Identificação pela ultrassonografia vascular da compressão da veia ilíaca comum esquerda em mulheres assintomáticas: ortostatismo pode influenciar o diagnóstico? / Left common iliac vein compression identified by vascular ultrasonography in asymptomatic women: does standing position influence diagnosis?

Resumo Contexto A ultrassonografia vascular é o exame de imagem de escolha para rastreamento inicial da compressão na veia ilíaca comum esquerda, cujo achado assintomático pode ser encontrado em até 25% em algumas casuísticas. Objetivo Identificar, pela ultrassonografia vascular, se há diferença na avaliação da compressão na veia ilíaca comum esquerda em mulheres assintomáticas em decúbito dorsal e ao ortostatismo. Métodos Trata-se de um estudo observacional transversal em 50 mulheres voluntárias, sem sintomas de compressão venosa pélvica. Os parâmetros avaliados pela ultrassonografia vascular em decúbito dorsal e ao ortostatismo foram os diâmetros e as velocidades máximas na veia ilíaca comum esquerda no local do cruzamento com a artéria ilíaca comum direita e antes desse cruzamento, além dos índices de velocidade na veia ilíaca comum esquerda no local do cruzamento. Resultados Foram identificados oito casos de compressão significativa na veia ilíaca comum esquerda na avaliação em decúbito dorsal (16%) e somente dois casos (4%) ao ortostatismo. Os diâmetros na veia ilíaca comum esquerda foram estatisticamente maiores (p = 0,002) no local de cruzamento com a artéria ilíaca comum direita ao ortostatismo, e as velocidades e índices de velocidades foram estatisticamente maiores (p < 0,001) em decúbito dorsal. Não houve identificação de compressão significativa na veia ilíaca comum esquerda em ortostatismo quando os índices de velocidades estavam normais em decúbito dorsal. Conclusão Não houve diferença na detecção de compressão significativa da veia ilíaca comum esquerda ao ortostatismo em relação ao decúbito dorsal; no entanto, o estudo mostrou que pode haver menor compressão anatômica da veia ilíaca comum esquerda em posição ortostática.

Abstract Background Vascular ultrasonography is the imaging exam of choice for initial screening for left common iliac vein compression, which is an asymptomatic finding that can be detected in up to 25% of some patient samples. Objective To determine, using vascular ultrasonography, whether findings of left common iliac vein compression in asymptomatic women are different when assessed in the prone and standing positions. Methods This is a cross-sectional observational study of 50 adult female volunteers with no symptoms of pelvic venous compression. The parameters assessed with vascular ultrasonography in the prone and standing positions were diameters and maximum velocities of the left common iliac vein at the point at which it crosses behind the right common iliac artery and before this point, in addition to left common iliac vein velocity indices at the crossing. Results Eight cases of significant compression of the left common iliac vein were identified when assessed in prone position (16%) and just two cases (4%) were identified in the standing position. Left common iliac vein diameters were statistically larger (p = 0.002) at the point where it crosses behind the right common iliac artery in the standing position and velocities and velocity indices were statistically higher (p < 0.001) in the prone position. No significant compression of the left common iliac vein was identified in the standing position when velocity indices were normal in the prone position. Conclusions There was no difference in detection of significant compression of the left common iliac vein when assessed in the standing position in comparison with assessment in the prone position. However, the study showed that anatomic compression of the left common iliac vein may be reduced in the standing position.

Prevalência de compressão da veia ilíaca esquerda em imagens tomográficas de uma população / Prevalence of left iliac vein compression on computed tomography scans from a population

Resumo Contexto A síndrome de May-Thurner (SMT) é a compressão da veia ilíaca esquerda (VIE) entre a artéria ilíaca direita e o corpo vertebral associada à hipertensão venosa crônica unilateral no membro inferior esquerdo. Porém, o achado tomográfico da compressão não necessariamente se reflete em sintomas. Objetivos Avaliar o achado de compressão da veia ilíaca esquerda em tomografias realizadas por outros motivos. Métodos Angiotomografias ou tomografias computadorizadas (TCs) com fase venosa foram analisadas. Foram coletados os dados demográficos e o motivo do exame, quando presente, e foi analisada a relação do diâmetro da veia ilíaca esquerda no ponto de maior compressão com um ponto a montante. Resultados De janeiro a julho de 2016, 590 tomografias foram analisadas, sendo 357 de mulheres e 233 de homens. A compressão da VIE ocorreu em 87 (14,74%) pacientes, dos quais 74 (85,05%) eram mulheres e 13 (14,9%) homens. O diâmetro médio do ponto de maior compressão entre os pacientes que apresentavam VIE < 5 mm foi de 4,4 mm, variando de 2,67 mm a 4,97 mm. O diâmetro no ponto de maior compressão representou até metade do diâmetro na última imagem justaposta ao corpo vertebral (índice de 0,5) em 179 (30,3%) dos pacientes. Conclusões Nosso estudo sugere que a ocorrência de compressão da VIE em TC de pacientes aleatórios, sem conhecimento de insuficiência venosa crônica ou TVP em MIE, é comum. Isso mostra que o achado tomográfico de compressão não necessariamente resulta em sintomas e não deve ser a única razão para tratar um paciente.

Abstract Background May-Thurner syndrome (MTS) is defined as compression of the left iliac vein between the right iliac artery and the lumbar vertebral body in the presence of signs and symptoms of unilateral left chronic venous insufficiency. However, imaging findings of compression are not manifest in symptoms of the syndrome in all subjects. Objectives To evaluate findings of compression in an asymptomatic population. Methods Computed tomography angiographies or venous phase computed tomographies were analyzed. Demographic data and reason for the exam were recorded. Vein diameter was measured at the site of greatest compression and distal of the compression and the ratio between the two diameters was calculated. Results From January to July of 2016, 590 computed tomography scans were analyzed (357 women and 233 men). Left iliac compression was found in 14.74% of patients. Patients with a left iliac diameter below the 5mm threshold had a mean diameter at the site of greatest iliac vein compression of 4.4 mm (range: 2.67 mm-4.97 mm). The ratio between the two measurements was < 0.5 in 30% of patients. Conclusions Our study suggests that iliac vein compression is common among random patients who have had computed tomography for any other reason. This indicates that compression found on tomography images is not the only finding to consider when treating a patient.

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.

Corona mortis: importancia anatomo ­ clínica y ocurrencia en una muestra de la población colombiana / Corona mortis: anatomical and clinical relevance and occurrence in a sample of the Colombian population

Corona mortis es una variación anatómica referida a la anastomosis de los vasos iliacos externos e internos, mediante vasos que se arquean por encima y por detrás del ramo superior del pubis. En caso de resultar lesionados iatrogénicamente, se pueden presentar hemorragias de difícil manejo. El objetivo del estudio fue caracterizar los vasos obturatrices en una muestra cadavérica de la población colombiana, para determinar su morfometría y la frecuencia con que se presentan los diferentes patrones venosos y arteriales. Se estudiaron hemipelvis de 14 cadáveres, pertenecientes al anfiteatro del Departamento de Morfología de la Universidad del Valle en Cali, Colombia. Tras acceder a la cavidad pélvica y completar la disección de todos los vasos que se relacionaban con el canal obturador y la cara pélvica del ramo superior del pubis, se determinaron sus características morfológicas y sus dimensiones. Las variaciones arteriales, corona mortis y arteria obturatriz aberrante, se presentaron en el 35,7% de las hemipelvis y las variaciones venosas en el 82,1%. La arteria corona mortis sólo se presentó en el 3,6% de las hemipelvis y el 32,1% presentaron arteria obturatriz aberrante. La moda de las frecuencias absolutas de los patrones venosos fue la vena corona mortis que se presentó en el 75,0% de las hemipelvis. El conocimiento de los patrones arteriales y venosos de los vasos obturatrices y de sus variaciones anatómicas para la población colombiana es indispensable para evitar lesionarlos durante procedimientos clínico - quirúrgicos que comprometan el anillo pélvico anterior y la región inguinal.

The corona mortis is an anatomical variation related to the anastomosis between the internal and external iliac blood vessels, through certain arteries and veins that form arches above and behind the superior pubic ramous. Serious hemorrhages can result from iatrogenic injury of these vessels. The study objective was to characterize the obturator vessels in a sample of Colombian cadavers, to determine their morphometric features and the frequencies in which the arterial and venous patterns are present. Hemipelvises of 14 cadavers from the dissection room of the Department of Morphology at the Universidad del Valle, in Cali, Colombia, were taken as sample. Once the dissection of the vessels related with the obturator canal and the pelvic surface of the superior pubic ramous was completed, their morphological features were determined and measurements were taken of their diameters and lengths. The arterial variations, corona mortis and aberrant obturator artery, were present in 35.7% of the hemipelvises and the venous variations in 82.1%. The corona mortis artery was only present in 3.6% of the hemipelvises and 32.1% presented an aberrant obturator artery. The mode of the absolute frequencies of the venous patterns was the corona mortis vein, present in 75.0% of the hemipelvises. The knowledge of the arterial and venous patterns of the obturator vessels and their anatomical variations for the Colombian population is very important in order to avoid causing any injury to them in the course of clinical and surgical procedures that have to do with the anterior pelvic ring and the inguinal region.

Anatomical variations of the position of the aortic bifurcation, iliocava junction and iliac veins in relation to the lumbar vertebra.

OBJECTIVE: To determine the position of the aortic bifurcation and the iliocava junction in relation to the lumbar vertebra, aortic bifurcation angle, interiliac angle, and anatomical variation of the iliac veins anterior to the lumbar vertebra of Thai people. MATERIAL AND METHOD: The present study was done on 65 cadavers. The mean ages of the cadavers were 73 +/- 10 years (range from 50 to 90 years). The dissections were performed by anterior approach to the lumbar vertebra. The position of the aortic bifurcation and the iliocava junction, aortic bifurcation angle and interiliac angle were measured in relation to the lumbar vertebra. Anatomical variations of the iliac veins were observed anterior to the lumbar vertebra. RESULTS: The aortic bifurcation was between L3 and L5, most often at the L4 vertebral body level (63%), at the middle third in vertical plane of vertebra (31%) and at the median third in horizontal plane of vertebra (57%). The iliocava junction was between L4 and L5-S1 disc, most often at the L5 vertebral body level (69%), at the upper third of vertebra (28%) and at the right lateral third in horizontal plane of vertebra (60%). The mean aortic bifurcation angle was 54 degrees (male 55 degrees, female 53 degrees. No significant difference in the mean aortic bifurcation angle was observed between male and female at p > 0.05 and the mean interiliac angle was 71 degrees (male 73 degrees, female 68 degrees). A significant difference in the mean interiliac angle was observed between male and female at p < 0.05. In the abdomen, variation of common iliac vein was found on the left side connecting IVC with left external iliac vein. CONCLUSION: The anatomical variations of the position of the aortic bifurcation, iliocava junction, and common iliac veins at the anterior of lumbar vertebra can be found in a normal population and cause trouble to vertebral surgery during the operation. Therefore, precaution and full investigation of the anatomical position of the vessels might be required before surgery is performed.

Anatomical variation of obturator vessels and its practical risk: a case report from an anatomic study / Variação anatômica de vasos obturatórios e seu risco prático: relato de caso de um estudo anatômico

Obturator artery is frequently a branch of anterior division of the internal iliac artery. It has drawn attention of pelvic surgeons, anatomists and radiologists because of the high frequency of variations in its course and origin. The obturator vein is usually described as a tributary of the internal iliac vein. During routine dissection classes to undergraduate medical students we have observed obturator artery arising from external iliac artery, obturator vein draining into external iliac vein, communicating vein between obturator vein and external iliac vein and inferior epigastric artery arising from the obturator artery. The anomalous obturator vessels and inferior epigastric artery in the present case may be in a dangerous situation in pelvic surgeries that require dissection or suturing along the pelvic rim. Developmental reasons and clinical significances of the variations are discussed.

A artéria obturatória é muitas vezes um ramo da divisão anterior da artéria ilíaca interna. Ela tem chamado atenção de cirurgiões pélvicos, anatomistas e radiologistas devido à alta freqüência de variações em seu trajeto e origem. A veia obturatória é geralmente descrita como uma tributária de veia ilíaca interna. Durante aulas de dissecação para estudantes de medicina, observamos a artéria obturatória surgindo a partir da artéria ilíaca externa, veia obturatória drenando para a veia ilíaca externa, veia comunicante entre a veia obturatória e a veia ilíaca externa e artéria epigástrica inferior surgindo a partir da artéria obturatória. Os vasos obturatórios anômalos e a artéria epigástrica inferior no presente caso podem se encontrar em situação perigosa em cirurgias pélvicas que exigem dissecação ou suturas ao longo da borda pélvica. Discutem-se as causas de desenvolvimento e a significância clínica das variações.

Avaliação ultra-sonográfica do sistema urinário, figado e útero do macaco-prego, Cebus apella / Ultrasonographic evaluation of the urinary system, liver and uterus of Cebus apella monkey

O macaco-prego, Cebus apella, é muito difundido no norte e sul da Amazônia Legal Brasileira e no Cerrado. Estes animais encontram-se rotineiramente submetidos à caça predatória, aumentando assim a necessidade de preservação desta espécie silvestre. Realizou-se um estudo ultra-sonográfico de 10 macacos-prego como forma de descrever a anatomia ultra-sonográfica normal de sua cavidade abdominal. A vesícula urinária apresentou parede com espessura média 0,2cm e em posição anatômica cuja topografia permitiu contato com as paredes do corpo do útero e cólon descendente. À varredura abdominal caudal foi visualizada a aorta, veia cava caudal e veia ilíaca direita. O fígado foi visto em varredura sagital e transversal, possibilitando a observação da vesícula biliar e vasos hepáticos. A varredura renal demonstrou com precisão a pelve, seio renal e relação cortico-medular. O comprimento médio de ambos os rins foi de 6,24±0,31cm, não existindo diferença estatística entre o rim direito e esquerdo (Teste t de Student e ANOVA). O volume renal foi 2,37±0,18cm³. Os coeficientes de Correlação de Pearson entre os comprimentos renais direito e esquerdo e entre volumes renais direito e esquerdo foram dispostos como r = 0,74 e 0,51. As espessuras médias para a região cortical e medular foram 0,75±0,11cm e 0,39±0,06cm, respectivamente. O coeficiente de correlação para a relação cortico-medular entre os rins direito e esquerdo foi de r = 0,19. O exame ultrasonográfico mostrou-se como uma técnica eficiente, nãoinvasiva, rápida e reprodutível, que provê dados importantes aos profissionais da área de clínica e cirurgia de animais silvestres.

The Brown Capuchin, Cebus apella, has a wide distribution in the northern and southern Brazilian Amazon region and in the Cerrado (savanna). These monkeys are usually submitted to predatory chase, increasing the need for preservation of this wild animal species. An ultrasonographic examination of 10 Brown Capuchins was made in order to describe the normal ultrasonographic anatomy of their abdominal cavity. The urinary bladder revealed its wall thickness with an average of 0.2cm, the topographic situation of which allowed close relation with the wall of uterus and descendent colon. Using caudal abdominal scan, images of aorta, caudal vena cava and right iliac vein were obtained. Liver was accessible for examination by sagittal and cross-section ultrasound, allowing visualization of gallbladder and hepatic vessels. Renal scan allowed accuracy to evidence the echogenicity differences between pelvis, renal sinus, as well as the cortical-medullary relationship. The mean length of the kidneys was 6.24±0.31cm, and no significant differences were observed between left and right kidney length (Student's t-test and ANOVA). The renal volume obtained was 2.37±0.18cm³. Correlation Coefficients of Pearson between right and left renal length and between right and left renal volume were r = 0.74 and 0.51. Mean thickness for cortical and medullar regions was 0.75±0.11 and 0.39±0.06cm, respectively. Correlation Coefficient of corticomedullar relation between right and left renal was r = 0.19. Examination by ultrasound was considered an efficient, noninvasive, fast and repeatable technique which provides useful data for clinicians and surgeons engaged in wild animal medicine.

Incidence of corona mortis; preperitoneal anatomy for laparoscopic hernia repair.

The present study 66 half pelvis of cadaver for vascular structure called corona mortis, vessel that connect between external iliac and internal iliac system. The vessel was found 77.27% and the incidence of aberrant is 13.6%. The average distance from symphysis pubis to the vessel is 5.28 cm and distance above superior pubic rami is 1.37 cm.

Anatomical observation on draining patterns of saphenous tributaries in Korean adults

This study was done to identify the normal and variants of saphenous tributaries in Korean adults. The pattern of confluence of saphenous tributaries, medial accessory saphenous, lateral accessory saphenous, superficial epigastric, superficial circumflex iliac and superficial external pudendal veins, was carefully examined in 249 lower limbs (right, 129; left, 120) of embalmed Korean cadavers (73 males and 56 females). The medial accessory saphenous vein drained into the great saphenous vein directly (in 82.3%) or by a common trunk (in 17.7%) with the superficial epigastric or superficial external pudendal vein. The lateral accessory saphenous vein entered the great saphenous (in 67.1%) or the femoral vein (in 32.9%) directly or, forming a common trunk with other saphenous tributaries. The superficial epigastric vein joined the great saphenous (in 77.1%) or the femoral vein (in 22.9%) directly or, by a common trunk with other saphenous tributaries. The superficial circumflex iliac vein reached the great saphenous (in 83.1%) or the femoral vein (in 16.9%) directly or, by a common trunk with other saphenous tributaries. The superficial external pudendal vein opened into the great saphenous (in 95.2%) or the femoral vein (in 4.8%) directly or by a common trunk with other saphenous tributaries. In Koreans, the incidence of the normal pattern of saphenous tributaries was 23.7% and in 76.3% any one of variant saphenous tributaries entered the femoral or the great saphenous vein by a common trunk with other saphenous tributaries.