greater and venous retrograde flow in the pampiniform plexus of veins during the Valsalva maneuver or when changing from a supine to an upright position. Diagnosis of the left renal vein entrapment was based on the following criteria: antero-posterior diameter of greater than 1 cm and peak velocity of less than 15 cm/s for the left renal vein at the mid portion and anteroposterior diameter of less than 0.2 cm and peak velocity of greater than 110 cm/s (or, alternatively, a diameter ratio and peak velocity ratio of >5) for the left renal vein between the aorta and superior mesenteric artery. All patients underwent surgical varicocele repair. In postoperative follow-up, we compared the presence of left renal vein entrapment with the frequency of varicocele recurrence. RESULTS: Sixteen (19%) of 84 patients had left renal vein entrapment with a left-sided varicocele. Postoperatively (mean follow-up +/- SD, 19.3 +/- 11.7 months), 27 (32.2%) of 84 had varicocele recurrence, including all 16 patients with left renal vein entrapment and 11 (20.1%) of 68 patients without left renal vein entrapment. The varicocele recurrence rate was significantly greater in patients with left renal vein entrapment (P < .001, Fisher exact test). CONCLUSIONS: The presence of left renal vein entrapment resulted in a significantly higher varicocele recurrence rate. Patients with varicoceles should routinely be evaluated for the presence of left renal vein entrapment before surgical repair.     

多排螺旋计算机断层摄影肾上腺静脉成像

  目的  探讨多排螺旋计算机断层摄影(multi-slice spiral computed tomography, MSCT)静脉成像显示双侧肾上腺静脉的图像质量, 并对肾上腺静脉解剖及变异进行形态学观察。  方法  回顾性分析100例双侧肾上腺形态大致正常的患者腹部增强CT图像, 用最大密度投影(maximum intensity projection, MIP)或多平面重建(multi-planar reconstruction, MPR)显示双侧肾上腺静脉, 评价图像质量, 并分别描述肾上腺静脉解剖位置、变异及与左肾静脉和下腔静脉的关系。  结果  以MIP或MPR技术评价图像质量, 左肾上腺静脉97例(97%)为1级, 1例(1%)为2级, 2例(2%)为3级; 右肾上腺静脉52例(52%)为1级, 19例(19%)为2级, 29(29%)例为3级。左肾上腺静脉均为1支; 91%与膈下静脉汇合后汇入左肾静脉; 左肾上腺静脉平均直径(3.6±0.6)mm(2.4~4.5 mm); 左肾上腺静脉与左肾静脉形成交角, 平均为(121.9±16.0)°(150~58°)。2例发现右侧双支肾上腺静脉; 67例(94%)右肾上腺静脉汇入下腔静脉, 4例(6%)汇入右副肝静脉; 右肾上腺静脉平均直径(3.2±0.5)mm(1.9~4.0 mm); 右肾上腺静脉与下腔静脉形成交角, 平均为(75.3±16.6)°(90~35°)。  结论  多排螺旋CT双侧肾上腺静脉成像结合MIP和MPR技术可清晰显示大部分肾上腺静脉, 尤其是左肾上腺静脉。     

Incidence of the retroaortic left renal vein in patients with varicocele.

OBJECTIVE: The purpose of this study was to investigate the incidence of the retroaortic left renal vein (RLRV) in patients with varicocele. METHODS: The left renal vein was ultrasonographically investigated for the presence of the RLRV in 140 patients with varicocele and a control group of 137 age-matched patients. The main diagnostic criteria for varicocele were the presence of a varicose vein with a diameter of 3 mm or larger at rest and with a reflux lasting more than 2 seconds during the Valsalva maneuver. The RLRV was defined as a posterior course of the left renal vein to the aorta at the level of the origin of the superior mesenteric artery. RESULTS: The RLRV was observed in 13 (9.3%) of the 140 patients with varicocele and 3 (2.2%) of the control patients. The incidence of the RLRV was found to be significantly higher in patients with varicocele compared with the control patients (P = .018, Fisher exact test). In 13 patients with the RLRV, left varicocele and bilateral varicocele were detected in 10 and 3 cases, respectively. CONCLUSIONS: In this study, the incidence of the RLRV was found to be significantly higher in patients with varicocele compared with control patients. Thus, we suggest that the presence of the RLRV may be considered one of the etiologic factors in the development of varicocele.     

腹腔镜肾上腺手术肾上腺中央静脉的应用解剖

目的 根据作者术中所见并结合文献回顾，总结肾上腺血管的应用解剖和变异，阐述腹腔镜肾上腺手术时的注意事项。方法 经腹腔及后腹腔入路腹腔镜肾上腺或腺瘤切除，回顾性总结肾上腺血管的解剖及变异。结果 右肾上腺的血管解剖变异包括：中央静脉与右下肝静脉汇合后汇入下腔静脉；中央静脉汇入右肾静脉与下腔静脉的交汇处；多支中央静脉。左肾上腺的血管解剖变异包括：中央静脉与膈下静脉分别汇入左肾静脉；中央静脉与左副肾静脉汇合为主干后汇入左肾静脉。结论 了解并能在术中正确辨别肾上腺的血管解剖变异，有助于安全地进行腹腔镜肾上腺手术。     

Intravascular ultrasonographic findings in May-Thurner syndrome (iliac vein compression syndrome).

The objective of this series was to describe the findings in 2 types of iliac vein compression syndrome on intravascular ultrasonography. We conducted a retrospective review of the intravascular ultrasonographic findings in 2 patients with iliac vein compression syndrome due to 2 different types of venous spur and correlated those findings with the contrast-enhanced venographic findings. Intravascular ultrasonography allowed differentiation of the 2 different types of iliac vein compression syndrome in analogy to the venographic classification. Both cases had compression of the left common iliac vein between the right common iliac artery and the vertebral bodies. In addition, hyperechogenic eccentric wall thickening, the presence of multiple vascular channels separated by hyperechogenic structures, and the presence of sequelae of deep venous thrombosis such as synechiae and organized thrombus can be seen on intravascular ultrasonography. The ability to perform exact measurements of the venous dimensions is an added benefit of intravascular ultrasonography. Intravascular ultrasonography can assist in the diagnosis and classification of iliac vein compression syndrome, allows assessment of its complications, and can be potentially helpful for planning endovascular treatment.     

Supraclavicular Vein Approach for Upgrading an Implantable Cardioverter Defibrillator to a Biventricular Device

Total occlusion of the left subclavian vein was found in a 52‐year‐old patient, 5 years after implantation of an implantable cardioverter defibrillator (ICD). During replacement, the ICD was upgraded to a biventricular device for worsening of the patient's congestive heart failure to New York Heart Association class III. Insertion of the left ventricular lead in the ipsilateral vein system was successfully achieved by using the supraclavicular approach, enabling puncturing of the left subclavian vein medially to the obstruction. (PACE 2010; 634–636)     

Normal pulmonary veins anatomy is associated with better AF-free survival after cryoablation as compared to atypical anatomy with common left pulmonary vein

Background: Pulmonary vein cryoablation (PVC) is a new approach in the treatment of recurrent atrial fibrillation (AF). Computed tomography (CT) can be used to evaluate the left atrium anatomy and PVs dimensions to facilitate the procedure. In radiofrequency procedures, some anatomic variants such as common left (CLPV) or right (CRPV) PV were reported as factors associated with technical procedure difficulties and potential long‐term complications. We hypothesized that the absence of CLPV as determined by CT would predict better AF‐free survival after PVC. Methods and results: We included 118 consecutive patients (mean age 56 ± 10 years; 77% males) with drug refractory paroxysmal (72%)/persistent (28%) AF, with more than 6 months follow‐up, who underwent PVC. On CT scanning images performed within 1 month prior to ablation, we evaluated PV anatomic patterns: presence of CLPV or CRPV. Each patient was evaluated by 24‐hour Holter monitoring within 1 and 3 months and all patients were periodically evaluated at 1, 3, and 6 months, and every 6 months thereafter. Patients were asked to record their 12‐lead electrocardiogram whenever they experienced symptoms suggestive of AF. Recurrence was defined as AF that lasted at least 30 seconds. CLPV was present in 30 (25%) patients and no patients with CRPV were identified. At the end of the 13 months follow‐up, patients with normal PVs had significantly better AF‐free survival compared to patients with CLPV (67% vs 50%, P = 0.02). The difference was present in patients with paroxysmal AF (P = 0.008) but not in patients with persistent AF (P = 0.92). Conclusion: In patients undergoing cryoballoon PV isolation for AF, the presence of normal PVs pattern is associated with better AF‐free survival as compared to atypical PV anatomy with CLPV, particularly in patients with paroxysmal AF. (PACE 2011; 34:837–843)     

正常肺静脉经胸超声心动图与64层螺旋CT对比定位观察

目的 探讨经胸超声心动图显示肺静脉及对4条肺静脉定位的有效方法.方法 选取同时行肺静脉CT血管造影检查及超声心动图检查的拟行心房颤动消融患者12例.进行CT三维图像后处理分析,观察4条肺静脉与相邻重要解剖结构的空间位置关系,同时对比分析CT三维图像后处理相关断层与超声心动图切面.结果 12例患者肺静脉螺旋CT血管造影成像均清晰显示,且无结构异常及解剖变异.右上肺静脉开口紧邻房间隔,近端与上腔静脉相邻.右下肺静脉相对于右上肺静脉稍远离房间隔,位于右侧.左上肺静脉紧邻左心耳.左下肺静脉相对于左上肺静脉远离左心耳,靠近胸降主动脉.超声心动图标准切面左心室长轴、大动脉短轴、心尖四腔观在调整探头的基础上可以显示4条肺静脉.结论 经胸超声心动图可以显示4条肺静脉,参照邻近重要的解剖结构可以对4条肺静脉进行空间位置定位.     

浸润式超声与接触式超声测量头静脉内径的可重复性研究

目的 评价浸润式、接触式超声在测量头静脉内径中的可重复性.方法 由2名从事超声诊断工作10年以上的医师,对重庆医科大学附属大学城医院收治的38例预行桡动脉-头静脉内瘘成形术前的患者,在左前臂同一位置处、不同时间点,分别使用浸润式、接触式超声2种方法进行头静脉内径测量.使用组内相关系数(interclass correl...     

呼吸触发B-TFE序列在门静脉成像中的初步应用

目的探讨呼吸触发B-TFE序列在门静脉系统成像的应用价值。方法使用呼吸触发B-TFE序列,对40例病例进行门静脉系统成像,冠状位,使用呼吸触发技术,不使用对比剂。所有病例均在近期进行了双功多普勒超声检查,并和B-TFE门静脉成像结果进行比较。检查的内容包括:门静脉主干、门静脉右支、门静脉左支、肠系膜上静脉和脾静脉以及可能出现的侧支循环情况。结果呼吸触发B-TFE序列门静脉成像准确地显示了本组全部病例的门静脉系统情况;呼吸触发B-TFE门静脉成像结果和双功多普勒超声结果相关性良好,且具有一定的优势。结论呼吸触发B-TFE序列门静脉成像技术可以在不使用对比剂情况下准确地评价门静脉系统情况。     

Fetal Isolated Prominent Left Brachiocepalic Vein

The objectives of this series were to describe the prenatal sonographic findings of a fetal isolated prominent left brachiocephalic vein with its in utero natural history and neonatal outcome and to discuss the differential diagnosis, especially with a total or partial anomalous pulmonary venous return malformation. We reviewed all cases referred to 2 tertiary medical centers with the presenting finding of a prominent, upper thorax transverse vein entering the superior vena cava. The primary suspicion of a subjective dilated left brachiocephalic vein, as a part of a supracardiac anomalous pulmonary venous return malformation, was investigated by a systematic anatomic evaluation. After exclusion of other cardiac and structural anomalies, we followed the pregnancies and their outcomes. Eight cases were recruited during a 7 year period. The mean maternal age was 31 years, and the mean gestational age at the time of diagnosis was 17 weeks. In 7 cases, the dilatation was not evident during 6 weeks of follow up. In 1 case, the dilatation was evident until delivery at 39 weeks and was not apparent on postnatal echocardiography or spiral computed tomography. All neonates developed without any heart or other complications. We conclude that after exclusion other malformations, a prominent left brachiocephalic vein is a benign transient phenomenon that does not persist post‐partum in the neonate.     

Incidence and importance of reflux in testicular veins of healthy men evaluated with color duplex sonography

PURPOSE: Reflux in the testicular veins plays a crucial role in the diagnosis of a varicocele. The aim of this study was to evaluate the incidence and the sonographic features-duration and velocity-of reflux in testicular veins of healthy men using color duplex sonography (CDS). METHODS: Healthy male volunteers, 18-45 years old, whose physical examinations and semen analyses were normal, were recruited for this study. The maximum diameters of testicular veins during both normal respiration and Valsalva's maneuver were measured by CDS using a 7.5-MHz linear-array transducer. Veins greater than 2 mm in diameter were considered to be a varicocele, and the subjects in these cases were excluded from the analysis. In cases in which reflux was present, the velocity and duration of reflux in the testicular veins during Valsalva's maneuver were measured. RESULTS: Seventy men, whose mean (+/- standard deviation) age was 27 +/- 7 years, were enrolled in this study. Fourteen of the 70 patients had a left varicocele and thus were excluded from the analysis. Of the 112 hemiscrotums in the remaining 56 patients, 61 (54%) had reflux induced by Valsalva's maneuver and 51 (46%) did not. Twenty-two (39%) of refluxes were on the right side, with a mean duration of 1.1 +/- 0.5 seconds, and a mean velocity of 4.2 +/- 2.1 cm/second; 39 (70%) of the refluxes were on the left side, with a mean duration of 1.1 +/- 0.5 seconds and a mean velocity of 4.9 +/- 2.3 cm/second. The incidence of reflux was significantly higher on the left side (p = 0.003). The duration and velocity of the reflux did not differ significantly between the right and left sides. The difference in the testicular vein diameters between the right (1.3 +/- 0.2 mm; n = 56) and left (1.6 +/- 0.2 mm; n = 56) sides was statistically significant (p < 0.001). CONCLUSIONS: Normal-sized testicular veins in healthy subjects had a remarkably high incidence of reflux induced by Valsalva's maneuver. The presence of reflux in subfertile men with normal testicular vein diameters is a diagnostic criterion, but it is necessary to quantify the reflux to prevent misdiagnosis of a varicocele and unnecessary surgery. The measurement of the duration and velocity limits of reflux in a large series of subjects may provide a reliable indicator for the diagnosis of varicocele.     

Spontaneous Left Main Coronary Artery Dissection and the Role of Intravascular Ultrasonography

Objective. Spontaneous left main coronary artery (LMCA) dissection is a rare event with an unknown incidence and high risk of sudden cardiac death. The diagnosis of LMCA dissection is often challenging given the limitations of 2‐dimensional angiography. The 3‐dimensional perspective of intravascular ultrasonography (IVUS) is often indispensable in confirming or excluding the diagnosis of spontaneous LMCA dissection. We report 2 cases of spontaneous LMCA dissection with unique angiographic presentations wherein IVUS was essential in defining the extent of LMCA involvement and facilitated the subsequent referral for emergent coronary artery bypass grafting. Methods. Two patients presented to our facility with acute coronary syndrome prompting coronary angiography, which was notable for an unusual angiographic appearance of the LMCA. Intravascular ultrasonography was performed in each case, revealing spontaneous LMCA dissection. Results. Intravascular ultrasonography permitted the prompt diagnosis and aided in definitive surgical intervention in our 2 cases of spontaneous LMCA dissection. Conclusions. Intravascular ultrasonography is a useful adjunctive imaging modality in the diagnosis and management of spontaneous LMCA dissection.     

Computational Method to Predict Esophageal Temperature Elevations During Pulmonary Vein Isolation

Background: The esophagus is in close proximity to the posterior wall of the left atrium, which renders it susceptible to thermal injury during radiofrequency (RF) ablation procedures for atrial fibrillation (AF). Real‐time assessment of esophageal position and temperature (T °) during pulmonary vein (PV) isolation has not been extensively explored. Objective: To develop a protocol that allows estimation of the potential for, and avoidance of, esophageal heating. Methods: In consecutive patients who underwent PV isolation, a thermal probe was used to monitor T ° fluctuations in the esophagus during application of RF energy. The tip of the thermal probe was positioned at the level of the targeted PV and RF was discontinued for T ° rise >0.5°C. The proximity of individual PVs to the esophagus was measured from the temperature probe tip to the closest posterior part of the Lasso catheter from review of biplane projections (left anterior oblique 60° and right anterior oblique 30°). These raw distances were entered into the Pythagorean theorem and the actual distance between the esophageal thermal probe and PV antrum was determined. Results: The study cohort included 44 patients (60 ± 11 years, 61% male, 57% lone AF). The thermal probe in the esophagus was closer to the left‐sided PVs (left common pulmonary vein: 20.9 ± 13 mm, left upper pulmonary vein: 20.5 ± 11 mm, left lower pulmonary vein: 23.4 ± 10 mm) than the right‐sided ones (right common pulmonary vein: 31.0 ± 11 mm, right upper pulmonary vein: 41.9 ± 18 mm, right lower pulmonary vein: 34.5 ± 16 mm). A T ° increase >0.5°C occurred during 116/1,495 (7.8%) deliveries. A T ° rise was more likely during ablation of left‐sided PVs than right‐sided PVs (55% vs 10%, P < 0.0001) and when RF was delivered ≤24 mm from the esophagus (sensitivity 91%, specificity 81%, positive predictive value 75%, and negative predictive value 93%). Conclusion: A thermal probe placed in the esophagus provides real‐time T ° monitoring and anatomic localization. A T ° rise is more likely during ablation of left PVs and during RF deliveries within 24 mm of the esophageal thermal probe. (PACE 2010; 33:1239–1248)     

Evaluation of left gastric vein in Chinese healthy adults with multi-detector computed tomography

Objectives: To evaluate the classification and diameter of left gastric vein (LGV) in healthy Chinese adults with multi-detector computed tomography (MDCT).

Methods: MDCT angiography was performed in 234 healthy adults for the portal venous system. CT cross-sectional thin-layer reconstruction combined with maximum intensity projection, volume rendering and multiplanar reconstruction were applied. The diameter of LGV was measured at the point within 2 cm from LGV origination.

Results: Of 234 subjects, 11 subjects (4.70%) who did not have clear images were excluded, and 223 subjects (95.30%) with excellent images were included. The LGV was originated from the portal vein in 46.15%, splenic vein in 30.77%, portal splenic angle in 14.53%, and the left branch of the portal vein in 3.85%. The maximal diameter of LGV was 4.74 ± 0.84 mm with a 95% confidence interval of 4.63–4.85 mm, and the LGV diameter was positively correlated with the weight of patients (R = 0.26, P = 0.006). No significant difference existed in the maximal diameter of LGV at different origination sites (P = 0.35). The diameter of LGV was significantly greater in males than in females (4.90 ± 0.85 vs. 4.56 ± 0.80 mm, P = 0.002), and the maximal diameter of LGV was significantly (P = 0.02) greater in the age range of 30–39 and 40–49 years than in the range of >70 years. No statistical significance (P = 0.36) was detected in the other groups.

Conclusion: MDCT can clearly display the detailed anatomy and variation of LGV in healthy adults, providing a normal range of LGV diameter for clinical reference for diagnosing possible portal hypertension and for possible intervention.     

MSCT经足注射髂静脉成像的技术探讨

目的探讨多层螺旋CT经足注射髂静脉成像的技术和临床应用价值。方法50例髂静脉进行多层螺旋CT血管造影,对比剂注射方案为经患侧足背浅静脉以2.5～3.0ml/s注射浓度为150mgI/ml的非离子型对比剂,延迟16～22s后开始扫描。利用多种重建方法进行重建。分析髂静脉的成像质量以及髂静脉疾病的影像特点。结果所有50例患者均成功完成CT血管造影。其中31例完全阻塞;9例管腔狭窄或见局部充盈缺损;10例完全通畅。图像质量优良率:优24%(12/50),良60%(30/50),差16%(8/50),总体优良率84%(42/50)。结论应用经患侧足部浅静脉注入造影剂,延迟约20s后经螺旋CT扫描并重建的方法,可获得较为良好的髂静脉图像能准确判断各种髂静脉异常,发现髂静脉梗阻的部位、程度,显示侧支循环的形成情况,有助于临床作出病因诊断,是目前髂静脉病变较为理想的无创性影像学检查方法之一,特别是对缺乏DSA设备的医疗机构其作用尤其突出。     

左生殖静脉-下腔静脉转流术治疗胡桃夹综合征合并精索静脉曲张一例

胡桃夹综合征是一种罕见疾病,可导致患者出现蛋白尿、肾功能受损及生殖静脉曲张等系列症状。传统开放手术方式首选左肾静脉转位术,但手术创伤较大,术后近、远期并发症较多,影响患者生活质量。本文报道1例胡桃夹综合征合并左精索静脉曲张的男性青年患者,采用左生殖静脉-下腔静脉转流术并左精索静脉高位结扎术的手术方式,取得了良好治疗效果。该手术方式为胡桃夹综合征合并精索静脉曲张患者提供了新的治疗思路,值得临床借鉴。