Compressões das veias renal e ilíaca comum esquerdas em tomografias computadorizadas: com que frequência são detectadas? / Compression of left renal vein and left common iliac vein on CT scans: how often are they detected?

Resumo Contexto As síndromes de nutcracker e May-Thurner são raras e, apesar de muitas vezes subdiagnosticadas, podem causar sintomas limitantes de gravidade variável. Frequentemente são consideradas diagnóstico de exclusão e não há consenso na literatura quanto a prevalência, incidência e critérios diagnósticos. Objetivos Estimar a frequência da compressão das veias ilíaca comum e renal esquerdas em tomografias computadorizadas de abdome e pelve. Métodos Estudo descritivo, quantitativo e transversal. Para veia renal esquerda, foram considerados como critérios de compressão a relação diâmetro hilar/aortomesentérico > 4 e o ângulo aortomesentérico < 39° e, para veia ilíaca comum esquerda, o diâmetro < 4 mm. Resultados Foram analisadas tomografias computadorizadas de 95 pacientes; destes, 61% eram mulheres e 39% eram homens. A compressão da veia renal esquerda foi encontrada em 24,2% da amostra, com idade média de 48,8 anos, ocorrendo em 27,6% das mulheres e 18,9% dos homens (p = 0,3366). A compressão da veia ilíaca comum esquerda foi detectada em 15,7% da amostra, com idade média de 45,9 anos, ocorrendo em 24,10% das mulheres e 2,7% dos homens (p = 0,0024). Em 7,4% dos pacientes, ambas compressões venosas foram detectadas. Conclusões A compressão da veia renal esquerda ocorreu em mulheres e homens com frequência semelhante, enquanto a compressão da veia ilíaca comum esquerda foi mais frequente em mulheres. Ambas as compressões venosas foram mais frequentemente encontradas em pacientes com idade entre 41 e 50 anos.

Abstract Background The nutcracker and May-Thurner syndromes are rare and, although often underdiagnosed, they can cause limiting symptoms. They are frequently considered only after exclusion of other diagnoses and there is no consensus in the literature on prevalence, incidence, or diagnostic criteria. Objectives To estimate the frequency of compression of the left common iliac vein and left renal vein in CT scans of the abdomen and pelvis. Methods Descriptive, quantitative, cross-sectional study. The criteria used to define compression of the left renal vein were a hilar/aortomesenteric diameter ratio > 4 and aortomesenteric angle < 39° and the criterion for compression of the left common iliac vein was a diameter < 4mm. Results CT scans of 95 patients were analyzed; 61% were women and 39% were men. Left renal vein compression was observed in 24.2% of the sample, with a mean age of 48.8 years, occurring in 27.6% of the women and 18.9% of the men (p = 0.3366). Compression of the left common iliac vein was detected in 15.7% of the sample, with a mean age of 45.9 years, occurring in 24.1% of the women and 2.7% of the men (p = 0.0024). Both veins were compressed in 7.4% of the patients. Conclusions Left renal vein compression was detected in women and men at similar frequencies, whereas left common iliac vein compression was more frequent in women. Both venous compressions were most frequently found in patients aged 41 to 50 years.

Trombosis vascular en injerto renal visualizado en renograma con 99mtc - mag3, un evento infrecuente / Vascular thrombosis in renal graft visualized in 99mtc- mag3 renogram, in unfortunate event / Trombose vascular do enxerto em renal renogram exibido em 99m - mag3, um evento pouco freqüente

El trasplante renal es el tratamiento de elección para la enfermedad renal terminal. Pueden presentarse diversas complicaciones médicas y quirúrgicas posteriores, entre ellas las vasculares (trombosis/estenosis de la vena y/o arteria renal) que son poco frecuentes y resultan en la pérdida del injerto. Presentamos el caso de un paciente masculino que al tercer día posterior al trasplante persisten con anuria y elevación de azoados, realizándose renograma con 99m - Tc MAG3 con hallazgos compatibles de trombosis vascular.

Kidney transplantation is the treatment of choice for end-stage renal disease. Various medical and surgical complications can occur later, among them the vascular ones (thrombosis/stenosis of the vein and/or renal artery) that are infrequent and result in the loss of the graft. We present the case of a male patient who persisted with anuria and azoate elevation on the third day after transplantation, performing a renogram with 99m - Tc MAG3 with compatible findings of vascular thrombosis.

Study of kidney morphologic and structural changes related to different ischemia times and types of clamping of the renal vascular pedicle

ABSTRACT Purpose This study aimed to study morphological and renal structural changes in relation to different ischemic times and types of renal vascular pedicle clamping. Methods Sixteen pigs were divided into two groups (n = 8): Group AV - unilateral clamping of the renal artery and vein and Group A - unilateral clamping of the renal artery only, both with the contralateral kidney used as control. Serial biopsies were performed at 0, 10, 20, 30, 40, 50, 60, 70, 80, and 90 minutes after clamping. Results there is a correlation between the occurrence of renal damage as a function of time (p <0.001), with a higher frequency of Group A lesions for cellular alterations (vascular congestion and edema, interstitial inflammatory infiltrate, interstitial hemorrhage and cell degeneration), with the exception of in the formation of pigmented cylinders that were evidenced only in the AV Group. Conclusion the number of lesions derived from ischemia is associated with the duration of the insult, there is a significant difference between the types of clamping, and the AV Group presented a lower frequency of injuries than Group A. The safety time found for Group A was 10 minutes and for Group AV 20 minutes.

Síndrome del cascanueces / Nutcracker syndrome

El síndrome del cascanueces es una anomalía vascular en la que se comprime la vena renal izquierda a su paso entre la unión de la aorta y la arteria mesentérica superior, debido a un ángulo muy cerrado entre ambas arterias. Clínicamente puede presentarse como hematuria macro o microscópica, dolor episódico en flanco izquierdo, dolor pélvico, várices gonadales o simplemente cursar de forma asintomática. Presentamos dos casos clínicos, uno de ellos con dolor abdominal tipo cólico nefrítico y hematuria macroscópica y otro estudiado por hipertensión pero con antecedentes de embolización de la vena renal izquierda por varicocele izquierdo. Discutimos los aspectos clínicos, diagnósticos y terapéuticos de este síndrome.

Nutcracker syndrome is a vascular anomaly consisting in the compression of the left renal vein between the superior mesenteric artery and the aorta. Clinical features in nutcracker syndrome include pelvic pain, flank pain, haematuria, gonadal varices or simply asymptomatic. We are presenting two cases, one of them with macroscopic haematuria and flank pain and the other was studied for hypertension but with previous antecedents of left renal vein embolization in the setting of varicocele. We discuss the clinical presentation as well as diagnostic and therapeutic aspects related to this syndrome.

Cavernoma portal complicada con biliopatía secundario a enfermedad de Gaucher tipo 1: reporte de un caso peruano / Cavernoma complicated with biliopatia secondary to type 1 Gaucher disease: report of a Peruvian case

La enfermedad de Gaucher, es un trastorno autosómico recesivo de depósito lisosomal que se caracteriza por deficiencia de la beta-glucocerebrosidasa que lleva a la acumulación de glucosilceramida principalmente en células del sistema fagocítico mononuclear causando afectaciones sistémicas. Se presenta paciente varón de 20 años que cursa con dolor crónico en hipocondrio izquierdo con episodios de sangrados desde hace 3 años y sensación de alza térmica, al examen físico se identificó ictericia y esplenomegalia masiva, sin afectación neurológica. Como apoyo al diagnóstico se mostró osteoporosis severa, pancitopenia y como hallazgo inesperado la presencia de trombosis de vena porta con transformación cavernomatosa complicada con biliopatía portal simulando un tumor de klatskin, los estudios de médula y enzimáticos eran compatibles con enfermedad de Gaucher, por lo cual recibió tratamiento con imiglucerasa realizando seguimiento. Es un caso poco frecuente, de gran interés, heterogeneidad en sus manifestaciones clínicas e inéditas por su complicación, constituyendo un desafío llegar a su diagnóstico de esta enfermedad huérfana.

Gaucher disease is an autosomal recessive lysosomal storage disorder characterized by deficiency of beta-glucosidase that would lead to the accumulation of glucosylceramide mainly in cells of the mononuclear phagocytic system causing systemic effectations. We present a patient of twenty years who is suffering from chronic pain in the left hypochondrium with episodes of bleeding for 3 years and sensation of thermal rise, physical examination revealed jaundice and massive splenomegaly, without neurological involvement. Severe osteoporosis, pancytopenia, and the presence of portal vein thrombosis with cavernomatous transformation complicated by portal biliopathy simulating a klatskin tumor, marrow and enzymatic studies were compatible with Gaucher disease, were shown as unexpected findings. he received treatment with imiglucerase, following up. It is a rare case, of great interest, heterogeneity in its clinical manifestations and unpublished by its complication, constituting a challenge to reach its diagnosis of this orphan disease.

Síndrome del cascanueces anterior y posterior acompanado de vena renal izquierda circumaórtica en un adolescente: A propósito de un caso / Anterior and posterior nutcracker syndrome accompanying left circumaortic renal vein in an adolescent: Case report

La vena renal izquierda (VRI) presenta diversas variantes en su desarrollo; las dos más frecuentes son la circumaórtica y la retroaórtica. El síndrome del cascanueces anterior es la compresión de la VRI entre la aorta y la arteria mesentérica superior, mientras que el síndrome del cascanueces posterior se produce entre la columna vertebral y la aorta. Derivaron a un varón adolescente (16 años de edad) a la sala de emergencias debido a dolor en una de las fosas renales. En la tomografía computada se halló la combinación de síndrome del cascanueces anterior y posterior en la vena renal izquierda circumaórtica, circunstancia nunca antes descrita en un adolescente.

The left renal vein (LRV) has many developmental variations; the two most common are the circumaortic and the retrocaval. Anterior nutcracker syndrome is the compression of the LRV between the aorta and superior mesenteric artery, whereas posterior nutcracker syndrome occurs between the vertebral column and the aorta. An adolescent male (aged 16 years) was referred to the emergency department for flank pain. CT findings showed the combination of anterior and posterior nutcracker syndrome in the left circumaortic renal vein, which has not previously been described in an adolescent.

Nefrectomía radical laparoscópica en angiomiolipoma renal con invasión de vena renal / Laparoscopic radical nephrectomy of angiomyolipoma with renal vein involvement

Background: Angiomyolipomas associated with tuberous sclerosis may invade the renal vein and generate intramural thrombi. Case report: We report a 36-years-old woman, consulting for left flank pain. CT scan showed a large tumor in the left kidney consistent with the diagnosis of infiltrating renal angiomyolipoma with tumor invasion of the vein. Laparoscopic nephrectomy was performed, with removal of tumor thrombus. The operative time was 127 minutes and estimated bleeding 20 ml. There were no intraoperative or postoperative complications. The patient is currently asymptomatic after 12 months of follow up. The pathological study of the surgical piece showed a renal angiomyolipoma with invasion of the kidney and a solid tumor in the lumen of the renal vein.

Objetivo: Se presenta el caso clínico de un Angiomiolipoma renal con extensión a vena renal, patología de muy baja frecuencia. Caso clínico: Mujer de 36 años, quien consulta por dolor en flanco izquierdo. En una tomografía computada se encuentra una lesión tumoral extensa del riñón izquierdo compatible con un Angiomiolipoma renal infiltrante e invasión tumoral de la vena renal. Se realiza nefrectomía laparoscópica, con extirpación de trombo tumoral. El tiempo operatorio fue de 127 min y el sangrado estimado de 20 ml. No hubo complicaciones intra ni postoperatorias. La paciente se encuentra actualmente asintomática luego de 12 meses de seguimiento. La histología mostró un Angiomiolipoma renal con invasión del riñón y un tumor sólido en el lumen de la vena renal. Conclusión: La invasión de vena renal por un Angiomiolipoma es extremadamente raro. Su resolución laparoscópica es posible, con sólo una comunicación previa en la literatura.

CT Findings of Intrarenal Yolk Sac Tumor with Tumor Thrombus Extending into the Inferior Vena Cava: A Case Report

Yolk sac tumor (YST) is a rare germ cell neoplasm of childhood that usually arises from the testis or ovary. The rare cases of YST in various extragonadal locations have been reported, but the primary intrarenal YST is even more uncommon. Here, we report a case of a primary intrarenal YST with tumor thrombus of the inferior vena cava and left renal vein in a 2-year-old boy, with an emphasis on the CT features. To our knowledge, this is the first reported case of an intrarenal YST with intravascular involvement.

The Usefulness of Fast-Spin-Echo T2-Weighted MR Imaging in Nutcracker Syndrome: a Case Report

Nutcracker syndrome occurs when the left renal vein (LRV) is compressed between the superior mesenteric artery and the aorta, and this syndrome is often characterized by venous hypertension and related pathologies. However, invasive studies such as phlebography and measuring the reno-caval pressure gradient should be performed to identify venous hypertension. Here we present a case of Nutcracker syndrome where the LRV and intra-renal varicosities appeared homogeneously hyperintense on magnetic resonance (MR) fast-spin-echo T2-weighted imaging, which suggested markedly stagnant intravenous blood flow and the presence of venous hypertension. The patient was diagnosed and treated without obtaining the reno-caval pressure gradient. The discomfort of the patient lessened after treatment. Furthermore, on follow-up evaluation, the LRV displayed a signal void, and this was suggestive of a restoration of the normal LRV flow and a decrease in LRV pressure.

[Idiopathic renal vein thrombosis. About two cases]

Renal vein thrombosis is a rare pathology diffcult to diagnose. It has quite various clinical expression and biological consequences. The diagnosis is based upon radiologic explorations. This entity may have various causes. Detecting this condition may lead to restoration of renal function compromised by renal vein thrombosis. The treatment of renal vein thrombosis is mainly medical and based on anticoagulants. The role of fibrinolytic treatment is controversial. Surgical is exceptional. We report two cases of idiopathic thrombosis of the renal vein in adult patient. Also, we have done a review of the literature on this clinical syndrome and its diagnostic and therapeutic aspects

Crossing renal vessel causing ureteropelvic junction obstruction-report of two cases

Ureteropelvic junction [UPJ] obstruction is caused by the presence of an aperistaltic dysplastic segment at the UPJ. Besides this intrinsic aetiology, extrinsic factors, mainly crossing vessels, may be the causative factor. The controversy regarding the functional significance of vessels crossing at the UPJ is not a new one, though this debate has been resurrected in recent years because of improved detection due to advent of advanced imaging techniques like multidetector row computed tomography [MDCT] and fast magnetic resonance imaging. We present two similar cases where MDCT proved the crossing renal vessel [CRV] to be the cause for UPJ obstruction

Crossing renal vessel causing ureteropelvic junction obstruction

Ureteropelvic junction UPJ obstruction is caused by the presence of an aperistaltic dysplastic segment at the UPJ. Besides this intrinsic etiology, extrinsic factors, mainly crossing vessels, maybe the causative factor. The controversy regarding the functional significance of vessels crossing at the UPJ is not a new one, though this debate has been resurrected in recent years because of improved detection due to the advent of advanced imaging techniques such as multidetector row computed tomography MDCT and fast magnetic resonance imaging. We present a similar case where MDCT proved the crossing renal vessel to be the cause for UPJ obstruction

Renal vein thrombosis after kidney transplantation: a study of 3 cases from a series of 635 kidney transplantations

Background and renal vein thrombosis [RVT] after kidney transplantation [KT] is a rare and early complication. It had been noted to occur in 4-6% of cases. The object of this study is to report the incidence of RVT after KT in our experience, presenting symptoms, modality of diagnosis, types of treatment, and outcome of our cases. Patients and between October 1985 and July 2003, 635 KT were performed in two centers, the Al Mouassat University Hospital [478 cases from living related donors] and the Kidney Hospital [157 cases from living and unrelated donors]. Pulsed and color Doppler ultrasound was available for our patients after April 1998. It was routinely performed for every patient in the post-operative period and repeated when there was any renal disorder. All cases of RVT in this series were studied whether they were diagnosed by surgery or by color Doppler. 3 cases of RVT were diagnosed in our series [0.47% 2 cases from Al-Mouassat University Hospital and one case from the Kidney Hospital]. All of these patients are treated with CsA. RVT was related to anatomical factors in two patients. The symptoms included anuria two hours after transplantation in patient number 1, hematuria then anuria 24 hrs after transplantation in patient number 2, and pain and anuria 48 hrs after transplantation in patient number 3. The diagnosis was suspected clinically in patient number 1 with immediate laparatomy and removal of the clot, which allowed the salvage of the transplant. In the second and third patients, the diagnosis was made by pulsed and color Doppler, 1 with subsequent transplant nephrectomy. the incidence rate of RVT in our series is less than reported in the literature possibly because we do not have a program of cadaver transplantation. Pulsed and color Doppler imaging permits early and easy diagnosis. Emergency surgery may salvage the graft when it is performed within 1-2 hours after the formation of the thrombosis. Transplant nephrectomy is often done because of the delay in the diagnosis. This prevents graft rupture and relieves the patient's pain

Leiomiosarcoma de la vena renal: un caso de excepción / Leiomyosarcoma of the renal vein: a case of exception

Se informa acerca de un caso de leiomiosarcoma de la vena renal. Se efectúa una revisión de la bibliografía existente sobre el tema. Se trata de una paciente de 55 años de edad, que presenta dolor lumbar izquierdo de siete meses de evolución. Los estudios practicados muestran una hidronefrosis en el urograma de excreción; en la TAC se visualiza una masa pararrenal en íntimo contacto con el pedículo vascular que se impregna con el material de contraste. El tratamiento practicado consiste en una nefrectomía radical. El informe anatomopatológico es compatible con un leiomiosarcoma de la vena renal. Se realiza tratamiento adyuvante con radioterapia de alto voltaje. A los dos años, se detectan metástasis hepáticas, pulmonares y mamarias por lo que se inicia quimioterapia con resultado incierto, ya que se encuentra cursando en la actualidad dicho tratamiento. Se resalta la excepcionalidad de esta variante de tumor, la dificultad diagnóstica clínica y el pronóstico desfavorable

Trombosis venosa del injerto renal: evaluación con Eco Doppler / Venous thrombosis of renal graft: evaluation with duplex Doppler sonography

Objetivo: Evaluar la utilidad del Eco Doppler en el diagnóstico de la trombosis venosa del injerto renal. Material y métodos: Desde el 1/1/94 al 1/12/97 se han realizado 147 trasplantes renales en la unidad de Nefrología del HGA Cosme Argerich. Todos los pacientes fueron evaluados con eco Doppler diariamente durante la primer semana de postoperatorio y cada vez que la evolución clínica y de laboratorio así lo requirió. Ante el hallazgo de flujo reverso durante toda la diástole o en alguna fase de la misma se sometió a los pacientes a distintos procedimientos (punción biopsia renal, cámara gamma, venografía, angiografía y exploración quirúrgica). Resultados: 4 pacientes (2,7 por ciento) presentaron trombosis de vena renal. Los hallazgos ecográficos fueron. Aumento del tamaño renal (3), disminución de ecogenicidad del parénquima (3), aumento del tamaño de las pirámides (2), sin cambios estructurales (1). En el análisis audioespectral se observó ausencia de reflujo arterial diastólico, con índice de resistencia mayor a 1 en todos los casos. Conclusión: En el riñón trasplantado, el hallazgo de flujo arterial reverso en diástole y la ausencia de registro Doppler en el árbol venosos del injerto son signos característicos de trombosis oclusiva de la vena renal

Thrombo-embolism in minimal change nephrotic syndrome.

A case report of thrombo-embolism in minimal change nephrotic syndrome was presented. Autopsy revealed massive bilateral pulmonary emboli, edema and congestion, bilateral adrenocortical atrophy and left renal vein thrombosis. Thrombo-embolic phenomenon should be borne in mind during management and treatment of nephrotic syndrome.