Association of left renal vein variations and pelvic varices in abdominal MDCT

Concomitant circumaortic and retro-aortic left renal veins associated with fenestrated renal artery

Variations of the left renal vein can be in the form of circumaortic vein or renal collar, retro-aortic vein, additional renal vein, or multiple primary tributaries. We report a unique complex venous pattern of concomitant circumaortic and retro-aortic left renal veins associated with a fenestrated left renal artery. Two renal veins, anterior and posterior to the renal artery, originated from the renal hilum. The anterior vein was further divided into two branches. One branch passed through the fenestrated renal artery to continue as the anterior limb of the circumaortic vein. It received the suprarenal and gonadal veins and drained into the inferior vena cava. The other branch coursed posterior to the fenestrated renal artery and joined the posterior renal vein. The posterior renal vein was divided into two branches: one forming the posterior limb of the circumaortic vein, and the other continued obliquely downwards as the retro-aortic vein. Variations in the left renal vein have been implicated in several clinical conditions, such as varicocele and pelvic varices. It also plays a crucial role in renal transplantation, as the left kidney is often used as the donor organ. Even though many reports have been published on circumaortic and retro-aortic veins, the complex venous pattern associated with a fenestrated renal artery has not been reported previously.

Vascular Variations and Incidental Pathologies in Potential Living Renal Donors Using 160-Slice Multidetector Computed Tomography Angiography

INTRODUCTION

The aim of the study is to evaluate the vascular variations and incidental pathologies in potential living renal donors using 160-slice multidetector computed tomography (MDCT) angiography.

METHODS

This is an observational study conducted at the Department of Radiology from January 2017 to May 2022. In this study, we performed retrospective data analysis of 61 CT renal angiograms, totaling 122 kidneys of potential renal donors, using a Toshiba 160 slice MDCT scanner with a four-phase CT image acquisition protocol, performed for pre-transplant workup. All patients had normal renal functions.

RESULTS

Of our 61 patients, 34 (55.7%) were male and 27 (44.3%) were female, and their mean age was 31.2 ± 9.4 years. We have found 31 (50.8%) variations in the right renal arteries and 21 (34.4%) in the left renal arteries. Of these patients, 13 had bilateral renal arterial variations. The late confluence of the renal vein was found in 3.3% of males, multiple right renal veins in 7 (11.5%), and left renal veins in 2 (3.3%). By distributing the data according to gender, we noticed more diversity in the renal vessels of male patients. Left renal artery variations were more frequent in males (16, 76.2%) than in females (5, 23.8%), and they were statistically significant (p=0.02). Likewise, variations in the right renal arteries were also more frequently found in males (19, 61.3%) as compared to females (12, 38.7%). Right renal vein variations were more common in males (9, 81.8%) as compared to females (2, 18.2%) (p=0.05).

CONCLUSION

Frequent renal vascular variations and incidental pathologies in potential living donors were found by MDCT examination, and these vascular variations should be analyzed before renal transplant.

Incidental Ovarian and Uterine Findings on Cross-sectional Imaging

Incidental adnexal masses and uterine findings occur with a high frequency on cross-sectional imaging examinations, particularly in postmenopausal women in whom imaging is performed for a different reason. These incidentalomas encompass a gamut of potential pelvic gynecologic disorders. Most are benign ovarian cysts; however, other less commonly encountered disorders and improperly positioned gynecologic devices may be seen. A knowledge of the management recommendations for such pelvic incidental findings is critical to avoid unnecessary imaging and surgical interventions, as well as to avoid failure in diagnosis and management of some of these conditions.

Hemodynamic and Radiological Classification of Ovarian Veins System Insufficiency

Ovarian veins system insufficiency is one of the most common reasons for pelvic venous insufficiency (PVI). PVI is a hemodynamic phenomenon responsible for the occurrence of venous insufficiency of the lower extremities and recurrent varicose veins in nulliparous and parous women, as well as for a set of symptoms described as pelvic congestion syndrome (PCS). In the years 2017–2019, 535 patients admitted to our center with symptoms of venous insufficiency of the lower extremities, underwent complete ultrasound diagnostics (color-duplex ultrasound) of the venous system of the abdomen, pelvis and lower limbs, as well as extended imaging diagnostics using computed tomography (CT) or magnetic resonance (MR) venography. On the basis of the obtained results, the authors proposed a 4-grade hemodynamic and radiological classification (grades I-IV) defining the stratification of ovarian veins insufficiency. Using the above mentioned classification approx. 32% patients were identified as Grade I and I/II, approximately 35% revealed morphological and hemodynamic changes corresponding to Grade II and II/III, approximately 25% were classified as Grade III, whereas the remaining 8% were assessed as Grade IV. The described classification allows for the grading of ovarian veins insufficiency based on transparent radiological criteria, making it easy to use in everyday clinical practice. According to the authors, the proposed classification could facilitate communication between diagnostic physicians, specialists dealing with the treatment of venous insufficiency and gynecologists, who admit patients with symptoms suggesting venous insufficiency of the pelvis.

A forgotten disease: Pelvic congestion syndrome as a cause of chronic lower abdominal pain

Objectives

Pelvic congestion syndrome is defined as chronic pelvic pain due to incompetent (dilated and refluxing) pelvic veins. The aim of this study was to investigate the prevalence of this condition by examining the prevalence of dilated ovarian and para-uterine veins in pre- and postmenopausal female patients, irrespective of their symptoms. We subsequently investigated how many women with dilated veins suffered from chronic pelvic pain. Additionally, we attempted to define diagnostic criteria that may allow for early identification of affected patients.

Methods

We reassessed 2384 abdomino-pelvic computed tomography scans performed on women at our institution. The maximal diameters of the ovarian and para-uterine veins were measured. Patients with a pathological process in the abdomen or pelvis affecting the veins were excluded. We considered ovarian vein dilation to be 6 mm or more in the axial plane. For patients that met these criteria, we performed a retrospective chart review to evaluate the clinical presentation and/or symptoms of these patients.

Results

Dilated pelvic veins were present in 293/2384 (12%) patients, 118/559 premenopausal (21%) and 175/1825 postmenopausal (10%). Chronic pelvic pain of unclear etiology had been documented prior to the CT in 54/293 (18%) women with dilated veins—2% of the whole study collective (54/2384); 8% of all premenopausal (44/559) and 0.5% of all postmenopausal (10/1825). It was often accompanied by urological symptoms such as hematuria, dysuria, and urinary frequency, in the absence of infection (p<0.05). We identified a strong correlation between the presence of dilated ovarian veins and chronic pelvic pain in premenopausal parous patients with hematuria.

Conclusions

Pelvic congestion syndrome appears to be an underdiagnosed and undertreated disease. In our study, 8% of all premenopausal women had documented chronic pelvic pain of unclear etiology and dilated ovarian and pelvic veins on cross-sectional imaging studies. The features we identified in this study as most relevant should enable a faster identification of patients who could benefit from a specific treatment regimen for this condition.

ACR Appropriateness Criteria® Postmenopausal Subacute or Chronic Pelvic Pain

Pelvic pain is common in both reproductive age and postmenopausal women, and the major etiologies change throughout the life cycle. Chronic pain is defined as lasting for at least 6 months. There are many gastrointestinal and urinary disorders associated with chronic pain in this age group, which are not discussed in this guideline. Pain may be localized to the deep pelvis, with potential causes including pelvic congestion syndrome, intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis. Ultrasound is the initial imaging modality of choice, while CT and MRI may be appropriate for further characterization of sonographic findings. Alternatively, pain may be localized to the vagina, vulva, or perineum, with potential causes including vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain. Imaging is primarily indicated in context of an abnormal physical exam and ultrasound is the initial modality of choice, while MRI may be appropriate for further characterization in select cases. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Association of congenital left renal vein anomalies and unexplained hematuria: multidetector computed tomography findings

OBJECTIVES

To investigate whether congenital renal vein anomalies are involved in the etiology of hematuria by analyzing abdominal multidetector computed tomography (MDCT) results.

METHODS

Six hundred and eighty patients undergoing MDCT for various abdominal pathologies in whom possible causes of hematuria were excluded were retrospectively assessed in terms of left renal vein anomalies, such as circumaortic left renal vein (CLRV), retroaortic left renal vein (RLRV) and multiple renal vein (MRV). Patients with CLRV, RLRV or MRV and patients with normal left renal veins were compared in terms of the presence of hematuria.

RESULTS

Left renal vein anomalies were detected in 100 patients (14.7%). RLRV, CLRV and MRV were identified in 5.4, 2.5 and 6.8% of patients, respectively. Hematuria was determined in 8.1% of patients with an RLRV anomaly and in 10.5% of patients with no RLRV anomaly (p=0.633). Hematuria was detected in 23.5% of patients with a CLRV anomaly and 10.1% of those without (p=0.074), and in 21.7% of patients with an MRV anomaly and 9.6% of those without (p=0.009).

CONCLUSIONS

In addition to increasing risk of complication during retroperitoneal surgery, numeric congenital renal vein anomalies are also significant in terms of leading to clinical symptoms such as hematuria.

The clinical anatomy of the inferior vena cava: a review of common congenital anomalies and considerations for clinicians

Anomalies in the course and drainage of the Inferior Vena Cava (IVC) may complicate normal functioning, correct diagnosis, and therapeutic interventions within the abdomen. Development of the IVC occurs during the 4th to 8th week of gestation, and due to its developmental complexity, there are many opportunities for malformations to occur. Although most IVC anomalies are clinically silent and are usually discovered incidentally on abdominal imaging, aberrations may be responsible for formation of thrombosis, back pain, and anomalous circulation of blood to the heart. In this review, we will discuss the most common variations and abnormalities of the IVC, which include the posterior cardinal veins, the subcardinal veins, the supracardinal veins, persistent left IVC, IVC duplication, situs inversus, left retroaortic renal vein, left circumaortic renal collar, scimitar syndrome, and IVC agenesis. For each abnormality outlined above, we aim to discuss relevant embryology and potential clinical significance with regards to presentation, diagnosis, and treatment as is important for radiologists, surgeons, and clinicians in current clinical practice.

Two vascular variations in one patient of the hepatogastric trunk and retro-aortic left renal vein

This study reports the case of a 61-year-old man with right upper quadrant pain who underwent abdominal computed tomography examination. A solid lesion originating from the biliary tract was detected on the images. While evaluating the vascular structures, the splenic artery was seen to directly originate from the abdominal aorta. Retro-aortic left renal vein was also seen on computerised tomography. Splenic artery originating from the abdominal aorta is a rare variation. The retro-aortic left renal vein is a malformation characterized by the presence of a vessel that drains the left renal blood up to the inferior vena cava crossing behind the aortic artery. Such anatomical variations are important for surgeons to be aware of.

MDCT of the ovarian vein: normal anatomy and pathology

OBJECTIVE

We intend to show the MDCT findings of normal ovarian (gonadal) vein anatomy and associated disorders, including the "ovarian vascular pedicle" sign, phlebolith, reflux, pelvic congestion syndrome, thrombosis, stenosis, and occlusion.

CONCLUSION

Volume-rendered images and curved planar reformatted images can be used to show the ovarian veins. MDCT findings allow the diagnosis of various ovarian vein disorders in patients with abdominal and pelvic pain, pulmonary thromboembolism, and pelvic mass.

Retroperitoneoscopic donor nephrectomy for retroaortic renal vein draining into left common iliac vein

Laparoscopic donor nephrectomy (LDN) for both retroaortic and circumaortic veins is described. LDN for left retroaortic vein draining into the common iliac vein (CIV) is not described previously. We report 2 cases of laparoscopic harvesting of left kidney having retroaortic renal vein draining into the left CIV and successful transplantation.

Venous variants and anomalies on routine abdominal multi-detector row CT

OBJECTIVE

This study aims to determine the types and prevalence rates of anatomic variations of the hepatic veins, portal vein, inferior vena cava and renal veins, and to establish statistical correlations between various anomalies and frequency differences between male and female using multi-detector row computed tomography (CT).

MATERIALS AND METHODS

One thousand one hundred and twenty patients (588 men, 532 women) were evaluated with routine abdominal CT. Frequencies of different variants were noted and compared, and correlations between three categories of variation were tested.

RESULTS

In total, 1261 abdominal vein variants and anomalies were identified in 756 (67.5%) of 1120 patients. Six hundred and forty-two hepatic vein variants were detected in 468 (41.8%) patients. One or more inferior right hepatic veins were identified in 356 (31.8%) individuals, and tributary hepatic veins were detected in 147 (13.1%) patients. Portal vein variations and anomalies were observed in 307 (27.4%) cases. The most frequent of these was trifurcation (139 patients, 12.4%). A total of 311 inferior vena cava and renal vein variants were identified in 258 (23%) cases. Six patients (0.5%) exhibited inferior vena cava anomalies, 62 (5.5%) had circumaortic renal veins, 53 (4.7%) had retroaortic renal veins, and 210 (18.8%) had multiple renal veins.

CONCLUSION

The prevalence of abdominal vein variations is high, and routine abdominal CT demonstrates these abnormalities very well. The data suggest that hepatic vein variants and multiple right renal veins are more frequent in women than in men, and that hepatic vein variation is correlated with portal vein variation.