Aorto-left renal vein fistula: an unusual complication of abdominal aortic aneurysm.

A patient with an abdominal aortic aneurysm with a preaortic left renal vein fistula is presented. Review of the 7 reported cases of aorto-left renal vein fistulae demonstrates many similarities in the clinical presentation with aorto-caval fisulae. However, in addition to the triad of pain, pulsatile abdominal mass and bruit, commonly found in aorto-caval fistulae, the presence of hematuria, proteinuria, and azotemia suggests a renal vein fistula. Radiographic studies often demonstrate a large non-functional left kidney. Operative management of the fistula may be performed by a variety of maneuvers. All 7 patients survived. When repair was undertaken without delay, function in the left kidney returned to normal within two months postoperatively.     

Haematuria and abdominal aortic aneurysm

Haematuria and left loin pain in a patient with abdominal aortic aneurysm and associated with the radiological finding of a poorly or non-functioning left kidney are the pathognomonic features of aorto-left renal vein fistula, a condition in which the aneurysm leaks into an anomalous retro-aortic left renal vein.     

Rupture of an aortic aneurysm into the renal vein presenting as a left-sided varicocoele. Case report

We report a case of aorto-left renal vein fistula secondary to an aortic aneurysm presenting with flank pain, a left-sided varicocoele and microscopic haematuria. These symptoms and signs should alert the clinician to this rare complication of abdominal aortic aneurysm.     

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.     

Traumatic fistula between the aorta and the left renal vein: case report and review of the literature

This report of an aorto-left renal vein fistula (ALRVF) of traumatic origin is the sixth such case on record. The fistula was successfully repaired, with preservation of the kidney, by autotransfusion. Review of the English language literature revealed the differences between spontaneous and traumatic ALRVF. Spontaneous fistulas were caused by rupture of an abdominal aortic aneurysm into a retroaortic left renal vein. Hematuria was almost constant (93% of cases). The operative mortality rate was 14%. By contrast, traumatic ALRVFs were the result of a penetrating wound to the abdomen. The left renal vein was in a normal position, anterior to the aorta. Hematuria was less common (16% of cases). The diagnosis was delayed because clinical signs were less acute. There were no reports of postoperative deaths.     

Aortic aneurysm rupture into a retroaortic left renal vein

We report the case of a patient who was transferred to our facility after a CT scan obtained at a local hospital revealed a leaking abdominal aortic aneurysm. Review of the scan showed an aorto-left renal vein fistula. Knowing this fistula was present made the operative repair of the aneurysm and control of the fistula much more straightforward than might otherwise have been the case. Although relatively rare, major anomalies of the renal veins and perirenal vena cava should be borne in mind when operating on the abdominal aorta. This case illustrates the merit of contrast-enhanced CT scanning prior to aortic surgery.     

Fistulas between the aorta and the left renal vein

Two cases of aorta-left renal vein fistula (ALRVF) resulting from abdominal aortic aneurysm (AAA) are reported. A review of the literature reveals only 10 other such cases. Clinical presentation included left flank pain in 75% of cases, hematuria in 92%, hypotension in 8%, a pulsatile mass in 58%, and an abdominal bruit in 75%. Intravenous pyelography was performed in 58% of cases and consistently showed decreased function of the left kidney. Arteriography was obtained in 58% of patients and was always diagnostic. Incidence, pathophysiology, and surgical management of this condition are discussed.     

Left renocaval venous bypass with autologous great saphenous vein for nutcracker syndrome

Nutcracker syndrome results from left renal vein compression by the abdominal aorta and the superior mesenteric artery. The consecutively increased renal venous pressure results in hematuria, proteinuria, flank pain, left-sided varicocele, pelvic congestion, and others. We report a 25-year-old man with nutcracker syndrome who underwent successful left renocaval venous bypass with autologous great saphenous vein. The patient's condition clearly improved, with no clinical relapse after treatment. Ultrasound imaging showed patency of the venous bypass and decreased venous hypertension. This technique is a feasible choice for surgical treatment of nutcracker syndrome, with a low incidence of complications and satisfactory results.     

Abdominal Aortic Aneurysm Rupture into a Retro-Aortic Left Renal Vein

We present a case of an abdominal aortic aneurysm ruptured into a retroaortic left renal vein. The patient presented with left flank pain, left-sided varicocoele and haematuria. Imaging showed a juxtarenal AAA associated with a retroaortic left renal vein and simultaneous contrast captation of the aneurysm, the vena cava, the left renal vein and the left vena testicularis. After opening of the aneurysm sac, the defect was controlled by digital pressure and closed by suture. The patient underwent a successful abdominal aorto bi-iliac replacement. We discuss prevalence, clinical features and treatment options of this rare condition.     

Preoperative evaluation of retroperitoneal venous system anomalies during abdominal aortic aneurysm rupture

The association of a retroaortic left renal vein and an abdominal aortic aneurysm (AAA) fistula is an infrequent event. We present two cases of AAA rupture into the retroaortic left renal vein. Preoperative computed tomography (CT) assessment showed retroperitoneal bleeding due to a large AAA rupture with an associated unusual retroaortic left renal vein. Patients underwent successful arteriovenous fistula sutures with abdominal aortoiliac replacement. The patients had uneventful recoveries, and they were discharged on the seventh to ninth postoperative day (POD) without renal complications. The clinical onset was characterized by the unique syndrome: continuous abdominal bruit, abdominal and left flank pain with an associated pulsatile mass (Mansour Triad). Moreover patients presented with haematuria, proteinuria and a large non-functional left kidney on the imaging scan. The CT-scan may suggest the presence of the venous anomaly. Unusual anatomical presentation recommends a careful surgical approach during AAA operations.     

Retroaortic left renal vein fistula masquerading as pelvic congestion syndrome: case report

This case study shows how aorto-left renal vein fistula in a female can present with left-sided pelvic pain secondary to ovarian vein reflux, a symptom of pelvic congestion syndrome, next to typical features such as epigastric and back pain.     

Left Renal Vein Anomaly Associated with Abdominal Aortic Aneurysm Surgery: Report of a Case

Retroaortic left renal vein occurs infrequently and poses potential hazards to the surgeon during abdominal aortic surgery. We herein report the case of a 77-year-old man with a retroaortic left renal vein who underwent an abdominal aortic aneurysm (AAA) repair. The retroaortic left renal vein was diagnosed preoperatively by contrast-enhanced computed tomography (CT). The patient underwent a successful abdominal aortic replacement with an uneventful postoperative course without any renal complications. The CT scan was useful for both evaluating the AAA and for establishing the presence of the venous anomaly. Major venous anomalies (retroaortic left renal vein, left renal vein collar, left-sided inferior vena cava, and caval duplication) should thus be taken into consideration in AAA operations.     

The "nutcracker phenomenon" with orthostatic proteinuria: case reports

The nutcracker phenomenon refers to compression of the left renal vein between the aorta and the superior mesenteric artery. Clinical features are hematuria, abdominal pain, left flank pain, pelvic or scrotal discomfort due to varicocele or ovarian vein syndrome. In this report, 2 patients with orthostatic proteinuria, in whom nutcracker phenomenon was detected as a cause, are presented. One of them had posterior nutcracker with also asymptomatic varicocele that was detected during ultrasonographic examination. Nutcracker phenomenon is a rare but important clinical condition that should be considered in the differential diagnosis of patients with proteinuria and hematuria.     

Ruptured abdominal aortic aneurysm with left-sided inferior vena cava

We present a case of ruptured abdominal aortic aneurysm with left-sided inferior vena cava. An 82-year-old man was admitted to our hospital with a sudden onset of severe abdominal pain and loss of consciousness. Computed tomography revealed rupture of an infrarenal abdominal aortic aneurysm and a left-sided inferior vena cava. At surgery, the inferior vena cava was found to cross anteriorly over the abdominal aorta at the usual level of the renal vein. Graft replacement was successfully performed, with careful mobilization and retraction of the inferior vena cava. The patient had an uneventful postoperative course without any deterioration of renal function.     

Arteriovenous fistaul from rupture of abdominal aortic aneurysm.

Two patients with spontaneous aortocaval fistulas are described and compared with 67 cases reported in the English literature. Symptoms may vary widely; however, the presence of an expansile abdominal mass with a continuous bruit is usually diagnostic. The only successful management is promt repair of the vena caval defect and the aortic aneurysm. A third patient with spontaneous rupture of an abdominal aortic aneurysm into the left renal vein is alos described. Only five similar cases could be found in the work literature. Left flank pain, pulsatile abdominal mass, continuous bruit, and hematuria is the usual clinical picture. All of these cases involved an anomalous left retroaortic renal vein and all patients survived the necessary surgical correction. The operation of choice is closure of the defect in the retroaortic left renal vein and repair of the aneurysm.     

Intravascular pressure measurements and phlebography of the renal vein: a contribution to the etiology of varicocele

Phlebography of the left renal vein was performed in 80 patients with left-sided varicocele demonstrating the nutcracker phenomenon. In 39 cases we could prove a compression of the left renal vein. In 10 varicocele patients additional intravascular pressure measurements were studied in both renal veins in the supine and erect position. We found no significant difference between the pressure in the left and right renal vein in the supine position: values varied with respiration. Changing from the supine to the erect position one can note a significantly elevated pressure, higher on the left side than on the right side due to the longer excursion of the left kidney. Urine investigations were done in 153 patients before and in 191 after sclerotherapy to detect protein or blood. Only in 4 patients we found proteinuria but no microhematuria. The results suggest that the aetiology of the varicocele formation is not the nutcracker phenomenon or renal vein hypertension; the predominant cause is a congenital incompetence of the valves in the left testicular vein. The driving force for the retrograde blood flow from the left renal vein into the testicular vein was the increase in pressure: in the supine position caused by respiration, the continuous reflux in the erect position caused by the hydrostatic pressure. The varicocele does not cause a congested kidney with hematuria and proteinuria.     

Ligation of the renal vein during resection of abdominal aortic aneurysm

In resection of abdominal aortic aneurysm, ligation and division of the left renal vein may be necessary in order to expose the perirenal aorta. This manoeuvre is possible, with conservation of the left kidney function, because of the extensive venous collateral circulation of the left kidney. It is of crucial importance however, that ligation of the vein is performed close to the inferior vena cava. A case is presented where ligation of the left renal vein was performed in relation to an operation for a ruptured abdominal aortic aneurysm. After the operation there was initially dysfunction of the left kidney, and later on sepsis-induced uraemia. The renal function stabilized at a moderately reduced level. No permanent kidney damage related to the venous ligation could be demonstrated. In the literature serious renal damage has been reported in 10 cases out of 89 reported ligations of the left renal vein. Ligation of the left renal vein is thus a reasonably safe and acceptable procedure for surgical exposure in difficult aortic procedures.     

Unusual aspects of aortovenous fistulas associated with ruptured abdominal aortic aneurysms

Three unusual cases of an abdominal aortic aneurysm spontaneously rupturing into the retroperitoneum and an adherent posterior vein are reported. No patient demonstrated signs or symptoms of an aortovenous fistula before surgery. Emergent surgery prevented extensive preoperative diagnostic testing. The three abdominal aortic aneurysms were very large and averaged 13 cm in diameter. One fistula involved an inflammatory aneurysm, which is the fifth such case reported. The aortic fistulas were to the inferior vena cava (158 other cases reported in the English-language literature), a left renal vein (16 other cases reported), and an iliac vein (7 other cases reported). Routine use of the cell-saver, oversewing of the fistula from within the aneurysm, and a heightened awareness that this unusual complication is more common in the presence of a very large, ruptured abdominal aortic aneurysm should improve survival.     

左肾静脉压迫综合征的诊断与治疗

目的探讨左肾静脉压迫综合征的临床特点及其诊断、治疗方法。方法回顾性分析3例男性左肾静脉压迫综合征患者的临床资料。临床表现主要为反复发作肉眼血尿,1例合并左侧精索静脉曲张。膀胱镜下均可发现左侧输尿管口喷血尿,B超及CT三维重建示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。3例均行左肾静脉下移与下腔静脉端侧吻合术。结果3例患者术前均明确诊断。术后血尿消失,痊愈出院。术后5个月及8个月复查B超、CT三维血管重建,3例患者肾脏大小均正常,左肾静脉通畅,受压现象消失,尿常规正常。结论左肾静脉压迫综合征临床特点为肾静脉高压,反复发作肉眼血尿或镜下血尿。左肾静脉下移与下腔静脉端侧吻合术是治疗该病的有效方法。     

Resection of abdominal aortic aneurysm in a patient with left-sided inferior vena cava and horseshoe kidney.

The presence of vascular and renal anatomical anomalies can create technical problems during abdominal aortic surgery and may give rise to serious intraoperative complications. We present a case of an abdominal aortic aneurysm resected in a patient with the extremely rare coexistence of a left-sided inferior vena cava and horseshoe kidney. The diagnosis of the anomalies was made prior to aortic surgery. CT-scan of the abdomen was the most accurate preoperative investigation. Aortic surgery was performed through a transperitoneal approach which allowed easy access to the aneurysm despite the presence of the left-sided inferior vena cava and horseshoe kidney. Recognition of vascular and renal anomalies on preoperative imaging studies is important in the surgical treatment of abdominal aortic aneurysms. If possible anomalies are recognized in time and treated correctly, the morbidity and mortality of aneurysm repair should not be influenced.