The term retro-aortic left renal vein (RLRV) is defined as the left renal vein coursing posterior to the abdominal aorta. RLRV is an uncommon condition in which the left renal vein passes posterior to the abdominal aorta and anterior to the vertebrae. RLRV may lead to left renal vein hypertension (LRVH) syndrome, which is also known as Nutcracker syndrome. Nutcracker syndrome (NCS) is a condition in which the left renal vein is compressed causing hypertension of the vessel. RLRV and Nutcracker syndrome are vascular anomalies considered to be of clinical importance especially during surgical procedures of the renal vasculature

Aichroth, RDMS, JoAnn

Fox, MS, RT(R), RDMS, RVT, Traci B.

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Radiologic Sciences Faculty Papers Department of Radiologic Sciences1-2013Retro-Aortic Left Renal VeinJoAnn Aichroth, RDMSThomas Jefferson University, joann.aichroth@jefferson.eduTraci B. Fox, MS, RT(R), RDMS, RVTThomas Jefferson University Hospital, traci.fox@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: http://jdc.jefferson.edu/rsfpPart of the Radiology CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Radiologic Sciences Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, pleasecontact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationAichroth, RDMS, JoAnn and Fox, MS, RT(R), RDMS, RVT, Traci B., "Retro-Aortic Left Renal Vein"(2013). Department of Radiologic Sciences Faculty Papers. Paper 4.http://jdc.jefferson.edu/rsfp/4 1     As submitted to:  Journal of Diagnostic Medical Sonography And later published as:  Retro-Aortic Left Renal Vein JoAnn Aichroth, RDMS Traci Fox, MS, RT(R), RDMS, RVT Thomas Jefferson University, Philadelphia, PA, 19107 January-February 2013, Vol, 29, No. 1, pp. 11-14.  DOI: 10.1177/8756479312471583   The term retro-aortic left renal vein (RLRV) is defined as the left renal vein coursing posterior to the abdominal aorta. RLRV is an uncommon condition in which the left renal vein passes posterior to the abdominal aorta and anterior to the vertebrae. RLRV may lead to left renal vein hypertension (LRVH) syndrome, which is also known as Nutcracker syndrome. Nutcracker syndrome (NCS) is a condition in which the left renal vein is compressed causing hypertension of the vessel. RLRV and Nutcracker syndrome are vascular anomalies considered to be of clinical importance especially during surgical procedures of the renal vasculature.   Keywords retro-aortic, left renal vein, Nutcracker syndrome, hypertension     The development of the left renal vein coincides with the development of the Inferior Vena Cava. The left renal vein arises from the left kidney to eventually drain into the IVC. The IVC is formed from three pairs of veins including the posterior cardinal veins, the subcardinal veins, and the supracardinal veins. [3] The subcardinal and supracardinal veins anastamose to form a network of veins that course  2 along the ventral and dorsal aspect of the abdominal aorta. [3] Typically, the ventral portion of the network continues as the dorsal network deteriorates, causing the ventral network to form the left renal vein coursing anterior to the abdominal aorta (Figure 1). If the dorsal network continues, then the ventral portion deteriorates and the left renal vein passes posterior to the abdominal aorta (Figure 2). When the left renal vein courses posterior to the aorta it is referred to as retro-aortic left renal vein (Figure 3). Occasionally, there may be a duplication of the left renal vein in which the vessel passes both anteriorly and posteriorly to the aorta to drain into IVC.   Left renal vein hypertension syndrome, also known as Nutcracker Syndrome, was described by Grant: "the left renal vein as it lies between the aorta and the superior mesenteric artery resembles a nut between the jaws of a nutcracker". [7] Nutcracker syndrome is defined as compression of the left renal vein leading to hypertension of the vessel. There are two forms of NCS including the anterior nutcracker phenomenon and the posterior nutcracker phenomenon. [5] Anterior NCS describes hypertension of LRV due to compression of the vein between the superior mesenteric artery and the abdominal aorta. Posterior NCS refers to hypertension of the LRV due to compression of the vein between the abdominal aorta and the vertebral column.   Nutcracker syndrome may present with left flank and/or abdominal pain and hematuria (macroscopic or microscopic). The key symptom in detecting posterior NCS is hematuria. In females, LRVH may present as Pelvic Congestion Syndrome which is characterized by lower abdominal pain, dysmenorrhea, emotional distress, or varices of the lower limbs. In males, compression of the left renal vein may cause reflux between the left renal and gonadal veins resulting in varices of the lower limbs. [6]  The etiology of Nutcracker syndrome has not yet been medically proven. However, several factors may be of cause for the disorder including inadequate stretching of the left renal vein or abnormal branching of the SMA. [7] Normally, the SMA originates from the aorta at a 90 degree angle and travels about 4-5mm before taking a caudal descent, which typically avoids compression of the LRV. However,  3     in the case of NCS the SMA branches from the aorta at an acute angle, immediately descending caudal to the vessel which increases the risk of compression of the LRV. [7]  There are several methods that can be used to diagnose compression of the left renal vein. It is important to know and remember that compression of the left renal vein is increased if the patient is in a standing position due to the weight of the bowel. Therefore, compression of the vein may not be accurately diagnosed with exams that require the patient to be in an upright or decubitus position. Duplex ultrasound is a useful method that demonstrates both color and spectral Doppler to detect compression of the left renal vein (Figure 4). Duplex scanning is used to detect anomalies of the LRV including stenosis, flow abnormalities, or collateral pathways. [2] Evaluation of a stenosis would include the comparison between the anteroposterior diameter of LRV to the left of the aorta before draining into the IVC and at the level of the stenosis. Flow abnormalities would be evaluated by calculating the peak systolic velocity at the level of the stenosis and within the hilum of the left kidney. The main collateral pathway of the LRV is the gonadal vein which should be carefully evaluated and measured. [2] Duplex scanning is also used to evaluate the SMA to ensure its location, angle, and the distance between the SMA and the aorta at the level of the LRV. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are also useful methods in detecting compression of the LRV because they both show the LRV and reveal its relation to other structures and organs surrounding it. Phlebography and pressure measurements can also be used to evaluate compression of the LRV. [2]   Treatment of Nutcracker syndrome depends upon the severity of the disorder. Patients may be asymptomatic which would result in conservative treatment. Patients with severe or ongoing symptoms may undergo various surgical procedures to reduce compression including left renal vein transposition, renal autotransplantation, or stenting of the left renal vein. [2] Transposition of the left renal vein involves dividing the left renal vein as it intersects the IVC. The LRV is re-positioned to a lower level than its initial junction with the IVC. [8] Renal autotransplantation involves the anastamosis of the left renal vein and artery to the common iliac vein and artery. It is an invasive procedure in which a kidney is removed  4 from its original origin, repaired, and then transplanted to another location within the body. Typically, the kidney is transplanted into the iliac fossa by attaching the renal vein and artery to the common iliac vein and artery. [4] Stenting of the left renal vein is used to reduce compression of the vein and eliminate symptoms. A balloon angioplasty is typically performed after the stent is inserted to dilate the vein and decrease the pressure gradient within the vessel. (1)  Renal vein anomalies can influence the effects of retroperitoneal surgery. Severe hemorrhage and/or renal failure can result in failure to detect renal vein anomalies prior to surgical procedures. [6] The left renal vein is longer than the right renal vein because it travels a longer distance to drain into the IVC, which is anatomically located on the right (Figure 5).  Due to the longer length of the left renal vein, surgeons prefer the left over the right renal vein with renal transplantations. This is a crucial reason for why it is important to know whether the left renal vein passes anterior to the aorta or whether it is retro-aortic. It is always useful to look up clinical history prior to surgery to avoid venous and organ damage, or even death.   The left renal vein generally courses anterior to the abdominal aorta. There are instances when the left renal vein takes a different path, traveling posterior to the aorta. Retro-aortic left renal vein is an anomaly of the renal vein that may cause damage to the vessel. RLRV can lead to Nutcracker syndrome which results in venous hypertension. This anomaly is relatively uncommon and most patients are asymptomatic. It is crucial to identify the course of the left renal vein so that surgical procedures of the vessel can be accurately performed. Anomalies of the renal vein are frequently overlooked but with appropriate testing and imaging, abnormalities can be detected and properly maintained.       5               References  [1] Guzzo, James L., and Heitham T. Hassoun. "EVToday.com > AprilÂ 2010 > Renal Vein Stenting for  Nutcracker Syndrome." Bryn Mawr Communications. N.p., n.d. Web. 1 July 2012. <http://www.bmctoday.net/evtoday/2010/04/article.asp?f=guest-chief-medical-editor>. [2] Hartung, Olivier . "Nutcracker syndrome | Phlebolymphology." Phlebolymphology - An international scientific journal devoted to venous and lymphatic diseases. N.p., n.d. Web. 1 July 2012. <http://www.phlebolymphology.org/2009/07/nutcracker-syndrome/>. [3] Hemalatha,  Narayani,  Moorthy,  Korath, and  Jagadeesan. "Retro-aortic Left Renal Vein and Hypertension." Bombay Hospital Journal 50.1 (2008): 6-10.  6 <http://www.bhj.org/journal/2008_5001_jan/download/retro-aortic-left-renal-vein-hypertension.pdf> Web. 2 June 2012. [4] Huelsman, Shawn. "Renal Autotransplantation:Past,Present and Future." The Surgical Technologist 277 (2007): 11-19. Print.< http://www.ast.org/publications/Journal%20Archive/2007/1_January_2007/ST_Jan07_CEarticle.pdf> [5] Jang, Yong, Kyung Kang, Sik Lee, Won Kim, Hyo Kwak, and Sung Park. "Posterior nutcracker phenomenon ." Oxford Journals | Medicine | Nephrology Dialysis Transplantation. N.p., n.d. Web. 4 June 2012. <http://ndt.oxfordjournals.org/content/20/11/2573.full>. [6] Nam, Jong, Sung Park, Sang Lee, and Moon Chung. "The Clinical Significance of a Retroaortic Left Renal Vein." National Center for Biotechnology Information. N.p., n.d. Web. 1 June 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858856/>. [7] Saleipour, Mehdi, Alireza Rasekhi, Abdolreza Haghpanah, Medhi Shirazi, Shahrokh Jahanbini, and Seyed Eslahi. "The role of renal autotransplantation in treatment of nutcracker syndrome Salehipour M, Rasekhi A, Shirazi M, Haghpanah A, Jahanbini S, Eslahi SA - Saudi J Kidney Dis Transpl." Saudi Journal of Kidney Diseases and Transplantation (SJKDT): Free full text articles from Saudi J Kidney Dis Transplant (SJKDT). N.p., n.d. Web. 1 July 2012. <http://www.sjkdt.org/article.asp?issn=1319-2442;year=2010;volume=21;issue=2;spage=237;epage=241;aulast=Salehipour>. [8] Xu, Danfeng, Yushan Liu, Yi Gao, Lei Zhang, Junkai Wang, Jiangping Che, and Youhua Zhu. "Management of renal nutcracker syndrome by retroperitoneal laparoscopic nephrectomy with ex vivo autograft repair and autotransplantation: a case report and review of the literature ."  7     Journal of Medical Case Reports 3 (2009): n. pag. http://www.jmedicalcasereports.com/content/3/1/82. Web. 4 June 2012.  

Retro-Aortic Left Renal Vein

Name not available

http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1003&context=rsfp

Retro-Aortic Left Renal Vein

Abstract

Similar works

Full text

Available Versions

Jefferson Digital Commons

Name not available