Two cases of the retroaortic left renal vein and a morphogenetic consideration of the anomalous vein

The left renal vein rarely passing behind the abdominal aorta is called "the retroaortic left renal vein". We encountered two cases of the retroaortic left renal vein during the student course of dissection at Iwate Medical University School of Medicine in the years 1986-1997. The incidence of the retroaortic left renal vein was calculated at 2/266 or 0.75%. We observed and recorded the two cases of the retroaortic left renal vein by photographs and line drawings. Then, to consider the morphogenesis of the anomalous vein, we studied 16 cases of the renal collar (the circumaortic renal venous ring) from 149 bodies. Moreover, we observed and recorded the relations between the left renal vein and the lumbar veins in 19 bodies dissected in 1996. Results were compared with those of the reports by some different authors and conclusions were as follows. 1. The incidence of the retroaortic left renal vein is estimated approximately at 0.75%. 2. The retroaortic left renal vein is derived from the renal collar (circumaortic renal venous ring) at an embryonic stage and is completed by the regression and disappearance of the ventral (preaortic) limb and the persistence of the dorsal (postaortic) limb at a later stage. The ventral limb originates from the anastomosis between the subcardinal veins and the dorsal limb originates from the anastomosis between the supracardinal veins (external vertebral venous plexus). The left lumbar veins drain into the inferior vena cava by using the intersupracardinal anastomosis (external vertebral venous plexus). The dorsal limb and the left lumbar veins are considered to use a same venous route passing dorsal to the abdominal aorta. Indeed, in the 16 cases of the renal collar studied, the dorsal limb use the left second lumbar vein in 7 cases, the third lumbar vein in 6 cases, the fourth lumbar vein in 1 case, both the second and the third lumbar veins in 1 case and unknown lumbar vein in 1 case. Moreover, in the two cases of the retroaortic left renal vein the dorsal limb use the third lumbar vein. 3. The retroaortic left renal vein of our cases leaves the renal hilus behind the renal artery (usually in front of the artery) at the level of the intervertebral disc between the second and the third lumbar vertebrae (just one verteral body lower than usual) and flows into the inferior vena cava by using the left third lumbar vein. The reason why ventral (normal) route of the left renal vein disappear may be that the vein leaves the renal hilus at the lower level and the more dorsal position than usual.     

Retrohepatic cavoatrial shunt with a ringed polytetrafluoroethylene graft for the Budd-Chiari syndrome. A case report

This report describes a patient with Budd-Chiari syndrome who was operated on successfully by means of shunt formation with polytetrafluoroethylene graft between the inferior vena cava (IVC) and right atrium. The patient is a sixty-two-year-old woman suffering from persistent edema of the lower limbs for four years. The examination disclosed complete obstruction of the IVC at the level of the diaphragm with a patent right inferior hepatic vein. Following the operation, edema of the limbs disappeared, hypersplenism improved, and the serum ammonium concentration decreased to the normal range. In conclusion, a retrohepatic cavoatrial shunt is feasible and useful in treating a patient with the Budd-Chiari syndrome who has patent major hepatic veins.     

Mechanical thrombectomy in acute and subacute thrombosis with use of the Amplatz device: arterial and venous applications

PURPOSE: To perform a feasibility study of the Amplatz Thrombectomy Device (ATD) in a variety of vascular territories with acute or subacute thrombosis. MATERIALS AND METHODS: Thirteen patients (mean age, 44.6 years) with multiple risk factors who had acute/subacute thrombosis of the inferior vena cava (IVC) and iliac veins (n = 3), superior vena cava (SVC) and/or subclavian veins (n = 3), lower extremity polytetrafluoroethylene (PTFE) graft (n = 2), iliac artery (n = 2), portal vein and transjugular intrahepatic portosystemic shunt (TIPS) (n = 2), and an IVC to pulmonary artery Fontan conduit (n = 1), were treated by means of mechanical thrombectomy with use of the ATD. Thrombolysis failed to recanalize the vessels when used before thrombectomy for 12-34 hours in three patients, and was contraindicated in three other patients. Thrombolysis was used as a complement to the ATD procedure in five patients. RESULTS: Technical success was achieved in 11 patients, and procedure success was achieved in 10 patients. Failure was observed in the remaining three patients. One patient with a PTFE graft was successfully declotted but thrombosis occurred 2 weeks later, requiring surgery. The other patient with a PTFE graft did not improve and needed surgery to declot and treat the distal anastomosis and distal circulation. The two patients with an occluded iliac artery underwent successful declotting but rethrombosis occurred in one shortly after the procedure requiring thrombolytic therapy. One patient with TIPS thrombosis improved and another patient with a thrombosed portal vein did not improve after thrombectomy. CONCLUSION: The ATD is useful for recanalization of acute/subacute clotted native vessels and grafts. The application of the device is broad, and although declotting can be achieved in most cases, long-term success may be limited by anatomical and technical problems of the grafts and multifactorial clinical problems of severely sick patients, as was the case in the series. The use of additional thrombolytic therapy may be necessary in a number of patients.     

Use of the donor iliac vein to replace the retrohepatic vena cava in pediatric reduced-size liver retransplantation

The authors describe a new technique that used the donor common iliac vein and its bifurcation into the external iliac and internal iliac veins to replace the retrohepatic vena cava; this was used in a recipient who underwent her second reduced-size transplantation (segments II and III). Anastomosis of the donor hepatic vein to the internal iliac vein, with use of this segment of the venous graft to replace the retrohepatic vena cava, is for patients who have had more than one surgical procedure before liver transplantation.     

Replacement of the retrohepatic vena cava in segmental liver transplantation

Reduced grafts represent an important technical development in paediatric liver transplantation. The use of a left lateral segment graft has required preservation of the native inferior vena cava to "piggy-back" the graft onto it. We report four children who underwent left lateral segment transplantation with caval replacement using the donor iliac vein because the native retrohepatic inferior vena cava was small, friable or difficult to preserve. There were no caval or hepatic vein complications post-transplant and the donor iliac vein proved to be a satisfactory interpositional graft. The technique offers the advantages of a wider retrohepatic cava avoiding venous outflow or caval obstruction, provides good tissue to suture and is well suited for the triangulation technique of the left hepatic vein.     

Congenital calcified thrombosis of inferior vena cava, bilateral renal veins and left spermatic vein

An infant with severe congenital calcified thrombosis in the inferior vena cava, bilateral renal veins and left spermatic vein is presented. Five previously published cases and pertinent points concerning this rare occurence are discussed. The etiology of this calcified thrombosis remained unknown.     

Thrombosis of the superior vena cava and lateral-cervical lymphadenopathy (probably of metastatic origin). Report of a case

The authors describe a case of superior vena cava thrombosis with laterocervical lymphoadenopathy (probably of metastatic origin). Vascular tumors are a large neoplasm family with a wide clinical and histological spectrum. They may localize on the skin, soft tissues, liver, spleen and parotid gland. The case describes a 65 year-old male, affected by COLD and chronic hepatitis. He came to the hospital for strong gastric pain, which did not vary with meal assumption and objectivity of inflated superficial veins of arms, jugular veins, chest superficial veins and venous capillars and of the epigastric zone, accompanied with right laterocervical lymphoadenomegaly. Endoscopic ultrasonic and X-ray examinations showed a superior vena cava thrombosis determining superficial collateral, azygos and emiazygos vein inflation. The histologic examination of pathologic lymph nodes resulted as hemangioendotelioma/angiosarcoma, a rare case of lymphonodal vascular tumor with a very poor prognosis.     

Brief report: successful extension of the transplant renal vein with a synthetic vascular graft

Unexpected intraoperative vascular complications in the graft of the recipient during organ transplantation can be most vexing and require immediate attention and careful management so as not to impair the integrity and fate of the graft. We were confronted with a diabetic recipient with total fibrosis of the left iliac vein, patent inferior vena cava, totally and circumferentially calcified aorta and left iliac artery with the exception of a small area in the distal external iliac artery. The problem was solved by anastomosing the artery low onto the external iliac, and by interposing a venous polytetrafluoroethylene vascular graft between the renal vein and the inferior vena cava. The kidney function was excellent for 2 years but the patient succumbed to unrelated liver complications. A second patient with a renal vein PTFE graft has had normal graft function for 10 years. Probably because of the high blood flow through the kidney, venous synthetic grafts can be successfully used to correct venous problems during kidney transplantation.     

Transiliac catheterization of the inferior vena cava for long-term venous access in children

In infants and children requiring prolonged, multiple central venous (CV) catheterizations, the superior (SVC) and inferior vena cava may become thrombosed or stenotic, making CV access a difficult problem. Use of the iliac vein may be an acceptable alternative. We report a patient with thrombosis of the SVC in whom the external iliac vein was accessed through a retroperitoneal approach for placement of an implantable port. This technique is easy to perform, and there are no special materials or patient positioning required.     

Budd-Chiari syndrome: a common complication of Beh?et's disease

OBJECTIVE: The Budd-Chiari syndrome is characterized by venous outflow obstruction of the liver, usually occurring as a consequence of thrombosis of the hepatic veins. Vasculitis is a major component of Beh?et's syndrome. The aim of this study was to determine the incidence of hepatic vein thrombosis in patients with Beh?et's disease and to estimate the effect of this entity upon the clinical features and course of Beh?et's syndrome. METHODS: During an 8-yr period from 1985 to 1994, from a total of 493 patients with Beh?et's disease seen at Hacettepe University Hospital, the incidence and effect of hepatic vein thrombosis on the clinical course of Beh?et's syndrome was investigated. The hepatic vein thrombosis in each case was documented by hepatic venography and confirmed by digital subtraction angiography, computed tomography, ultrasonography, and liver biopsy. Coagulation parameters including protein C, protein S, and anti-thrombin III levels were easured in each case. The survival of cases with Beh?et's syndrome complicated by Budd-Chiari syndrome and the effect of the Budd-Chiari syndrome on the survival of individuals with Beh?et's syndrome were determined using the Kaplan-Meier technique. RESULTS: Of the 493 cases of Beh?et's syndrome, 53 (10.8%) were found to have one or more large vessel thrombosis. Of these 53 patients, 14 (26.4%) had hepatic vein thrombosis. Of these 14 patients, 8 had an additional inferior vena cava thrombosis and 4 had portal vein as well as total inferior vena cava thrombosis. Only two patients with isolated hepatic vein thrombosis were identified. These two patients and two additional patients with hepatic vein thrombosis plus thrombosis of the hepatic portion of the inferior vena cava are currently alive. Of the 10 patients with total inferior vena cava and hepatic vein thrombosis (4 also had portal vein thrombosis), all 10 died with a mean survival of 10.3 months. During the same time period, 37 patients obtained from a total of 1494 patients with clinical evidence of either portal hypertension, hepatic venous outflow obstruction or inferior vena caval obstruction without Beh?et's syndrome were found to have a Budd-Chiari syndrome. Of these 37 patients, 19 (51%) had an identifiable underlying disorder responsible for their hepatic vein thrombosis. CONCLUSION: Based upon this experience, it appears as if Budd-Chiari syndrome is a relatively frequent complication of Beh?et's disease. When individuals with Beh?et's syndrome have BCS, concurrent thrombosis of the portal vein and inferior vena cava are often found, if the patency of these vessels is assessed. The clinical course of patients with Beh?et's syndrome complicated by Budd-Chiari syndrome is poor. The extent of the vascular thrombosis within the inferior vena cava rather than the presence of the hepatic vein thrombosis per se is the major determinant of survival.     

Inferolateral retraction reduces the risk of thermal injury to biliary structures

A liver transplant technique is described in a patient with a thrombosed portal vein and a functioning surgically created renal-lieno shunt. Permanent portal inflow to the graft was provided by division of the left renal vein (LRV) at its junction with the inferior vena cava and anastomosis of the LRV end-to-end with the donor portal vein. Although this results in splanchnic blood traversing a 360 degree roundabout from the superior mesenteric vein via the splenic and disconnected left renal veins to the donor portal vein, the anastomosis lay well and the procedure was successful.     

An unusual case of persistent renal collar in a human adult male

There are relatively few reports in the literature on accessory renal veins, and particularly that anomaly described as a persistent renal collar. The present paper describes a case in which a left renal vein is encountered in a human adult, both anterior and posterior to the abdominal aorta, though without a persistent left inferior vena cava.     

Anti-P-selectin antibody decreases inflammation and thrombus formation in venous thrombosis

PURPOSE: Venous thrombosis and inflammation are interrelated. P-selectin contributes to activation of leukocyte-mediated inflammation. Therefore, we hypothesized that the neutralization of P-selectin would decrease vein wall inflammation and thrombosis. METHODS: Twelve baboons underwent infrarenal inferior vena caval balloon occlusion to induce thrombosis. Two groups of four baboons received neutralizing intravenous anti-P-selectin antibody (PSab) GA6 or CY1748 before occlusion and at days 2 and 4. Four baboons received saline control injections. One baboon per group was killed at days 2, 6, and 13, and at 2 months. Analysis included phlebography, ultrasound, gadolinium (Gd)-enhanced magnetic resonance venography (reflecting vein wall inflammation), and histologic, morphometric, and protein evaluation of the vein wall. Thrombus presence or absence was assessed. RESULTS: By day 2 in PSab baboons, vein wall Gd enhancement was decreased in the mid-inferior vena cava and the right iliac vein (p < 0.05; GA6 vs control baboons), normalizing by 2 months. The mid-inferior vena cava revealed fewer neutrophils and total leukocytes in PSab baboons; however, for GA6 in the right iliac vein these decreases were not present despite the absence of Gd enhancement; they were decreased with CY1748. PSab baboons demonstrated significantly less thrombus than control baboons (p < 0.01, GA6 and CY1748 vs control baboons). CONCLUSIONS: Anti-P-selectin antibody decreases vein wall inflammation and thrombus formation. Inhibition of P-selectin may be useful in venous thrombosis prophylaxis.     

Rupture of pectoralis major during parallel bar dips: case report and review

We report herein the case of a 28-year-old woman who presented with a mediastinal mass, subsequently confirmed to be idiopathic mediastinal fibrosis. Preoperative chest computed tomography (CT) showed a noncalcified mediastinal mass and surgery was performed to exclude malignancy. The mass was hard and dense, involved the left phrenic nerve, vagus nerve, and left upper lobe, and surrounded the subclavian artery, subclavian vein, superior vena cava, and left pulmonary artery. Pathologic examination showed the findings of mediastinal fibrosis and the mass was partially excised. Postoperative medical treatment was performed with prednisolone and tranilast, and a 3-year follow-up has not demonstrated any complications.     

Modified repair of mixed anomalous pulmonary venous connection

A modified repair technique is reported for mixed total or partial anomalous pulmonary venous connection with the right superior pulmonary vein connecting to the superior vena cava, the right inferior pulmonary vein to the right atrium or left atrium, and the left pulmonary veins to the coronary sinus. The superior vena cava is transected above the highest right superior pulmonary vein, its cephalad end is anastomosed to the right atrial appendage, and a pericardial baffle is constructed between the cardiac ostium of the superior vena cava, the ostium of the right inferior pulmonary vein, and the left atrium, including the coronary sinus, which is unroofed. The reported technique may be valuable to avoid pulmonary venous obstruction in complex mixed forms of total or partial anomalous pulmonary venous connection.     

Proposal of a new nomenclature for Budd-Chiari syndrome: hepatic vein thrombosis versus thrombosis of the inferior vena cava at its hepatic portion

Budd-Chiari syndrome (BCS) was initially defined as a symptomatic occlusion of the hepatic veins, but subsequent reports on various obliterative changes that occur in the hepatic portion of the inferior vena cava (IVC) and hepatic vein orifices have resulted in a broadened and ambiguous definition. Membranous obstruction of the inferior vena cava has been regarded by many as a congenital vascular malformation, but its relation to the classical BCS has remained obscure. With modern imaging and recent histological study of new cases, membranous obstruction of the IVC is now considered to be a sequela to thrombosis. How to classify various forms of occlusion and stenosis of the IVC and hepatic vein ostia is a major challenge. In this review, we emphasize that primary hepatic vein thrombosis (classical Budd-Chiari) and an obliterative disease predominantly affecting the hepatic portion of the IVC, both of which account for most patients with venous outflow block, are clinically quite different. In the West, the former is more common than the latter, which constitutes the vast majority of cases of outflow block in developing countries such as Nepal, South Africa, China, and India. The latter is frequently complicated by hepatocellular carcinoma (HCC), and primary hepatic vein thrombosis is not. The major cause of thrombosis is a hypercoagulable state in hepatic vein thrombosis, but more of the latter cases are idiopathic. The clinical presentation of the latter is milder, and onset is frequently inapparent, whereas the former is more severe, sometimes causing acute hepatic failure. Markedly enlarged subcutaneous veins over the body trunk characterize the latter. We propose that these two disorders be clinically distinguished with a suggested term "obliterative hepato-cavopathy" for the latter against classical BCS.     

Diagnostic imaging in deep vein thrombosis of the limbs

The clinically suspected deep vein thrombosis (DVT) should always be confirmed by instrumental procedures. In fact, about 70% of patients with clinically suspected DVT are shown to be negative on instrumental investigations. Phlebography is still the gold standard in the diagnosis of peripheral DVT. Main phlebographic findings are: persistent filling defect; abrupt interruption of contrast in a vein; lack of opacification in all or some deep veins; flow diversion with opacification of collateral branches. At present, peripheral phlebography is performed when the other noninvasive exams (Color Doppler US and Duplex Doppler) are doubtful, technically limited or when thrombosis of innominate veins or superior vena cava, is suspected. Real-time US enables direct visualization of the limb proximal veins. The venous wall, the venous valves, the thrombus and its development, the anatomic variants, the perivenous structures which may impact on the normal physiology of venous return, are depicted. However, the distal veins of the leg and arm and deep veins (the iliac veins, the superficial femoral vein in the adductor canal) are not accurately visualized. The US findings in DVT include: the presence of echoes within the vascular lumen; the veins in axial scans are not compressible. Pulsed Doppler and duplex Doppler combine the morphologic and functional study. Injury caused by DVT at the valvular level (postphlebitic syndrome) is visualized. Primary deep vein thrombosis caused by valvular disorders (valvular aplasia) is identified. Inadequate superficial and perforating veins to be treated with surgery are mapped. Color Doppler US depicts directly superficial and deep limb veins combining the morphologic with the functional assessment represented by the visualization of the map of flow velocity and direction. Recently, a new diagnostic procedure, the color Doppler Energy (CDE) or Power Doppler has been introduced. Together with mean flow velocity and spectral variance, the signal energy or power is also analyzed. The CDE is independent of the US incidence angle, it does not shows the flow direction, detects particularly slow flows, early canalization of thrombi and non occlusive thrombosis. Color Doppler diagnosis of thrombosis is prompt because an area with absence of color is visualized. Collateral vessels and flow direction within them, is well depicted. Beside the site and extension of thrombosis, color Doppler US is able to directly visualize the distal end of the thrombus, which when floating is at high risk for embolism. CT allows an adequate study of the iliocaval axis and is useful if phlebography or color Doppler US are not diagnostic. Iliocaval thrombosis represents a not infrequent finding during abdominal CT. The thrombus appears as a hypodense mass encircled by the hyperdense rim of contrast medium.     

Solitary intra-articular osteochondroma of the fingers in children

Injuries to the hepatic veins and retrohepatic vena cava have a high mortality due to uncontrolled hemorrhage. Successful repair may necessitate interruption of flow through the retrohepatic vena cava. Active bypass of the area is then needed to provide adequate venous return. Published methods for active bypass require cannulation of axillary and femoral veins in addition to clamping of the vena cava above and below the liver, often with limited exposure and significant risk. This report describes active bypass of the retrohepatic vena cava utilizing two right atrial cannulae. The simplicity of establishing the bypass together with the excellent exposure allowed repair of a bullet wound of the vena cava in one patient and the orderly performance of a left trisegmentectomy for a huge hepatic tumor in a second patient.     

Hepatic vein reconstruction at inferior vena cava confluence using left renal vein graft

BACKGROUND/AIMS: To preserve remnant liver function, extended left hepatectomy combined with middle hepatic vein reconstruction using a left renal vein graft was performed in resection of liver metastasis from sigmoid colon cancer, involving the confluence of the middle and left hepatic veins. METHODOLOGY: The tumor, 5 cm in size, occupied the superior part of segment 4, and involved the confluence of the middle and the left hepatic veins. An extended left hepatectomy, including the left lobe, left caudate lobe and part of segment 8, together with the middle hepatic vein trunk, was performed. The left renal vein was resected as a graft from the confluence of the inferior vena cava just distal to the branches of the gonadal vein, renal-azygos, splenorenal communications and vertebral veins. The middle hepatic vein was reconstructed using the left renal vein 3 cm in length. RESULTS: Impaired values of liver function tests were normalized by the third postoperative day. Renal function was good throughout the postoperative period. The patient was discharged two weeks after the surgery. The reconstructed middle hepatic vein was patent, which was evaluated by a color Doppler ultrasonography, computed tomography and magnetic resonance imaging 60 days after the surgery. The patient remained well in the eight months thereafter. CONCLUSIONS: Hepatic vein reconstruction using a left renal vein graft is a new and preferable addition for the selection of an optimal graft.     

Mammalian base excision repair and DNA polymerase beta

OBJECTIVE: To describe six dogs with congenital abnormalities involving the portal vein, caudal vena cava, or both. ANIMALS: Six client-owned dogs with congenital interruption of the portal vein or the caudal vena cava, or both. METHODS: Portal vein and caudal vena cava anatomy was evaluated by contrast radiography and visualization at surgery. Vascular casts or plastinated specimens were obtained in three animals. RESULTS: Portal blood shunted into the caudal vena cava in four dogs and the left hepatic vein in one. Two of these five dogs also had interruption of the caudal vena cava with continuation as azygous vein, as did an additional dog, in which the portal vein was normally formed. Portal vein interruption was present in 5 of 74 (6.8%) dogs with congenital portosystemic shunts evaluated at the Veterinary Teaching Hospital during the study period. CONCLUSIONS: Serious malformations of the abdominal veins were present in more than 1 in 20 dogs with single congenital portosystemic shunts. CLINICAL RELEVANCE: Veterinarians involved in diagnosis and surgery for portosystemic shunts should be aware of these potential malformations, and portal vein continuity should be evaluated in all dogs before attempting shunt attenuation.