CT findings after left renal vein division during abdominal aortic surgery.

BACKGROUND: The rationale behind left renal vein division (LRVD) is the assumption that adequate collateral draining channels will develop. PURPOSE: To describe computed tomography (CT) findings after LRVD during aortic surgery. MATERIAL AND METHODS: Among 61 consecutive patients who underwent LRVD during aneurysm repair or revascularization for aortic occlusive disease between January 2003 and December 2017, 51 patients (40 men, mean age 71.4 ± 8.4 years) were enrolled. Contrast-enhanced CT images were analyzed to evaluate collateral drainage, patency, left renal vein diameter, and left renal parenchymal thickness. A total of 115 radiologic reports were reviewed to check whether these findings were accurately mentioned. RESULTS: The median time period of the first postoperative follow-up CT was 36 days (range 7-1351 days). The gonadal vein (n = 47) was the most common collateral draining channel, followed by the retroperitoneal veins (n = 42) and adrenal vein (n = 33). Thrombosis occurred in five patients between postoperative days 7 and 17 in the remnant renal vein (n = 3), remnant renal vein plus gonadal and adrenal veins (n = 1), and gonadal vein (n = 1). There was a significant decrease in renal vein diameter (-0.48 ± 2.12 mm, P = 0.006). There was no significant difference in parenchymal thickness (-0.25 ± 1.27 mm, P = 0.193). Neither LRVD nor any associated findings were correctly stated on radiologic reports. CONCLUSION: Postoperative contrast-enhanced CT can delineate collateral draining channels and complications following LRVD. However, these findings tend to be either missed or misinterpreted.

Intravascular Ultrasound for Evaluation of Left Gonadal Vein Anatomic Variations During Coil Embolization.

We illustrate the intravascular ultrasound (US) findings in the evaluation of left gonadal vein anatomic variations. During a 2-year period, 4 consecutive patients (mean age, 37 years; range, 28-45 years) with left-sided varicocele underwent embolization. Intravascular US examinations and retrograde venography were performed to assess varicocele anatomy. Anatomic variants were recorded and categorized. A comparison between intravascular US and fluoroscopic findings was performed. The Fisher exact test was used for statistical analysis (P < .05). Technical success was achieved in all cases. There was a statistically significant difference in the maximum gonadal vein diameter between venography and intravascular US (P = .0087). Intravascular US showed left gonadal vein anatomic variations and better ability in the evaluation of the vein diameter.

Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome.

Nutcracker syndrome is a rare entity caused by extrinsic compression on the left renal vein (LRV) crossing between the superior mesenteric artery and the aorta. This article reports the treatment of two cases of nutcracker syndrome using laparoscopic inferior mesenteric-gonadal vein bypass, knowing that this treatment option would avoid renal reperfusion injury and LRV hypertension. In addition, it is easier to operate compared with laparoscopic splenorenal venous bypass and laparoscopic transposition of LRV into the inferior vena cava.

Current results of left gonadal vein transposition to treat nutcracker syndrome.

OBJECTIVE: Nutcracker syndrome can cause disabling chronic pain requiring surgical intervention. At present, data describing a straightforward management approach are lacking. Transposition of the left gonadal vein is one of the surgical therapeutic alternatives. The aim of the present study was to describe our clinical results with gonadal vein transposition. METHODS: All 11 patients from three centers who had undergone left gonadal vein transposition for nutcracker syndrome from 2016 to 2019 were retrospectively included. The surgical cases were mainly selected according to the morphologic criteria of the left gonadal vein. The diameter and length dictated the type of approach (laparotomy or retroperitoneal) and the transposition level. A minimally invasive retroperitoneal approach was preferred. Pain was assessed using a numeric rating scale. RESULTS: We included 11 patients (10 women) with a median age of 35 years (range, 25-69). Preoperative computed tomography angiography showed anterior nutcracker syndrome in 10 patients (91%). All 11 patients had experienced lower back and/or pelvic pain, which was associated with pelvic congestion syndrome in 6 patients (55%) and hematuria in 5 patients (45%). The median preoperative numeric rating scale score for pain was 7.0 (range, 3.5-10.0) and 6.0 (range, 3.5-8.0) for lower back pain and pelvic pain, respectively. At the level of the iliac vein crossing (external or common), the median diameter of the left gonadal vein was 7.87 mm (range, 6.45-11.28). The left gonadal vein was transposed to the inferior vena cava in one case (9%), the left external iliac vein in five (45%), and the left common iliac vein in five cases (45%). The median in-hospital stay was 4 days (range, 2-20 days). Two early complications (18%) requiring surgical revision occurred: one of active bleeding and one hematoma. The median follow-up was 15 months (range, 6-44 months). The median postoperative pain score was 1.0 (range, 0.0-4.0) and 0.0 (range, 0.0-6.0) for lower back and pelvic pain, respectively. Incisional and/or neuropathic pain was noted, with a median score of 3.5 (range, 1.0-6.0) in seven patients (64%). Two late complications (18%) were observed: one case of thrombosis and one case of anastomotic stenosis. The hematuria had disappeared in all patients who had presented with it initially. CONCLUSIONS: Left gonadal vein transposition can be proposed as a first approach if the diameter of the left gonadal vein is sufficient to perform the anastomosis. It is an easily achievable, minimally invasive alternative that achieves satisfactory results without the use of foreign material.

Comparative analysis of the efficacy and safety of endovascular and endoscopic interventions on the gonadal veins in the treatment of pelvic congestion syndrome.

OBJECTIVE: Comparison of the efficacy and safety of endovascular and endoscopic interventions on the gonadal vein in the treatment of patients with pelvic congestion syndrome (PCS). METHODS: We evaluated the treatment outcomes in 95 patients with PCS who underwent endovascular embolization of gonadal veins (EEGV) (group 1, n = 67) or endoscopic resection of the gonadal veins (ERGV) (group 2; n = 28). A comparative analysis of the efficacy and safety of EEGV and ERGV in the treatment of PCS included assessments of their effects on pelvic venous pain, pelvic venous reflux, diameter of the pelvic veins, and restoration of daily activity, as well as treatment safety assessment. Clinical examinations and ultrasound studies of the pelvic veins were repeated at 1, 10, and 30 days, and 36 months after EEGV and ERGV. Pain was assessed using a visual analogue scale and the Von Korff questionnaire. RESULTS: A decrease in pelvic venous pain intensity was observed at 3.6 ± 1.4 days after EEGV and 2.5 ± 0.8 days after ERGV (P = .49 between the groups). At 1 month after the intervention, a complete relief of pelvic pain was reported by 52 and 25 patients in the EEGV and ERGV groups, respectively. The rates of valvular incompetence of the uterine veins were decreased from 85% in both groups at baseline to 3% in group 1 and 0% in group 2 at 36 months after the intervention, respectively. In the early postprocedural period, pain in the femoral or jugular vein puncture site was reported by eight patients (12%) who underwent EEGV (2.2 ± 0.7 scores). Postembolization syndrome was diagnosed in 13 patients (19.4%). After ERGV, all patients experienced pain in the area of the surgical wound, with a severity of 3.9 ± 0.5 scores. Hematoma at the puncture site of the main vein was observed in 6% of patients after EEGV. Protrusion of coils was identified in three patients (4.5%). The VTE incidence was four times greater in group 1 vs group 2 (14 vs 3 patients; P < .05). The relative risk of this complication after EEGV was 1.4 (95% confidence interval, 1.146-1.732). In two patients (7.1%) after the bilateral laparoscopic resection of the gonadal veins, an ileus developed. No complications of anesthesia were observed in either group. CONCLUSIONS: Endovascular and endoscopic techniques for decreasing blood flow through the gonadal veins are effective and safe in treating the PCS. The obvious advantages of EEGV are minimal injury and possibility to perform procedure under local anesthesia. The ERGV is associated with at least similar and, in some cases, even superior outcomes, in the terms of significantly (P < .05) shorter time to the postprocedural pain relief and avoiding postembolization syndrome.

Gonadal vein transposition is a safe and effective treatment of nutcracker syndrome.

BACKGROUND: Nutcracker syndrome (NCS) is a pelvic venous disorder that results from outflow obstruction of the left renal vein, most often due to a decreased aortomesenteric angle, leading to gonadal vein reflux, pain, and varices. Although a number of open and minimally invasive procedures to treat NCS have been described, the optimal management of this condition remains uncertain. To the best of our knowledge, we have presented the largest case series to date using gonadal vein transposition (GVT) to treat NCS. METHODS: Patients considered for intervention to treat NCS underwent a rigorous and standardized workup, including axial imaging studies, catheter-based diagnostic procedures, and urinalysis. GVT has been the institutional first-line treatment of NCS for appropriate patients. With institutional review board approval, a retrospective review of patients who had undergone GVT for NCS was conducted. RESULTS: From 2014 to 2019, 18 GVTs had been performed. Of the 18 patients, none had died or required reintervention, although 2 had required readmission. During a median follow-up of 178 days, complete symptom relief was achieved in 11 patients (61.1%), with 4 patients (22.2%) reporting partial symptom relief and 2 (11.1%) reporting transient symptom relief. CONCLUSIONS: GVT is a safe and effective procedure to treat NCS in appropriately selected patients with outcomes that compare favorably with those of other described procedures. Appropriate patient selection for this procedure is critical and requires a rigorous and standardized approach to diagnosis and management.

Common iliac vein obstruction in a symptomatic population is associated with previous deep venous thrombosis, and with chronic pelvic pain in females.

OBJECTIVE: The objectives of this study were to determine the incidence of common iliac vein obstruction, gonadal vein incompetence, and renal vein compression/stenosis and to ascertain which referral reasons were associated with common iliac vein obstruction and gonadal vein incompetence in a population symptomatic for chronic venous insufficiency. METHODS: Data were obtained from patients, at least 18 years old, who were referred to a private vascular laboratory for venous duplex ultrasound examination between 2016 and 2017. Transabdominal ultrasound was used to assess the iliac, gonadal, and renal veins in a dedicated protocol. Demographic data, referral reasons (varicose veins, lower limb pain, lower limb edema, lower limb ulcers, chronic pelvic pain [CPP]) and history of previous deep venous thrombosis (DVT) were recorded. RESULTS: Among 421 patients (78.6% female; 57.7 ± 16.7 years), 46.7% had iliac vein obstruction, 40.1% had gonadal vein incompetence, and 29.9% had renal vein compression/stenosis. Venous disorders were significantly more prevalent among female patients and on the left side. The most common referral reasons were varicose veins for both sexes, followed by lower limb pain for females and lower limb edema for males, none of which were associated with any venous obstruction or incompetence. Previous DVT was significantly associated with common iliac vein obstruction for all patients (ß = .189; P = .001), despite its being a previous known diagnosis for only 11.4% of patients. Among females, CPP was also significantly associated with common iliac vein obstruction and gonadal vein incompetence (ß = .246 [P < .001] and ß = .201 [P = .012], respectively). Among those with CPP in this study, common iliac vein obstruction, with and without gonadal vein incompetence (33% and 35%, respectively), was more prevalent than gonadal vein incompetence alone (14%). CONCLUSIONS: History of DVT, as well as CPP among females warrants investigations of common iliac vein obstruction. Common iliac vein obstruction is likely to be a more significant contributor to CPP than gonadal vein incompetence.

Reconstruction of the portal and hepatic veins using venous grafts customized from the bilateral gonadal veins.

BACKGROUND: Surgical resection for pancreatic and hepatic cancer sometimes involves combined resection and reconstruction of the major veins using venous grafts. Autologous venous grafts made from the bilateral gonadal veins (BGVs) have never been utilized or discussed. MATERIALS AND METHODS: We reconstructed the portal vein (PV), superior mesenteric vein (SMV), and middle hepatic vein (MHV) using cylindrical or patch grafts customized from the BGVs in two female patients and in one male patient. In order to assess the sexual difference in the availability of the cylindrical graft to replace these major veins, we measured the diameters of the BGVs, PV, SMV, and MHV on computed tomography in 50 male and 50 female patients, and estimated the diameter-ratios (DRs) of the cylindrical graft made from BGVs/PV, SMV, and MHV. We assumed that the cutoff value of the DR would be 0.8, for replacing of major veins using cylindrical grafts. RESULTS: The reconstructed PV, SMV, and MHV presented sufficient patency, and the postoperative courses were uneventful. The DRs of BGVs graft/PV, graft/SMV, and graft/MHV were significantly larger in female patients than those in male patients (0.82 vs. 0.54, p < 0.01, 0.96 vs. 0.61, p < 0.01, 1.39 vs. 0.95; p < 0.01) and were larger than 0.8 in 50%, 70%, and 92% in female patients, respectively, and 0%, 8%, and 68% in male patients, respectively. CONCLUSIONS: The present newly customized cylindrical and patch grafts made from the BGVs showed sufficient feasibility. A cylindrical graft made from the BGVs would be better utilized in female patients than in male patients.

RUG technique: replacement of the ureter with gonadal vein. A cadaveric study.

BACKGROUND: Ureteral defect lesions may result from retroperitoneal fibrosis, radiation damage, tumors, or surgical procedures; the management of long-segment ureteral defects is a challenge for urologists. Total or partial replacement of the ureter is sometimes required, with consequent ileal interposition, but this technique may lead to several complications, such as severe urinary infections. In a few cases, nephrectomy may be required. Starting from the above considerations, we can postulate the RUG technique (replacement of the ureter with gonadal vein), using the gonadal vein (GoV) as an autologous graft to substitute the ureter. For this reason, we decided to test this novel idea on an experimental model. METHODS: We tested the above technique on a cadaveric model, performing complete procedure (RUG #1), segmental replacement of the ureter (RUG #2), and ureteroplasty with a GoV patch (RUG #3). All the procedures involved an open approach. After RUG #3, the treated segment of the ureter was sampled for histologic analysis. RESULTS: Four RUGs were performed (two RUG #1, one RUG #2, one RUG #3). All anatomic structures were easily identified, and all procedures were completed successfully. The dimensions of the ureters were comparable to those of the GoV in all cases, as usual. Histologic analysis demonstrated perfect adherence of the two anastomosed structures. CONCLUSIONS: The RUG technique resulted in an adequate, safe and easy-to-perform surgical alternative.

Vascular ontogeny within selected thoracoabdominal organs and the limbs.

The cardiovascular system is fundamental to life. Its vessels are the conduits for delivery of nutrients and oxygen to organs and the removal of wastes. During embryonic development, the vascular system is instrumental in the formation of organs. It contributes to the form and pattern of organs as diverse as the limbs and the gonads. Recent advances in molecular biology and genomics have afforded great insight to the control of vascular development at subcellular levels of organization. Nevertheless, there is little assembled information concerning the vascular development of the organ systems of the body. This paper begins by reviewing the modes of formation of embryonic blood vessels. This is followed by summaries of the ontogeny of the vasculature that supplies selected major thoracic and abdominal organs (heart, gut, liver, gonads, and kidney). The paper concludes with a description of the arterial development of the upper and lower extremities.

Kidney Transplantation Using Gonadal Vein for Venous Anastomosis in Patients With Iliac Vein Thrombosis or Stenosis: A Series of Cases.

BACKGROUND: Kidney transplantation is the treatment of choice for patients with end-stage renal disease. The standard surgery uses the recipient's iliac vessels for vascular anastomosis. Thrombosis and/or stenosis of the iliac vein, which are possible complications of multiple vascular access points for dialysis, can be detected intraoperatively, constituting a surgical challenge. An infrequently reported option is the use of the gonadal vein. OBJECTIVES: This study aims to evaluate the outcomes of venous anastomosis in the gonadal vein in patients with iliac vein thrombosis and/or stenosis submitted to kidney transplantation. METHODS: We reviewed the records of five adult recipients with iliac vein thrombosis and/or stenosis detected intraoperatively during emergency kidney transplantation with deceased donor due to vascular access failure from February 2013 to December 2014. Antithrombotic prophylaxis was not performed. We evaluated the postoperative complications, length of stay, early graft echo-Doppler, and renal function during the first year postoperatively. RESULTS: Delayed graft function occurred in three cases. Two patients developed postoperative infection requiring antibiotics. One patient required reoperation due to post-renal biopsy complications. The mean length of stay was 31.2 days and the mean serum creatinine levels at discharge, at 6 months, and at 12 months postoperatively were 1.42 mg/dL, 0.86 mg/dL, and 0.82 mg/dL, respectively. All patients had normal ultrasonography. There were no losses of graft or deaths during follow-up. CONCLUSION: Venous anastomosis using the gonadal vein in kidney transplantation for patients with iliac vein thrombosis and/or stenosis showed good clinical and surgical results, showing this method to be a viable alternative to venous drainage in these complex patients.

Less calcemic Vitamin D analogs enhance creatine kinase specific activity and modulate responsiveness to gonadal steroids in the vasculature.

Vitamin D receptors are widely expressed in the cardiovascular system, in which Vitamin D and its metabolites exert a variety of biological activities such as regulation of cellular proliferation and differentiation, cell calcium transients and cell energy metabolism in vitro. The latter is mediated through the control of the brain type creatine kinase specific activity (CK), which serves to provide a readily available reservoir for ATP generation under increased work-load. In the present study we undertook to assess the role of Vitamin D on energy metabolism in the rat heart and aorta in vivo by using CK, which is a key energy metabolizing enzyme and compare Vitamin D depleted and repleted animals. Vascular tissues from female or male Vitamin D-depleted rats showed 61-80% lower CK activity in the aorta (Ao) and left ventricle of the heart (Lv) than control, Vitamin D-replete rats. Moreover, neither estradiol-17beta (E2) nor dihydrotestosterone (DHT), which increases CK specific activity in Ao and Lv of intact female or male rats, respectively, were able to stimulate CK in Vitamin D-depleted rats. Treatment of intact female rats for 2 weeks or 2 months with the less-calcemic Vitamin D analogs JKF 1624F2-2 (JKF) or QW 1624F2-2 (QW) (Fig. 1), did not significantly affect CK specific activity. However, after pretreatment with these analogs, there was an up regulation of the E2-induced CK response in Ao and Lv. In intact female rats, all Vitamin D analogs also potentiated the in vivo CK response to the SERMs raloxifene (Ral) and tamoxifen (TAM) in Ao and Lv. However the inhibitory effect of Ral or TAM on E2-induced CK activity was lost after pretreatment with Vitamin D analogs. The non-calcemic analog CB 1093 (CB) induced a significant increase in estradiol receptor alpha (ERalpha) protein in both myocardial and aortic tissue from intact and from ovariectomized female rats. Collectively, these results indicate that Vitamin D analogs modulate cell energy homeostasis in vascular tissues through induction of CK and up regulation of the response and sensitivity of CK in vascular tissues to E2 and to SERMs, possibly through via an increase in ERalpha protein in female derived organs. These results corroborate our previous in vitro studies in human vascular cells and further suggest that the Vitamin D system plays an important physiological role in maintaining normal cell energy reservoir in the vasculature.

Skeletopic analysis of the gonadal veins in human foetuses.

During ontogenesis an imbalance is observable in the development of the skeletal and vascular systems. By means of anatomical and radiological methods the gonadal veins were studied in relation to the vertebral column in 60 human foetuses of both sexes aged from 4 to 6 months of prenatal life. In male foetuses aged 4--5 months the origin of the gonadal veins projected onto the sacral apex (r(1)=0.95, r(3)=0.85), and in 6(th) month they extended below the vertebral column (r(1')=0.80, r(3')=0.90). In female foetuses the origin of the gonadal veins in the 4(th) month projected symmetrically onto S(1) (r(5)=0.70, r(7)=0.70). In the 5(th) month of intrauterine life the origin of the left ovarian vein was found at S2 (r(7')=0.80) and the origin of the right one at S1-S2 (r(5')=0.80). In the 6th month the origin of the left ovarian vein was located at S(3) (r(7')=0.80) and the right one at S(2)-S(3) (r(5'')=0.90). The skeletopic analysis of the origin of the gonadal veins demonstrated gender (the origin was higher in females) and syntopic (the origin was higher on the right side) differences (p0.05). On the right side the termination of the gonadal (testicular and ovarian) veins projected constantly onto L(2). On the left side the termination of the left gonadal (testicular and ovarian) veins apparently descended by one vertebra (pseudodescensus).

Alloantigenicity of human endothelial cells. IV. Derivation, characterization, and utilization of gonadal vein endothelia to control endothelial alloantigenicity during lymphocyte-endothelial interactions.

Most previous studies to evaluate endothelial cell-T lymphocyte interactions have used human peripheral blood as a source of T lymphocytes and human umbilical vein endothelial cells as a source of endothelia. Implicit in this experimental system are allogeneic lymphocyte-endothelial interactions, which are largely ignored. To overcome this problem, we isolated gonadal vein endothelial cells (GVEC) along with matched splenic macrophages and T lymphocytes from cadaveric donors, thus providing a completely autologous series of cells for experimentation. First, GVEC were analyzed for morphology, surface phenotype, and cytokine mRNA expression, and found to be indistinguishable from human umbilical vein endothelial cells. Using this system, we observed that irradiated GVEC were able to promote a 2- to 3-fold increase in the proliferation of matched autologous splenic T cells after PHA stimulation. This indicates that the costimulator activity of endothelial cells reported by others is an intrinsic property of endothelial cells, and is not a consequence of endothelial alloantigens. We also used this system to assess the relative abilities of GVEC and macrophages obtained from the same donor to stimulate the proliferation of purified allogeneic CD3+ PBL. We found the following hierarchy of alloantigenicity in this experimental system: splenic macrophages > IFN-gamma-treated GVEC >> untreated GVEC = TNF alpha-treated GVEC. These studies demonstrate that allogeneic macrophages are intrinsically more antigenic than endothelial cells derived from the same donor. Furthermore, they illustrate the utility of this experimental system to obtain data regarding lymphocyte-endothelial interactions that are otherwise unobtainable.

Differential effects of gallium nitrate on T lymphocyte and endothelial cell activation.

The immunosuppressive agents used clinically to prevent allograft rejection exert their effects by interfering with antigen-dependent T cell activation, endothelial cell function, or both. Gallium nitrate (GN) is immunosuppressive both in vitro and in vivo, and has potential for clinical use in transplant recipients. Therefore, we analyzed the influence of GN on gonadal vein endothelial cell (GVEC) and T cell activation. GVEC were stimulated with IFN gamma or TNF alpha in the presence or absence of GN, and tested for changes in levels of MHC class I, MHC class II, vascular cell adhesion molecule-1, and intercellular adhesion molecule-1 expression. GN did not interfere with the baseline or cytokine-enhanced expression of these molecules. Rather, it increased the expression of intercellular adhesion molecule-1 on GVEC, and this effect was further augmented in the presence of IFN gamma. In contrast, GN inhibited T cell proliferation stimulated by allogeneic GVEC or allogeneic monocytes in a dose-dependent manner. In transwell experiments, GN blocked the induction of MHC class II expression on isolated GVEC caused by alloactivated T cells, but not by recombinant IFN gamma. This suggests that GN can interfere indirectly with inflammatory responses of endothelial cells by interfering with local T cell activation and lymphokine production. Once lymphokines are produced, GN does not interfere with their effects on endothelial cells. GN is thought to act through transferrin receptors, but GVEC, unlike T cells, do not increase their expression of transferrin receptors, after stimulation with cytokines. This may explain their relative lack of sensitivity to GN. In general, GN appears to stimulate endothelial cells but suppress T cells. This paradoxic effect suggests that therapy with GN may enhance T cell-independent inflammatory responses, such as cellular infiltration and repair of tissue damage, while suppressing T cell-dependent responses, such as T cell-mediated tissue destruction and allograft rejection.

Systemic venous enhancement patterns during dynamic abdominal CT.

In 25 patients we assessed the enhancement of abdominal venous structures during dynamic computed tomography (CT). The degree of venous enhancement demonstrated great variation. In six instances (out of 250 observations) a vessel was visually perceived as not enhancing and potentially thrombosed, including three gonadal veins. CT measurements were helpful in identifying enhancement, but were occasionally low enough that thrombosis remained a radiological consideration. The great variation in venous enhancement makes the diagnosis of thrombosis suspect, based on CT alone. Corroboration of this finding is suggested, when clinically relevant.

[The inferior vena cava: anatomic and embryologic study of its malformations]. / La veine cave inférieure: étude anatomique et embryologique de ses malformations.

The authors recall the anatomy and embryology of the vena cava with particular emphasis on MacClure's embryological scheme which explains a number of anomalies of the vena cava and the renal veins.