Imaging of Type I Retroaortic Left Renal Vein & Nutcracker Syndrome

Retroaortic left renal veins are an often overlooked, but no so rare anatomic anomaly that might cause a few aspecific symptoms and signs, especially flank or inguinal pain, microscopic or even gross hematuria; in the vast majority of cases it is, thought, totally asymptomatic. The nutcracker syndrome that might arise in the case of RLRV is mainly due to the re- duced space between aorta and the vertebral body and the consequent compression on the venal rein; this might in turn cause upstream hypertension, hematuria, varicocele, pain. The compression of RLRV leads to hematuria because of renal venous hypertension, consequent left renal congestion. This upstream venous congestion might result, in some cases, in left-sided varicocele in men and pelvic congestion syndrome in women. From a radiologic point of view, the presence of RLRV and the precise reporting its subtypes is mandatory.

Immunoglobulin Light Chain Amyloidosis Presenting as Inferior Vena Cava Thrombosis

Immunoglobulin light chain (AL) amyloidosis is a rare disease characterized by the deposition of misfolded extracellular proteins within various body tissues resulting in dysfunction of the cardiac, renal, gastrointestinal, hematologic, and nervous systems, among others. Systemic AL amyloidosis often presents with a constellation of vague symptoms such as fatigue, dyspnea, and abdominal pain. Untreated AL amyloidosis with cardiac involvement is rapidly fatal with a median survival of 6 months. In this report, we will highlight the case of a 43-year-old female who presented with generalized abdominal symptoms and fatigue. She was found to have extensive inferior vena cava (IVC) thrombosis extending into the renal veins bilaterally in the setting of nephrotic range proteinuria, new onset arrhythmia, diastolic heart failure, gastrointestinal, and autonomic dysfunction. She received systemic thrombolytic therapy for the IVC and renal vein thrombosis. The multiorgan involvement led us to consider the possibility of amyloidosis. Abdominal fat pad biopsy was performed as part of the diagnostic effort. The abdominal fat pad biopsy did not reveal AL amyloidosis. Ultimately, the diagnosis of systemic AL amyloidosis was made on the basis of pathology from luminal biopsies obtained during outpatient esophagogastroduodenoscopy that was performed days prior to her admission. Unique to our case is the patient presentation with extensive thrombotic disease of the IVC and renal veins. It is important to understand the disease process, presenting signs and symptoms as well as diagnostic essentials based on current literature in order to minimize the morbidity and mortality of this rare disease.

Closing the defect of the inferior vena cava above the renal veins by moving the lower part of it

Resection of a part of the middle part of the inferior vena cava, located between the renal and hepatic veins, has to be performed when tumors from nearby organs and tissues grow into it. So, for example, kidney tumors in 13-15% of cases grow into the wall of the inferior vena cava (SP Fedorov, Israel, etc.).

Prevalence of Congenital Anomalies of the Inferior Vena Cava: CT Assessment in Thai Patients

Objective: To determine the prevalence of inferior vena cava (IVC) anomalies in Thai patients who underwent contrast-enhanced computed tomography (CT) of the abdomen. Materials and Methods: Two radiologists retrospectively and independently reviewed the contrast-enhanced abdominal CT examinations in 1,429 Thai patients between August 1, 2018 and January 25, 2019 who met the inclusion criteria. Patients were included, if (a) their CT showed well visualized IVC, renal veins, and right ureter that were not obliterated by tumor, cyst, fluid collection, or intraperitoneal free fluid, (b) they had not undergone previous abdominal surgery that altered anatomical configuration of the IVC, renal veins, and right ureter. The presence of all IVC anomalies were recorded. Results: Among the 1,429 studied patients, 678 were male (47.4%) and 751 were female (52.6%). The prevalence of IVC anomalies was 3.5%. Five types of IVC anomalies were presented. The most common was circumaortic left renal vein in 24 patients or 48.0% of all IVC anomalies and 1.7% of the study population, followed by retroaortic left renal vein in 15 patients or 30.0 % of all IVC anomalies and 1.0% of the study population. Other IVC anomalies included double IVC, left IVC, and retrocaval ureter at 0.5%, 0.2%, and 0.1% of the study population, respectively. Conclusion: The prevalence of IVC anomalies in the present study differed from the previous studies conducted in other countries, which may be attributable to differences in race and ethnicity. Awareness of these anomalies is essential when evaluating routine CT examinations in asymptomatic patients. Their presence should be carefully noted in radiology reports to avoid anomaly-related complications. Keywords: Prevalence; IVC anomalies; Circumaortic left renal vein; Retroaortic left renal vein; Double IVC; Left IVC; Retrocaval ureter

Abstract P509: Novel Protein Kinase C Epsilon Inhibitor Attenuates Uncoupled Endothelial Nitric Oxide Synthase And Vascular Endothelial Dysfunction

Endothelial nitric oxide synthase (eNOS) uncoupling reduces nitric oxide (NO) production when tetrahydrobiopterin (BH 4 ) is oxidized to dihydrobiopterin (BH 2 ), resulting in endothelial dysfunction and leukocyte adherence. Renovascular damage following shockwave lithotripsy (SWL) may occur via the potentiation of this mechanism. We aim to modulate uncoupled eNOS activity with myristoylated protein kinase C epsilon inhibitor ( myr -PKCε–; N- myr -EAVSLKPT) and activator ( myr -PKCε+; N- myr -HDAPIGYD). We hypothesize that myr -PKCε– with uncoupled eNOS (i.e., bound to BH 2 ) should reduce leukocyte-endothelial interactions in postcapillary venules and H 2 O 2 levels after SWL. Myr -PKCε+ should promote similar effects when eNOS is coupled (i.e., bound to BH 4 ). Mesenteric venules of anesthetized male SD rats (300g) were superfused for 120 min with 100 μM BH 2 and test solutions (Krebs’ buffer, 10 μM myr -PKCε+, or 10 μM myr -PKCε–) with or without 100 μM BH 4 . Leukocyte activity was evaluated via intravital microscopy. In separate SD rats, SWL was performed on left kidneys (16 kV, 500 shocks at 60 shocks/min and at 120 shocks/min). Then, normal saline or test solution cocktail ( myr -PKCε+ [0.9 mg/kg]/ myr -PKCε- [0.8 mg/kg] with BH 2 [2mg/kg] or BH 4 [0.8 mg/kg]) was given i.v. NO or H 2 O 2 levels were measured with 100 μm microsensors in left renal veins at baseline, end of SWL, and 5-min intervals for 30 min post-SWL. Data were analyzed using ANOVA Student-Newman-Keuls test. BH 2 -induced leukocyte rolling, adherence, and transmigration were significantly increased by myr -PKCε+ ( n = 6) and attenuated with myr- PKCε– ( n = 5) compared to control (n=5) at 120 min (p<0.01). Following SWL, all treatments except myr -PKCε+ with BH 2 significantly reduced H 2 O 2 ( n = 5, p < .01) and increased NO levels ( n = 5, p < .01) compared to control. NO and H 2 O 2 levels following administration of myr -PKCε+ with BH 2 were similar to SWL control. Results suggest that myr -PKCε– attenuates uncoupled eNOS activity and H 2 O 2 release in rat renal veins, after SWL. Promoting coupled eNOS activity with BH 4 yields similar results. Promoting eNOS coupling with BH 4 or inhibiting uncoupled eNOS with myr- PKCε– attenuates oxidative stress and endothelial dysfunction following SWL and BH 2 -induced inflammation.

Clinical and Anatomical Substantiation of Access to the Splenic and Left Renal Veins in the Operation of Distal Splenorenal Anastomosis

Aim of study. Development in an anatomical experiment of a technique for operative access to the splenic and left renal veins during distal splenorenal bypass surgery with justification of the possibility of its successful application in clinical conditions.Material and methods. In the conditions of an anatomical experiment on 40 unfixed corpses of adults of both genders, objective volumetric and spatial indicators in surgical wounds were studied in two variants of exposure of retroperitoneal space vessels, as the first stage of distal splenorenal anastomosis. In clinical conditions in 40 patients with portal hypertension of various genesis, during the operation of distal splenorenal anastomosis, the wide exposure of the anterior surface of the pancreas, spleen, left renal veins and most of their branches was performed using the original method of partial left — sided medial visceral rotation, followed by an objective assessment of the volume-spatial parameters of access. Measurements were performed using a medical goniometer in relation to the mobilized areas of the left renal and splenic veins. Statistical processing of the study results was carried out using the method of variation statistics. To identify statistically significant differences, the Student’s t-test was used for disjoint samples.Results. An original method of operative access to the splenic and left renal veins was developed during the operation of distal splenorenal bypass by lifting the internal organs of the left flank of the abdominal cavity from the posterior abdominal wall and diverting them to the right. In the anatomical experiment in the original method of partial left-sided medial visceral rotation, all indicators were better (depth of the wound is less and the angles of operative activity and the inclination of the axis of operative activity — larger) than with a classic approach of intraoperative intraperitoneal access via transverse incision in the mesentery of the transverse colon. Despite the various variants of vascular architectonics and various anthropometric indicators of patients, there were no any forced refusal of distal splenorenal bypass surgery or unintentional damage to both the vessels themselves and the pancreas, specific complications associated with the implementation of the proposed operative approach to the vessels of the left retroperitoneal space, including damage to the spleen and ischemia of the descending colon, in any of 40 clinical cases.Conclusion. The suggested option of operative access to the splenic, left renal veins and their branches at the first stage of performing distal splenorenal anastomosis in patients with portal hypertension of various genesis provides convenient spatial relations in the operating wound; creates comfortable conditions for performing the main surgical technique — applying vascular anastomosis; has a minimal risk of developing specific complications associated with the approach to the vessels of the left retroperitoneal space.

Reduction of Radiation Exposure in Adrenal Vein Sampling: Impact of the Rapid Cortisol Assay

Purpose To determine radiation exposure associated with adrenal vein sampling and its reduction by implementing the rapid cortisol assay and modification of the sampling protocol. Materials and Methods A single-center retrospective study of adrenal vein sampling performed between August 2009 and March 2020 revealed data from 151 procedures. Three subgroups were determined. In group I, a sampling protocol including sampling from the renal veins without the rapid cortisol assay was applied. In group II, blood was sampled using the same protocol but applying the rapid cortisol assay. In group III, a modified sampling protocol was used, in which the additional sampling from the renal veins was dispensed with, while the rapid cortisol assay was retained. Primary endpoints were radiation exposure parameters with dose area product, fluoroscopy time, and effective dose. As secondary endpoints, procedural data including technical success, lateralization, the correlation between patient BMI and radiation exposure, and concordance of lateralization with cross-sectional imaging were investigated. Furthermore, the correlation of aldosterone-cortisol ratios between the adrenal and ipsilateral renal vein was calculated to assess the benefit of sampling from the renal veins. Results For all procedures performed in the study collective, the median dose area product was 60.01 Gy*cm2 (5.71–789.31), the median fluoroscopy time was 14.90 min (3.27–80.90), and the calculated median effective dose was 12.60 mSv (1.20–165.76). Significant differences in radiation exposure parameters between the study subgroups could be revealed. Dose area product resulted in reductions of 57.94 % after implementation of the rapid cortisol assay and a further 40.44 % after revision of the sampling protocol. Fluoroscopy time was reduced by 40.48 % after integration of the rapid cortisol assay and a further 40.47 % after protocol refinement. Radiation doses were increased in cases of resampling (dose area product 51.31 vs. 118.11 Gy*cm2, fluoroscopy time of 12.48 vs. 28.70 min). A strong correlation between patient BMI and procedural dose area product could be found. After the introduction of the rapid cortisol assay, successive improvement of the technical success rate could be found (33.33 % in group I, 90.22 % in group II and 92.11 % in group III). The correlation of aldosterone-cortisol ratios between adrenal and renal veins was poor. Conclusion The introduction of the rapid cortisol assay significantly decreased the radiation exposure and increased the technical success rate. Renal vein sampling did not provide further benefit in the evaluation of primary aldosteronism subtype and its omission resulted in a further reduction of radiation dose. Key Points: Citation Format

Multidetector CT Angiography for Pre-Operative Evaluation of Living Renal Donors - An Observational Study at IGIMS, Patna

BACKGROUND We wanted to assess the renal abnormalities including parenchymal, arterial, venous and collecting systems that preclude renal donation or altered surgical approach on the basis of CT angiography. METHODS This is a hospital based retrospective observational study. 55 donors (110 kidneys) had undergone preoperative CT renal angiography. The data were collected from last 3 years (December 2016 - December 2019) and analyzed. Two different radiologists interpreted the results unaware of the findings of each other. Final report depended upon the common consensus of both the radiologists. RESULTS The percentage of multiple renal arteries, early branching of renal artery and retrocaval right renal artery were 30 %, 5.45 % and 3.64 % respectively. The percentage of multiple renal veins, circumaortic renal vein and retroaortic renal veins were 7.27 %, 5.45 % and 1.82 % respectively. The late confluence of renal vein (left side) was found in 1 donor. Renal parenchymal abnormalities were detected in the form of simple cortical cysts and renal calculus. No variation or abnormality was detected in the collecting system. CONCLUSIONS Multi detector computed tomography (MDCT) angiography provides an accurate and reliable tool to evaluate the renal parenchyma, collecting system, vascular anatomy and their variations in the living renal donor. It guides the surgeon immensely in decision making regarding proper donor selection and as to which kidney should be harvested. KEY WORDS MDCT Angiography, Renal Vessels, Anatomic Variations, Living Renal Donor

Left double polar renal arteries, left triplicate (preaortic, accessory and retroaortic) renal veins associated with extrinsic pelviureteric junction obstruction and posterior nutcracker phenomenon

The renal vasculature and its various congenital anomalies have been studied and documented widely in the literature. However, the concomitant occurrence of renovascular morphological anomalies with vascular compression phenomena in a single patient is a rarity. This is a case of a patient with double left renal arteries, preaortic, accessory and retroaortic left renal veins. There was also associated with vascular compression phenomena in the form of posterior nutcracker phenomenon and pelviureteric junction obstruction (PUJ) due to the double-crossing inferior left polar renal artery and retroaortic vein.