Feasibility of MRI assessment of maternal-fetal oxygen transport and consumption relative to maternal position in healthy late gestational pregnancies

Late gestational supine positioning reduces maternal cardiac output due to inferior vena caval (IVC) compression, despite increased collateral venous return. However, little is known about the impact of maternal position on oxygen (O2 ) delivery and consumption of the gravid uterus, fetus, placenta and lower limbs. We studied the effects of maternal positioning on these parameters in 20 healthy pregnant subjects at 36 ± 2 weeks using magnetic resonance imaging (MRI); a follow-up MRI was performed 6-months postpartum (n = 16/20). MRI techniques included phase-contrast and T1/T2 relaxometry for blood flow and oximetry imaging, respectively. O2 transport was measured in the following vessels (bilateral where appropriate): maternal abdominal descending aorta (DAoabdo ), IVC, ovarian, paraspinal veins (PSV), uterine artery (UtA) and external iliacs, and umbilical. Maternal cardiac output was measured by summing DAothoracic and superior vena cava flows. Supine mothers (n = 6) had lower cardiac output and O2 delivery in the DAoabdo , UtA and external iliac arteries, and higher PSV flow than those in either the left (n = 8) or right (n = 6) lateral positions during MRI. However, O2 consumption in the gravid uterus, fetus, placenta and lower limbs was unaffected by maternal positioning. The ratio of IVC/PSV flow decreased in supine mothers while ovarian venous flow and O2 saturation were unaltered, suggesting a major route of pelvic venous return unaffected by maternal position. Placental-fetal O2 transport and consumption were similar between left and right lateral maternal positions. In comparison to non-pregnant findings, DAoabdo and UtA O2 delivery and pelvic O2 consumption increased, while lower-limb consumption remained constant , despite reduced external iliac artery O2 delivery in late gestation. KEY POINTS: Though sleeping supine during the third trimester is associated with an increased risk of antepartum stillbirth, the underlying biological mechanisms are not fully understood. Maternal cardiac output and uteroplacental flow are reduced in supine mothers due to inferior vena caval compression from the weight of the gravid uterus. This MRI study provides a comprehensive circulatory assessment, demonstrating reduced maternal cardiac output and O2 delivery (uteroplacental, lower body) in supine compared to lateral positioning; however, O2 consumption (gravid uterus, fetus, placenta, lower limbs) was preserved. Unlike other mammalian species, the ovarian veins conduct substantial venous return from the human pregnant uterus that is unaffected by maternal positioning. Lumbar paraspinal venous flow increased in supine mothers. These observations may have important considerations during major pelvic surgery in pregnancy (i.e. placenta percreta). Future studies should address the importance of maternal positioning as a potential tool to deliver improved perinatal outcomes in pregnancies with compromised uteroplacental O2 delivery.

Unusual Right Gonadal Vein Drainage: A Journey Into Rarity

The gonadal veins, responsible for draining from the paired gonads (testes in males and ovaries in females), exhibit variations in anatomy. Traditionally, the right gonadal vein directs its drainage into the inferior vena cava, while the left gonadal vein typically connects to the left renal vein. However, in the case of a 45-year-old woman diagnosed with a non-functional right kidney who underwent a right nephrectomy, an intraoperative observation revealed an unusual configuration: the right gonadal vein (ovarian) was found to drain directly into the right renal vein instead of its usual route into the inferior vena cava. This case report aims to elucidate this anomalous finding and provide a literature review on the prevalence of such anomalies in the existing research. This case report aims to raise awareness about the atypical drainage patterns of gonadal veins and underscore the importance of meticulous dissection of hilar renal vessels.

Ventricular Tachycardia Induced by a Wandering Nephroureteral Stent

We present a unique case of a 56-year-old female with complex cloacogenic carcinoma history who experienced intraoperative episodes of ventricular tachycardia and pulselessness of unclear etiology. The etiology was later found to be related to a nephroureteral stent that had perforated the right ureter, entered the right ovarian vein, traversed up the inferior vena cava, and nestled in the right atrium.

A case of leiomyosarcoma of the ovarian vein with obstructive uropathy and hepatic metastasis

Leiomyosarcoma (LMS) is a smooth muscle-derived malignant mesenchymal tumour. Primary LMS arising from the ovarian vein is uncommon. A 51-year-old female presented with left loin pain and was diagnosed with a LMS arising from the gonadal vein. The patient refused any treatment. Early detection and timely diagnosis of retroperitoneal masses will improve the prognosis and survival rate in these patients. CT imaging plays an important role in diagnosis.

Leiomyosarcoma arising from the ovarian vein as a gynecologic malignancy: Two case reports and a review of the literature

Leiomyosarcoma arising from the ovarian vein has rarely been reported. Herein, we report two cases from a single institute. Given their direct connections to ovarian vessels, both leiomyosarcomas were initially suspected to be gynecological malignancies. In one case, leiomyosarcoma was discovered incidentally without any clinical symptoms; it had a close connection with the ovarian vein, was removed surgically, and the patient has survived for over 12 years. In another case, bowel obstruction caused by the tumor helped to identify metastatic leiomyosarcoma. Blood flow was supplied by the ovarian artery and grew into the lumen of the ovarian vein without invading adjacent organs. After surgical resection, the patient underwent 18 months of chemotherapy prior to palliative care. We propose that leiomyosarcoma arising from the ovarian vein should be treated as a gynecologic malignancy, especially if it develops in the lower abdomen.

Bilateral ovarian vein thrombosis without underlying conditions: A case report

Ovarian vein thrombosis (OVT) usually occurs on the right side in women with underlying conditions such as pelvic diseases and thrombophilia or during the postpartum period. Here, we present a patient with bilateral OVTs without underlying conditions. A 63-year-old woman without remarkable past or family histories complained of mild lower abdominal pain. Computed tomography revealed bilateral OVTs, with the right-sided thrombus nearly progressing into the inferior vena cava. The presence of symptoms and risk of thrombus extension/pulmonary embolism (PE) led us to administer an oral anticoagulant (rivaroxaban) promptly. Her symptom improved gradually and bilateral OVTs disappeared by 3 months without any evidence of PE. The present case suggests that OVT can occur in a woman without underlying conditions, and the use of an anticoagulant may be a treatment option in such a case.

Reconstruction of a Lower Polar Artery for Kidney Transplantation Using Donor Ovarian Vein: Case Report with Literature Review

Background: In the case of complicated kidney transplantation, when the accessory artery is severed, the main task is to decide whether to restore renal blood flow and which method should be used. In this report, we present a case of kidney transplantation with vascular reconstruction using an ovarian vein as an interposition graft between a larger branch of the main renal artery and the lower polar artery which was severed during kidney explantation. Case summary: Kidney transplantation using an ovarian vein was performed for a 34-year-old woman with end-stage renal disease on 1 April 2020 in the Hospital of Lithuanian university of health sciences (LUHS) Kaunas Clinics. A lower accessory renal artery was severed during kidney explantation. As the ovarian vein of the donor remained and matched the diameter of the severed vessel, it was decided to use it as an insertion between the main renal artery and the accessory renal artery of the inferior pole. The cold ischemic time was 770 min and the warm ischemic time was 37 min. A month after transplantation, the patient's condition and daily urine output were normal and the serum creatinine level decreased rapidly. Fifteen months after the surgery, the function and structure of the transplant remained normal and there was no evidence of serious vascular complications on CT scans. This is the first case where graft function was verified after transplantation using three-dimensional CT angiography. Conclusions: If an inferior polar artery is severed, vascular reconstruction must be performed to preserve the function of the graft. Usually, the gonadal vein is available during donor nephrectomy; therefore, it can be explanted without additional difficulties or incisions. Although we have not reported any complications, further studies are recommended on the long-term outcomes of this alternative approach for the reconstruction of short renal arteries.

Incidental Gonadal Vein Thrombosis Diagnosed Using Computed Tomography Imaging: A Single-Center, Retrospective, Cohort Study

Objectives

Gonadal vein thrombosis is an uncommon but serious condition that can be fatal if it goes unnoticed. Up to 80% of cases occur in patients after delivery, hysterectomy, or lymphadenectomy for gynecological neoplasms. The objective of this study was to determine the incidence of gonadal vein thrombosis using computed tomography (CT) imaging at our center and to describe associated risk factors.

Methods

A retrospective, single-center, observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. Data were collected for all patients diagnosed with incidental gonadal-vein-thrombosis using contrast-enhanced computed tomography imaging of the abdomen and pelvis between January 2005 and December 2017. We included all patients with incidental findings of gonadal vein thrombosis and excluded those with incomplete data.

Results

In total, 58/68,268 (0.08%) patients were included. Fifty-seven patients were females, and only one was male. The mean age (years) of the patients was 50.0±15.0 (range 4-87). Thirty-four patients (59%) had right gonadal vein thrombosis, 20 (34%) had thrombosis on the left side, and four (7%) had bilateral thrombosis. Nineteen patients (33%) had undergone pelvic surgery previously. Forty-four patients (76%) had a malignancy at the time of diagnosis. Forty-two patients (72%) were treated with anticoagulants after the diagnosis.

Conclusion

Gonadal vein thrombosis is a rare clinical entity with vague clinical presentation. The incidence in the oncology population is similar to the reported incidence in the obstetric population. Initiation of anticoagulation therapy is important to treat this condition and limit complications.

Operative and Clinical Outcomes of Minimally Invasive Living-Donor Surgery on Uterus Transplantation: A Literature Review

BACKGROUND

The surgical approach and choice of drainage veins for uterus transplantation living-donor surgery have been investigated to reduce invasiveness.

METHODS

A thorough search of the PubMed database was conducted. The search was not limited by language or date of publication. The data were collected on 13 October 2020. Two reviewers independently assessed each article and determined eligibility for inclusion in the review article. Inclusion criteria were English peer-reviewed articles reporting surgical information or postoperative course, articles regarding animal research on UTx, UTx on deceased donors, or not original articles.

RESULTS

Of the 51 operations within 26 articles reviewed, the mean operative time was shortest in the laparoscopic approach, and longest in the robot-assisted approach. The mean blood loss was less in the laparoscopic and robot-assisted approaches than in the open approach. In cases where the uterine veins were not preserved, the mean operative time was shortened by each approach and the mean blood loss decreased with the laparoscopic and robot-assisted approaches.

CONCLUSIONS

These procedures may contribute to less invasive living-donor surgery.

Case of caval lobular capillary hemangioma mimicking tumor thrombus

Introduction

We presented a rare case of caval lobular capillary hemangioma.

Case presentation

A 66‐year‐old female visited our department complaint with shadow defect in vena cava of right renal hilum appeared on computed tomography for periodically checking 3 years after radical hysterectomy with bilateral ovariectomy. Abdominal computed tomography identified a shadow defect of 35 mm in diameter in the inferior vena cava continuing posteriorly to a 35 mm mass of retroperitoneum. During the total removal of this lesion, we identified the lesion was connected to right ovarian vein. The specimen consisted of microcapillaries which formed reticular structure. Immunostaining of specimens identified positive CD31, CD34, and Factor 8 in all cells. Ki67 antibody was positive at 2–3% of all cells. These findings suggested the tumor was intravenous lobular papillary hemangioma.

Conclusion

This is the first report of intravenous lobular papillary hemangioma originated from right ovarian vein and extended to inferior vena cava.

Fenestration of the Proximal Left Ovarian Vein

A fenestration in the left ovarian vein was found in a fresh-frozen female cadaver. The opening did not have any vessels or additional anatomical structures passing through it. The ovarian vein is also referred to as the female gonadal vein. This type of anatomical variation is clinically relevant in procedures that deal with the manipulation of the gonadal veins, specifically conditions such as ovarian vein thrombosis, ovarian vein stenosis, and pelvic congestion syndrome.

Ectopic variceal bleeding due to portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein : case report and literature review of ectopic varices

Ectopic varices are dilated portosystemic venous collaterals located outside of the gastro-esophageal region. Whereas they are common endoscopic findings in patients with portal hypertension, ectopic variceal bleeding is rather rare and accounts for only 1 to 5 % of all variceal bleedings. The rectum and the duodenum are the most common sites for ectopic varices, but they can be present along the whole intestinal tract and neighborhood. At present, there is no consensus well established on diagnostic workup for ectopic variceal bleeding and their therapeutic strategies. Further investigation of large series or randomized-controlled trials is needed because nowadays most of the data available are based on case reports. We report here an unusual case of an ectopic variceal bleeding, presented as an acute small intestine bleeding, due to a portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein in a patient with alcoholic cirrhosis. The involvement of an ovarian vein in ectopic variceal bleeding is rarely described.

Successful third renal transplantation in a child with an occluded inferior vena cava: A novel technique to use the venous interposition between the transplant renal vein and the infrahepatic inferior vena cava

A girl aged 11 years and 3 months with occlusion of the inferior vena cava had experienced two renal transplant graft failures since birth. The third renal transplant from a live donor was carried out. Preoperative evaluation showed that the arteries from the right common to the right external iliac artery were absent, and the ilio-caval vein was occluded below the level of the renal vein. The donor's renal artery was anastomosed to the aorta. The donor's ovarian and large saphenous veins were used to extend the transplant renal vein to the recipient's patent inferior vena cava. The present report concludes that the extension of a short donor renal vein using other donor veins is a viable therapeutic option for pediatric patients with vascular occlusions.

Cadaveric Study of Mode of Termination of Gonadal Veins: Implications for Procedures Utilizing Terminal Ends of Gonadal Veins as Entry Portals

CONTEXT

The terminal ends of gonadal veins act as an entry portal in gonadal embolization procedures used for treating varicocele in males and pelvic congestion disease in females. Here, we studied the modes of termination of gonadal veins in adult cadavers.

MATERIALS AND METHODS

Thirty-five adult formalin-fixed cadavers (seventy sides) were studied over a period of 4 years. The modes of termination of gonadal veins were observed under the following study variables: (a) number, (b) locale of termination, and (c) termination angle.

RESULTS

Variations in study parameters were observed in eight sides of seven cadavers (seven unilateral and one bilateral). Double veins at termination were observed in six cadavers; anomalous termination was observed in three cadavers. Angle of termination differed from normal in 3 cadavers. In one of these cadavers, the left ovarian vein drained into the left suprarenal vein.

CONCLUSION

Duplication of terminal ends, anomalous drainage site, and varied angles of termination call for caution to ensure the success of procedures, which use terminal ends of gonadal veins as entry portals.

[LEIOMYOSARCOMA OF THE OVARIAN VEIN WITH THE RENAL VEIN INVASION: A CASE REPORT]

A 56-year-old woman had complained of two year's consecutive left-side abdominal pain. Retroperitoneal tumor was diagnosed and the patient was referred to our institute in December 2014. Laboratory data including endocrinological activity and serological markers were within the normal ranges. Imaging studies showed that the solid tumor measuring 5 cm in diameter was uncovered in the retroperitoneum, between the abdominal aorta and left kidney. The patient underwent surgical removal of the tumor with the left kidney because the mass was highly adhesive to the left ovarian vessels and left renal vein. Histological examination showed proliferating spindle cells in the tumor, and immunoreactivity for desmin and alfa-smooth muscle actin in tumor cells confirmed the diagnosis of leiomyosarcoma originated in left ovarian vein with left renal vein invasion. The patient has been free of disease 21 months after the surgery. Ovarian vein leiomyosarcoma is extremely rare and we have found 18 cases in literature. Furthermore, only three cases of leiomyosarcoma arising from the ovarian vein with the renal vein invasion were reported including our case.

Clinical outcome after treatment of pelvic congestion syndrome: sense and nonsense

Chronic pelvic pain accounts for approximately 10% of outpatient gynecologic visits and among the varied causes, pelvic congestion syndrome is second only to endometriosis in frequency. Manifestations may include pelvic pain, dyspareunia, dysuria, and dysmenorrhea as well as external varices and a number of psychosocial symptoms. Although a variety of treatments have been proposed-including pharmacologic ovarian suppression, hysterectomy with or without oophorectomy, and ovarian vein resection-transcatheter embolization is the least invasive and most efficacious management option. Complete or partial symptom improvement has been reported in 68.2-100% of patients and there has been a consistent reduction in visual analog pain scores after treatment. Based upon these results, recommendation of either pharmacotherapy or other surgical procedures is difficult to justify. However, it is also clear that 6-31.8% of patients do not get substantial relief from pelvic venous embolization. Potential explanations for an inadequate response to treatment include patient variability, procedural variability, and inadequate outcome measures. The latter are particularly important and future investigation should focus on the development of disease-specific quality of life measures as well as identifying those aspects of the procedure, such as choice of embolic agents and extent of embolization, associated with the best clinical outcomes.

Postpartum ovarian vein thrombophlebitis: Report of a case and review of the literature

Context:

Postpartum ovarian vein thrombophlebitis is an uncommon life-threatening situation. It should be systematically evoked in case of persistent fever during the postpartum. Diagnosis is often not immediately apparent clinically and there are many that mimic this condition.

Case Report:

A 26-year-old female presented with fever and acute right loin pain during four days after delivery. Right ovarian venous thrombosis was demonstrated on sonography and confirmed with computed tomography. The patient was given antibiotics and anticoagulation therapy with good response.

Conclusion:

Search for postpartum ovarian vein thrombophlebitis should be undertaken in patients with persistent fever. Treatment is more often medical.