Occlusion of left common iliac vein by a distended urinary bladder in a male with paraplegia due to spinal cord injury

STUDY DESIGN: A report of a male subject who sustained paraplegia at T-5 level due to spinal cord injury (SCI) 18 years ago, and in whom, occlusion of the left common iliac vein by a distended bladder was detected during a routine follow-up. OBJECTIVES: To illustrate a rare complication of chronic distension of the urinary bladder viz occlusion of the left common iliac vein, which persisted even after providing adequate bladder drainage by intermittent catheterisation. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: As part of a routine follow-up, we performed intravenous urography by injecting 50 ml of Ultravist 300 in a vein over the dorsum of the left foot. Opacification of collateral veins in the pelvis was seen in the 5- and 10-min films, which suggested iliac venous occlusion. In order to confirm the diagnosis, contrast was injected intravenously in the left foot and venography was performed. RESULTS: Venography revealed a distended left common iliac vein with contrast flowing into the right internal iliac vein through collateral veins in the pelvis; the right common iliac vein and inferior vena cava were patent. Duplex Doppler sonography showed compression of left common iliac vein by the posterior wall of a distended bladder with absence of blood flow through the compressed segment. Computerised tomography (CT) confirmed the diagnosis of extrinsic compression of the left common iliac vein against the promontory of sacrum by a distended bladder. CT excluded other causes for iliac vein occlusion. CONCLUSION: In a male subject with SCI, chronic bladder distension produced occlusion of the left common iliac vein. Health professionals caring for individuals with SCI should be aware that long-standing bladder distension could cause pressure effects upon adjacent structures in the pelvis.     

Interventional embolization with fibrin glue for a large inferior mesenteric-caval shunt.

We report an unusual case of a large inferior mesenteric-caval shunt in a 25-year-old man without cirrhosis with hypoproteinemia and hypochromic anemia. In this large shunt the direct communication was between the inferior mesenteric vein and the internal iliac vein. Hemodynamic change as a result of the shunt was thought to cause his present clinical problems and future portosystemic encephalopathy. Percutaneous transcatheter embolization of the shunt with fibrin glue was performed through the internal iliac vein, and this offered amelioration of hypoproteinemia and reduction of serum ammonia levels without any complications. An interventional radiologic approach instead of surgical ligation should be attempted for portosystemic shunts, and fibrin glue, as well as coils or a detachable balloon, is also valuable as an embolizing material.     

Immediate and long-term results of superior mesenteric vein-inferior vena cava shunt for portal hypertension in children.

Experience with 46 superior mesenteric vein-inferior vena cava shunts in children is reported, with postoperative follow-up of from 2 to 15 yr. The first procedure used as an end-to-side implantation of the vena cava into the right side of the superior mesenteric vein or portal vein after ligating the cava above the iliac vessels (16 cases). In the next 30 children, the vena cava was lengthened using the left or right common iliac vein, thus obtaining better anastomosis and reversed portal flow. Patency may be definitely assumed when the esophageal varices have disappeared within 3 mo; this was observed in 33 children. Results are nearly the same with superior mesenteric vein-inferior vena cava shunt, splenorenal shunt and portacaval shunt when the respective veins of the portal system are more than 1 cm in diameter. When it is less, the superior mesenteric vein-inferior vena cava shunt is more successful than others; this is the case in children under 7 yr of age. No serious trouble was observed after the interruption of the venous circulation of the limbs and pelvis when a superior mesenteric vein-inferior vena cava shunt was performed when the patients were less than 15 yr of age.     

精索静脉髂外静脉分流术治疗胡桃夹综合征1例报道并文献复习

目的探讨胡桃夹综合征（NCS）的诊断及治疗方法。方法对1例NCS患者临床表现及诊断与治疗进行分析讨论。结果术后3月复查精子情况好转,蛋白尿消失,彩超示新建循环通路畅通。结论NCS临床表现复杂,诊断应将症状与辅助检查相结合,精索静脉髂外静脉分流是治疗NCS的方法之一。     

Large external iliac vein aneurysm in a patient with a post-traumatic femoral arteriovenous fistula

We report about a young patient with a large aneurysm of the left external iliac vein associated with a traumatic arteriovenous fistula between the left superficial femoral artery and the femoral vein after a stab wound 20 years ago. The patient presented with swelling of the left leg, which developed during the past years and worsened after saphenectomy 12 months before hospital admission. The chronically hyperperfused common iliac artery proximal to the arteriovenous fistula was compressing the common iliac vein. The venous outflow obstruction and subsequent venous hypertension render a possible explanation for the formation of the iliac vein aneurysm. Surgical repair of the venous aneurysm by interposition grafting and closure of the arteriovenous fistula was successful. A postoperative computed tomography scan showed a 50% size reduction of the feeding artery, underlining the ability of the arterial system to normalize arterial diameter in response to flow reduction, even after a high flow situation had existed for probably >20 years.     

Treatment of extrahepatic portal hypertension following a whipple procedure with a Rex shunt: report of a case

The Rex shunt is a mesenteric vein to left portal vein decompressive shunt used for the treatment of portal vein thrombosis and portal hypertension. Its use has been reported primarily in the pediatric population where portal vein thrombosis occurs with some frequency. The shunt is thought to represent a more physiologic shunt, since it restores hepatopedal blood flow through the liver. This report describes the use of this shunt in an adult who had frequent gastrointestinal bleeding secondary to extrahepatic portal vein thrombosis, which occurred as a complication after a pancreaticoduodenectomy.     

Changes in hepatic ultrastructure and function following portal vein resection with a use of an internal shunt bypass

Experimental studies on ultrastructural and functional changes of mitochondria were carried out using adult dog livers after portal vein resection with an internal shunt bypass. As a comparative study portal vein resection with an external shunt bypass was also carried out. A 10 cm long anti-thrombotic UK catheter was inserted into the portal vein as an internal shunt bypass (internal shunt group). Similarly, a catheter was inserted between the portal vein and inferior caval vein as an external shunt bypass (external shunt group). The time of portal vein shunt bypass was 2 hrs for both groups. During operations, the blood flow of the hepatic artery was blocked. After the bypass was installed, the hepatic artery and the portal vein were declamped. As a control experiment the hepatic artery was clamped without making a shunt bypass (non-shunt group). Left lateral lobe was resected from the liver prior to the shunt implant and then the right lateral lobe was removed 2 hrs after the declamping of the hepatic artery. Biochemical analysis on mitochondria isolated from the livers of the internal and the external shunt groups was carried out. Changes of mitochondrial ultrastructure were also studied using electron microscope. Changes in serum m-GOT and OCT activities were also examined. Essentially no changes were detected in phosphorylating capacities and ultrastructure of mitochondria of the livers obtained from either the external shunt group or the internal shunt group. However m-GOT and OCT activities in the serum were definitely elevated in the external shunt group of animals compared to those in the internal shunt group of animals. This suggests that the permeability of hepatic mitochondrial membranes in the external group of animals was changed probably due to hypoxia. From these results we recommended the application of the internal shunt bypass for hepato-biliary surgery combined with the resection of the portal vein.     

Autogenous internal iliac artery bypass in the surgical treatment of renovascular hypertension: a case report

A 24 year old female with severe renovascular hypertension resulting from bilateral fibromuscular dysplasia was successfully treated surgically. The internal iliac artery was used for a left aortorenal grafts. The right renal artery was dilated through the amputated left renal stump. Although saphenous vein graft is most commonly used, the autogenous internal iliac artery is considered a satisfactory graft in aortorenal reconstruction, especially for a young patient.     

The valvular anatomy of the iliac venous system and its clinical implications

Clinical and phlebographic evidence exists that correlates the presence of varices of the vulva, posterior thigh, and the pelvic congestion syndrome with insufficiency of the internal iliac venous system (pelvic dumping syndrome). Information in the modern medical literature regarding the valvular anatomy of the internal iliac veins and its tributaries is limited. We dissected 82 iliac venous system specimens in 42 human cadavers (29 men, 13 women) to gain information on the relationship between the disease described and the anatomy of the region. Each specimen contained common, external, and internal iliac veins, including the tributaries of the latter. We recorded the anatomic variations of the internal iliac vein trunk and the location of valves in the complete iliac venous system, including 485 tributaries of the internal iliac veins. Five specimens of internal iliac vein had calcified thrombosis or were extensively involved with pelvic carcinoma and were not suitable for valve study, which left 79 specimens for analysis. The internal iliac vein drained into the external iliac venous system by means of a single trunk in 73% of the specimens and by two well-formed and separated trunks in 27% of the specimens. In one specimen (1.2%) the internal iliac vein drained directly into the inferior vena cava (parallel internal and external iliac veins). One specimen had a well-developed valve in the common iliac vein (1.2%). The external iliac vein had one valve in 26.2% of the specimens. This vein had three times as many valves on the right side as in the left (39.6% vs 14.6%: p = 0.0106).(ABSTRACT TRUNCATED AT 250 WORDS)     

Gastroportal shunt for portal hypertension in children

PurposeExtrahepatic portal venous obstruction is the most common cause of portal hypertension in children. The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of internal jugular vein. The authors describe a novel adaptation of gastroportal shunt, successfully carried out in 8 children with extrahepatic portal hypertension.MethodsThe mean age of the 8 patients (6 boys and 2 girls) was 66.6 months at the time of operation. All children had portal hypertension. Seven had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism. Gastroportal shunt was performed in all patients. The left gastric vein was mobilized and anastomosed to left portal vein. In 1 patient, the left gastric vein was not of adequate length and required a venous graft (the inferior mesenteric vein). All patients were followed up for 3 to 20 months (median, 9 months).ResultsThe gastroportal shunt was successfully performed in all patients. The median operative time was 265 minutes (range, 205-360 minutes). Operative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized, and the biochemistry tests were within reference range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the gastroportal shunt in each patient. The size of spleen decreased. There was no recurrence of variceal bleeding.ConclusionsThe gastroportal shunt is an effective treatment of extrahepatic portal hypertension.     

Hemodialysis catheter placement and recirculation in treatment of hyperammonemia

A 2-year-old girl with carbamoyl phosphate synthetase deficiency underwent emergency hemodialysis (HD) for treatment of acute life-threatening hyperammonemia. HD was performed via catheters placed in each femoral vein serving as vascular access. The tip of one of the catheters (aspirating line) was in the left external iliac vein and the tip of the other catheter (the return line) was in the inferior vena cava (IVC). High blood flow rates were used in order to rapidly lower the blood ammonia (NH₃) levels. However, unanticipated marked recirculation in the IVC, between the dialysis aspirating and return catheters, was encountered, preventing significant reduction in blood NH₃. The recognition of this problem, suggested solutions, and prevention are described. Received August 27, 1997; received in revised form and accepted February 4, 1998     

Noncirrhotic portal vein thrombosis. Physiology before and after shunts.

Controversy exists concerning the proper therapy for bleeding gastroesophageal varices secondary to noncirrhotic portal vein thrombosis. Disparity of opinion exists regarding the significance of hepatic portal blood flow and the consequences of total portal-systemic shunts in this condition. One patient is presented who developed severe, crippling encephalopathy 20 years after a central splenorenal shunt. This was associated with loss of portal flow to the liver and marked nitrogen intolerance. Closure of the shunt resulted in restoration of hepatic portal flow via collateral veins (HPI 0.36), clearance of encephalopathy and return to near normal protein tolerance. An additional patient was studied with hyperammonemia and early suggestive signs of encephalopathy eight years following a mesocaval shunt. Four patients were evaluated before and after selective distal splenorenal shunts. All had "cavernous transformation" of the portal vein with angiographic evidence of portal flow to the liver. Postoperative angiograms revealed continued hepatic portal perfusion and a patent shunt in each patient. Radionuclide imaging postoperatively gave an estimated portal fraction of total hepatic blood flow (HPI) of .39 and .60 in two of the four patients. We conclude that 1) there is significant hepatic portal perfusion in noncirrhotic portal vein thrombosis (cavernous transformation), 2) loss of this hepatic portal flow following total shunts can lead to severe encephalopathy, 3) the selective distal splenorenal shunt maintains hepatic portal perfusion and is the procedure of choice when there is a patent splenic vein and surgical intervention is indicated.     

May-thurner syndrome: A previously unreported variant

Irritation of the left common iliac vein by the overlying right common iliac artery may result in intraluminal obstruction and symptomatic venous occlusion of the left lower extremity. We recently treated a 39-year-old patient with such an obstruction of the left common iliac vein as a result of compression by the left internal iliac artery. This case stresses the need to consider etiologies of external venous obstruction of the left lower extremity other than the commonly reported right common iliac artery when planning surgical intervention.     

Successful mesenterico-left portal vein bypass in a child with duplicated round ligaments and rex recessi

A 3-year-old girl with idiopathic extrahepatic portal vein obstruction undergoing mesenterico-left portal vein bypass (MLPVB), or Rex shunt, for recurrent variceal bleeding was intraoperatively discovered to have duplicated round ligaments and Rex recessi. The left and right portal veins connected to their respective round ligaments but had minimal communication within the liver. Intraoperative venography identified a better preserved portal system on the left, and standard MLPVB resulted in excellent shunt flow. The shunt remains patent and the patient asymptomatic 9 months after her operation. Abnormal portal anatomy is not a contraindication to MLPVB.     

Arterial compression of the right common iliac vein; an unusual anatomical variant

Compression of the left common iliac vein by the right common iliac artery has been well described (Cockett's syndrome).The authors describe a case report of compression of the right common iliac vein by the right internal iliac artery. The patient presented with ipsilateral lower limb oedema. Venography showed smooth extrinsic compression of the right common iliac vein. The CT scan was initially interpreted as showing no extrinsic mass or obvious compressing lesion and lymphography was normal. It was the duplex scan which showed the bifurcation of the right common iliac artery crossing the right common iliac vein and causing significant extrinsic compression.     

Bilateral congenital absence of internal iliac arteries, prominent lumbar arteries, and a ruptured mycotic aneurysm of the abdominal aorta

A 46-year-old man was admitted for surgery on a ruptured mycotic abdominal aortic aneurysm. Emergency repair was performed, during which certain anomalies were noted. First, the bifurcation of the aorta was posterior to the left common iliac vein. Second there were no internal iliac arteries. Also, there were prominent lumbar arteries compensating for the absent internal iliac arteries bilaterally. This, we consider, is the first reported case of congenitally absent bilateral internal iliac arteries.     

The iliac vein occlusion]

Basing on roentgenological and morphological investigations the causes of the iliac veins passability disorder were studied up. In 45.1% of observations the stenosis was revealed of the left and in 1.2% of the right common iliac vein. Among the stenosis causes were osteal or cartilagenous prominences of vertebral column, intravascular structures (webs, membranes) in the left common iliac vein, the external iliac vein squeeze by internal iliac artery, retroperitoneal fibrosis, the right common iliac artery aneurysm, anomalous branching of parietal pelvic artery.     

Rex shunt for acute portal vein thrombosis after pediatric liver transplantation in children with biliary atresia

Background/Purpose

Posttransplantation portal vein thrombosis (PVT) can have severe health consequences, and portal hypertension and other consequences of the long-term privation of portal inflow to the graft may be hazardous, especially in young children. The Rex shunt has been used successfully to treat PVT patients since 1998. In 2007, we started to perform this surgery in patients with idiopathic PVT and late posttransplantation PVT. Herein we have reported our experience with this technique in acute posttransplantation PVT.

Methods

Three patients of ages 12, 15, and 18 months underwent cadaveric (n = 1) or living donor (n = 2) orthotopic liver transplantation (OLT). All patients had biliary atresia with portal vein hypoplasia; they developed acute PVT on the first postoperative day. They underwent a mesenteric-portal surgical shunt (Rex shunt) using a left internal jugular vein autograft (n = 2) or cadaveric iliac vein graft (n = 1) on the first postoperative day.

Results

The 8-month follow-up has confirmed shunt patency by postoperative Doppler ultrasound. There have been no biliary complications to date.

Conclusions

The mesenteric-portal shunt (Rex shunt) using an autograft of the left internal jugular or a cadaveric vein graft should be considered for children with acute PVT after OLT. These children usually have small portal veins; reanastomosis is often unsuccessful. In addition, this technique has the advantage to avoid manipulation of the hepatic hilum and biliary anastomosis. Although this study was based on a limited experience, we concluded that this technique is feasible, with great benefits to and low risks for these patients.     

Successful laparoscopic division of a patent ductus venosus: report of a case

Patent ductus venosus (PDV) is a rare condition of a congenital portosystemic shunt from the umbilical vein to the inferior vena cava. This report presents the case of an adult patient with PDV, who was successfully treated with laparoscopic shunt division. A 69-year-old male was referred with hepatic encephalopathy. Contrast-enhanced CT revealed a large connection between the left portal vein and the inferior vena cava, which was diagnosed as PDV. The safety of a shunt disconnection was confirmed using a temporary balloon occlusion test for the shunt, and the shunt division was performed laparoscopically. The shunt was carefully separated from the liver parenchyma with relative ease, and then divided using a vascular stapler. Portal flow was markedly increased after the operation, and the liver function of the patient improved over the 3-month period after surgery. Although careful interventional evaluation for portal flow is absolutely imperative prior to surgery, a minimally invasive laparoscopic approach can be safely used for treating PDV.     

Reversal of flow in the mammary artery to treat subclavian steal syndrome in conjunction with coronary bypass surgery

Occasionally patients with multi-vessel disease present with coronary stenoses and subclavian steal syndrome. A novel surgical approach for the treatment of these vascular problems is described. The in situ left internal mammary artery was used to create an aortosubclavian shunt, thus restoring antegrade vertebral flow and vein grafts were used for coronary revascularization.