Protean Drainage Patterns of the Left Renal Vein: A Cadaveric and Retrospective Clinical Study on the Surgical Implications and Technical Feasibility.

BACKGROUND: The diverse drainage patterns of the left renal vein (LRV), often with asymptomatic congenital anomalies, present considerable challenges in renal and retroperitoneal surgical contexts. The potential for significant bleeding and subsequent renal compromise upon vascular injury highlights the need for increased surgical awareness. OBJECTIVE: This study investigates the LRV's variable anatomical drainage patterns and morphometry. It also evaluates the embryological factors contributing to these variations and discusses their surgical implications and technical considerations. METHODS: Anatomical dissections were conducted on 21 adult human cadavers within the Department of Anatomy. Concurrently, a retrospective analysis was conducted on 15 patients who underwent various retroperitoneal surgical interventions in the Urology Department. Demographic variables and intraoperative findings were recorded and analyzed. RESULTS: Dissection analysis predominantly identified preaortic LRVs in 18 cadavers. Notable anatomical variations included a circumaortic left renal vein (CLRV), a delayed preaortic confluence of extrahilar duo LRVs, and an extrahilar tetramerous confluence with a retroiliac topography. The majority of LRVs usually end in the inferior vena cava. However, an extrahilar tetramerous variant had an unusual drainage pathway. Out of 15 cases, three (20%) had a retroaortic left renal vein (RLRV). One patient with a nonfunctioning kidney had type 1 RLRV, and another patient with pelvic ureteric junction obstruction had type 4 retroiliac left renal vein (RILRV). In both of these patients, symptoms were relieved after surgery. In a young patient with left varicocele and microscopic hematuria who had type 2 RLRV, symptoms resolved spontaneously after a few months. CONCLUSION: A thorough understanding of the variable anatomical drainage patterns of the LRV is crucial for surgeons. Accurate preoperative identification can provide valuable insights, potentially leading to improved surgical outcomes in renal procedures.

Prevalence and predictors of radiological left common iliac vein compression in asymptomatic patients.

OBJECTIVE: The aim of this study was to investigate the prevalence of radiological left common iliac vein (LCIV) compression among the asymptomatic population and identify possible predictors. METHODS: Contrast-enhanced abdominal and/or pelvic computed tomography scans of eligible asymptomatic patients were examined. The LCIV diameter was measured from different horizontal planes in the venous phase using PACSView. Degree of LCIV compression (Dc) was calculated by a predefined formula and graded as insignificant (Dc < 25%), mild (≥25% Dc < 50%), moderate (≥50% Dc <75%), and severe (Dc ≥ 75%). Venous stenosis was defined as a Dc of ≥50%. Comparison of variables, including gender, age, body mass index (BMI), and comorbidities was performed between the different grades of LCIV compression. RESULTS: Between November 2019 and July 2022, 1698 eligible asymptomatic patients (53.1% females; mean age, 39.3 ± 11.8 years; mean BMI, 22.9 ± 3.6 kg/m2) were reviewed. The mean Dc was 46.2% (range, 0.29%-90.4%). Insignificant, mild, moderate, and severe compression were distributed in 14.5%, 38.0%, 42.2%, and 5.2% of the cohort population, respectively. Prevalence of venous stenosis was higher in females than males (58.1% vs 42.2%; χ2 = 15.52; P < .001). Females aged ≥25 and <35 years accounted for the highest proportion of venous stenosis than other age groups and was a significant predictor (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.74-7.79; P < .001). In the Asian BMI classification group, being underweight is associated with venous stenosis (OR, 4.69; 95% CI, 2.70-8.14; P < .001) and obesity may be a protective factor (OR, 0.38; 95% CI, 0.23-0.64; P < .001). There is an inverse relationship between Dc and age and BMI. CONCLUSIONS: The prevalence of radiological LCIV compression on computed tomography scans was high, but all patients were asymptomatic. Female gender, especially those aged ≥25 and <35 years, and underweight were possible predictors for venous stenosis.

Traumatic Iliac Arteriovenous Fistula Treated With the Amplatzer Vascular Plug II: A Case Report and Literature Review.

Traumatic iliac arteriovenous fistula is a rare complication of vascular injury. Open surgical repair has an incidence of postoperative complications. In recent years, endovascular treatment has shown better efficacy. We report a 62-year-old female AVF patient with a stab injury history of more than 16 years. Computed tomography angiography (CTA) revealed a large arteriovenous fistula between the right internal iliac artery and the common iliac vein. After considering the patient's relevant conditions, an endovascular approach was satisfactorily performed with the implantation of an Amplatzer Vascular Plug II to interrupt the abnormal vascular communication and maintain arterial and venous patency. The final control images showed closure of the arteriovenous communication.

Enteric fistulization of a common iliac vein aneurysm.

Iliac vein aneurysm is rare. Its complications include rupture, thromboembolism, and enteric fistulization. If a patient with surgical history presents with gastrointestinal bleeding, the veno-enteric fistula should be part of the differential diagnoses. In presence of a veno-enteric fistula, surgical treatment consists of aneurysmectomy, venorraphy, and intestinal resection.

Three-Dimensional in Vivo Anatomical Study of Female Iliac Vein Variations.

OBJECTIVE: To investigate female iliac vein variations by using the computed tomography angiography (CTA) three-dimensional (3 D) reconstruction technique. METHODS: We retrospectively studied 1623 patients undergoing abdominal and pelvic CTA scanning for gynecological diseases from December 2009 to December 2018. Accurate digital 3 D models of the iliac vein were constructed using Mimics 19.0 software and used to study the morphology and variations. Variations in the common iliac vein (CIV), external iliac vein (EIV) and internal iliac vein (IIV) were classified as type I, abnormal number of veins; type II, abnormal communicating branches; or type III, other variations. RESULTS: The overall variation rates of the iliac vein and CIV were 51.57% (837/1623) and 20.33% (330/1623), respectively. The main type of CIV variation was type II. The main type I CIV variation was the absence of the CIV (98.15%), which mostly occurred on the right side (64.81%, 35/54). Type II CIV variation was the most common, with abnormal communicating branches between the left CIV and right IIV (81.78%, 211/258). The overall variation rates of the EIV and IIV were 36.66% (595/1623) and 49.60% (805/1623), respectively, mainly on the right side. The main type of variation was type I. Among them, the division of the IIV into two branches plus convergence with the ipsilateral EIV was the most common (22.98%, 373/1623). CONCLUSION: In this study, approximately half of the patients had iliac vein variations. The preoperative identification of iliac vein variation may reduce vascular injury in pelvic surgery.

Deep vein thrombosis of the common iliac vein caused by neurogenic heterotopic ossification in the anterior lower lumbar spine of a patient with complete paraplegia due to radiation-induced myelopathy.

Context: Deep vein thrombosis (DVT), a frequent complication of spinal cord injury, is occasionally caused by neurogenic heterotopic ossification (NHO). In most cases of NHO, the hip joint is affected. Herein, we present a case of paraplegia following radiation-induced myelopathy that presented with left leg swelling due to DVT in the common iliac vein (CIV) caused by venous compression by NHO on the anterior lower lumbar spine.Findings: A 28-year-old man with complete paraplegia due to radiation-induced myelopathy presented with left lower extremity swelling 6 years after the onset of paraplegia. DVT in the left CIV was observed on computed tomography venography. The left CIV was significantly compressed between the NHO at the anterior longitudinal ligament of the lumbar spine and the right common iliac artery, suggestive of May-Thurner syndrome. Slightly distal to that compressed area, the left CIV was significantly compressed by the large NHO at the anterior longitudinal ligament of the lumbar spine.Conclusions: We believe that such compression of the left CIV would have contributed to the development of DVT. This case shows that DVT might be caused by NHO at the anterior aspect of the lumbar vertebral body, and this may help clinicians identify the main cause of DVT in the leg.

Absence of right common iliac vein causing suprapubic and scrotal varices in a young athletic man.

We have described the case of a 26-year-old man who had presented to his primary care physician with persistent, painful varices across his lower abdomen and bilateral tender scrotal varicoceles, which intensified with exercise. Thorough investigations revealed a congenitally atretic right common iliac vein with right-to-left collateralization of the femoral and internal iliac veins. This shunting resulted in the development of suprapubic and pelvic and gonadal varicosities, which provided a critical venous outflow pathway for his right lower extremity. Heightened vigilance is, hence, paramount if our patient requires future abdominal and urologic procedures. Moreover, the present case has highlighted the importance of considering deep system venous anomalies when determining the differential diagnosis for venous diseases.

Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review.

PURPOSE: To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach. METHODS: PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance. RESULTS: Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases. CONCLUSIONS: Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.

An Unexpected Cause of Heart Failure in a Young Woman With Treated Lymphoma.

Arteriovenous fistula is a rare complication of lumbar surgery that may cause high-output cardiac failure. We describe the case of a patient with treated lymphoma and recent spinal surgery who presented with heart failure. Logical deduction from clinical and imaging findings helped us arrive at this unusual diagnosis. (Level of Difficulty: Intermediate.).

Nuances of oblique lumbar interbody fusion at L5-S1: Three case reports.

BACKGROUND: Oblique lumbar interbody fusion is a mini-open retroperitoneal approach that uses a wide corridor between the left psoas muscle and the aorta above L5. This approach avoids the limitations of lateral lumbar interbody fusion, is considered less invasive than anterior lumbar interbody fusion, and is similarly effective for indirect decompression and improving lordosis while maintaining a low complication profile. Including L5-S1, when required, adds to these advantages, as this allows single-position surgery. However, variations in vascular anatomy can affect the ease of access to the L5-S1 disc. The nuances of three different oblique anterolateral techniques to access L5-S1 for interbody fusion, namely, left-sided intra-bifurcation, left-sided pre-psoas, and right-sided pre-psoas approaches, are illustrated using three representative case studies. CASE SUMMARY: Cases of three patients who underwent multilevel oblique lumbar interbody fusion including L5-S1, using one of the three different techniques, are described. All patients presented with symptomatic degenerative lumbar pathology and failed conservative management prior to surgery. The anatomical considerations that affected the decisions to utilize each approach are discussed. The pros and cons of each approach are also discussed. A parasagittal facet line objectively assesses the relationship between the left common iliac vein and the L5-S1 disc and assists in choosing the approach to L5-S1. CONCLUSION: Oblique retroperitoneal access to L5-S1 in the lateral decubitus position is possible through three different approaches. The choice of approach to L5-S1 may be individualized based on a patient's vascular anatomy using preoperative imaging. While most surgeons will rely on their experience and comfort level in choosing the approach, this article elucidates the nuances of each technique.

Treatment of common iliac vein aneurysms: case report and literature review.

In this study we report on a patient with a left common iliac vein aneurysm; a condition rarely seen in vascular surgery. A 49-year-old man with no history of trauma or surgery underwent computed tomography (CT) for the evaluation of lumbago. A subsequent 64-slice CT angiogram revealed a left common iliac vein aneurysm. Surgery was performed due to the possibility of rupture. The aneurysm was successfully treated with clipping and sutures and a pre-discharge CT showed the aneurysm had shrunk. We combine our experience treating this patient with a review of the characteristics of other reported cases and methods used to treat iliac vein aneurysms. A definitive diagnosis is recommended in patients in whom an iliac vein aneurysm is suspected, with a CT angiogram being a dependable diagnostic method. There is still no unified standard for the treatment of aneurysms. Conservative treatment can be chosen for some small aneurysms in early stage, but close follow-up is needed. Surgical treatment is still recommended for some large aneurysms. Because we know that if an aneurysm ruptures, it can be life-threatening. If appropriate artificial blood vessels or coated stents are available, aneurysms resection combined with artificial blood vessel reconstruction or directly coated stents are good choices for aneurysms isolation. For some very large aneurysms, I personally think that lateral wall resection and suture of our aneurysms is also a method. Early follow-up results also proved that the method was effective. Surgery should be performed as early as possible. Our method of surgery may be used as a selective surgical method if the aneurysm is large or saccular in morphology.

Posterior extrapelvic tributaries to the internal iliac veins: Morphometrics, types, and variants.

BACKGROUND: In the distribution of the veins, it corresponds in the path and by its affluent to their arterial counterpart. For the pelvic surgeon faced with pelvic surgical pathology, the knowledge of the distribution of the venous vessels is especially important in view of novel surgical techniques and current approaches. The majority of the reports are on common iliac vein (CIV) or the inferior vena cava. To the best of our knowledge, there are no papers describing posterior extrapelvic affluents that drain into the internal iliac vein (IIV). OBJECTIVE: The aim of this work was to describe the pattern of the constitution of the IIV in 17 dissection specimens taken at our institution. MATERIALS AND METHODS: We dissected and registered the anatomic variations of the posterior extrapelvic tributaries to the IIVs. RESULTS: Moreover, we describe the presence of a vein here that is, as far as we know, the first report of a vein that is formed from the posterior extrapelvic veins that drain exactly onto the anterior surface of the CIV. We also describe herein the variants that we have found. CONCLUSIONS: The ignorance of the anatomic variations in the posterior extra-pelvic tributaries to the IIVs (internal iliac veins) can lead to fatal consequences in the patients undergoing pelvic surgery.

ANTECEDENTES: En la descripción de los trayectos venosos, estos corresponden casi exactamente a la distribución de su contraparte arterial, como es el caso de la vena iliaca interna. Para el cirujano que se enfrenta a la patología pélvica, el conocimiento de la distribución de los vasos venosos es de particular importancia. Los reportes que describen los grandes vasos venosos pélvicos se enfocan en las venas iliacas comunes o la vena cava inferior. En nuestro conocimiento, no existen ­reportes que describan los afluentes venosos posteriores que drenan a la vena iliaca interna ni las distancias que separan los vasos entre sí. OBJETIVO: Describir el patrón de constitución de la vena iliaca interna en 17 especímenes cadavéricos disecados en nuestra institución. MATERIAL Y MÉTODOS: Se identificaron los trayectos vasculares de los afluentes venosos posteriores extrapélvicos de las venas iliacas primitivas. RESULTADOS: En específico, describimos la presencia de una variante venosa que, hasta donde hemos revisado, es el primer reporte, pues esta vena posterior extrapélvica drena exactamente en la superficie anterior de la vena iliaca común. También describimos otras variantes encontradas. CONCLUSIONES: Conocer las variantes de los afluentes venosos posteriores extrapélvicos es de vital importancia para el cirujano que realiza cirugía pélvica.

Vertebroplasty-associated cement leak leading to iatrogenic venous compression and thrombosis.

A 91-year-old woman presented with left lower extremity swelling and pain diagnosed as phlegmasia cerulea dolens. Doppler ultrasound and venography revealed extensive left lower extremity deep venous thrombosis. Review of prior images revealed cement leakage causing compression of the left common iliac vein. She underwent successful mechanical thrombectomy using the ClotTriever device (Inari Medical, Irvine, Calif) and subsequent stent placement. Phlegmasia cerulea dolens resolved on the following day, and the stent remained patent at the 1-month follow-up appointment. Cement leakage from L5 vertebroplasty can cause extrinsic compression on the left common iliac vein, resulting in iatrogenic venous compression syndrome and the development of deep venous thrombosis in the affected lower extremity.

May-Thurner Syndrome in Operative Ankle Fracture Dislocations: A Case Report.

May-Thurner syndrome (MTS) is a rare condition in which patients develop iliofemoral deep venous thrombosis owing to an anatomic variant in which the right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine. Data regarding lower extremity trauma in patients with previously diagnosed MTS are rare. We discuss the operative approach for ankle trauma occurring 3 weeks after endovascular surgery for the treatment of MTS.

Stroke due to Paradoxical Embolization Related to Fibroid Uterus Enlargement Compressing the Right Common Iliac Vein.

Stroke in young women is commonly cryptogenic or associated with an underlying hypercoagulable state (e.g., hormonal contraception). Paradoxical embolization has been postulated as a potential risk factor for stroke in young adults. Many sources of venous thrombosis leading to paradoxical embolization have been described. There have been few reported cases of uterine enlargement leading to iliac vein compression and paradoxical embolization. We present the case of a young adult woman who had a left middle cerebral artery infarction related to patent foramen ovale and right common iliac vein compression from an enlarged fibroid uterus.

A median sacral artery anterior to the iliocaval junction: a case report-anatomical considerations and clinical relevance for spine surgery.

BACKGROUND AND IMPORTANCE: The median sacral artery (MSA) is a relatively small vessel that always arises from the posterior, terminal part of the infrarenal aorta. In most cases, the MSA runs behind the iliocaval junction. Here, we describe a very rare case of an MSA running in front of this junction. CASE REPORT: During a human cadaveric dissection of the retroperitoneal area, we unexpectedly observed that the MSA passed in front of the left common iliac vein. CONCLUSION: The anatomy of the MSA has been extensively described and variations are quite rare. On the basis of this specific case, knowledge of the anatomic interactions between the MSA and other lumbar retroperitoneal vessels may help to avoid potential complications during surgery.

Spontaneous rupture of the iliac vein.

Spontaneous iliac vein rupture is a rare diagnosis with less than 40 cases documented worldwide. There are certain similarities between many of the previously reported cases described in the literature and there are various proposed theories as to why patients develop a spontaneous rupture. A delay in diagnosis is not uncommon and the mainstay of treatment is laparotomy. Here, we report a case of a 51-year-old female with lower extremity swelling for 2days who subsequently developed hemorrhagic shock and had to be taken emergently to surgery, where a rupture of the common and external iliac veins was identified. After multiple blood products, vasopressors, and continuous renal replacement therapy the patient expired on day 3 of hospitalization.

Reparación de vena iliaca primitiva con segmento de ligamento falciforme / Repair of the common iliac vein with a segment of falciform ligament

Reportar cómo, en el manejo de un paciente con lesión de vena iliaca primitiva, brindó buenos resultados el realizar autoplastia con ligamento falciforme. Presentamos el caso de un varón de 26 años sin antecedentes personales de importancia. Ingresó al servicio de urgencias del Hospital San Vicente de Paúl, Medellín, Colombia, con múltiples heridas por arma de fuego, hemodinámicamente estable. En laparotomía demostró perforaciones en intestino delgado y meso, desgarro en unión ileocecal y vena iliaca primitiva en un 50 de su circunferencia. Se realiza anastomosis término-lateral en unión ileocecal y reparación de vena iliaca con autoplastia del ligamento falciforme. El paciente evolucionó satisfactoriamente, no presentó complicaciones inmediatas post-quirúrgicas como tromboembolismos, estenosis u obstrucción en el sitio de sutura. Las lesiones vasculares abdominales presentan una alta mortalidad y morbilidad. El conocimiento anatómico del retroperitóneo, las vías de abordaje de los vasos, así como la exploración clínica adecuada, ayudará a disminuir las complicaciones y la mortalidad de estos pacientes. La reparación de heridas de grandes vasos venosos abdominales con parche de peritóneo es una buena alternativa para este tipo de traumas vasculares.

Objective: To report on how, handling a patinet with an injury in the common iliac vein, autoplasty with falciform ligament provided good results. This is the case of a male, 26 years old with no significant medical history. He was admitted in the ER of the San Vicente de Paul Hospital in Medellín, Colombia with multiple firearm wounds, in a stable condition regarding his hemodynamics. In laparotomy showed perforations in the small intestine and the mesocolon and tears in ileocecal joint and common iliac vein in 50 of its circumference. End-to-side anastomosis in ileosecal joint and repair of iliac vein with autoplasty from falciform ligament were made. Patient evolution was satisfactory, there were no post-operative complications such as thromboembolism, stenosis, or obstruction in the suture level. Abdominal vascular injuries have a high mortality and morbidity rate. Anatomic knowledge of retroperitoneum, ways of approach of vessels as well as na appropriate clinical exploration will be helpful in reducing complications and mortality in these patients. Repair of wounds of big abdominal venous vessels with peritoneum patch is a good choice for this type of vascular trauma.

Multi-detector CT Imaging of Double Left Renal Veins.

Advance awareness of the renal vascular anatomy, including variants of the left renal vein, is important for abdominal and renal surgery. The migratory nature ofrenal embryology and significant transformation of precursors of the inferior vena cava and renal veins can make the final configuration of these structures complex. Two uncommon instances of dual left renal vein with orthotopic left common iliac vein and ectopic caval drainage are presented with multi-detector CT imaging.