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.

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.

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.

Five veins at the deep inguinal ring: can they reduce the chances of indirect inguinal hernia and increase the chances of varicocele? / Cinco venas en el anillo inguinal profundo. ¿pueden reducir las probabilidades de una hernia inguinal indirecta y aumentar las posibilidades de varicocele?

Complete duplication of testicular veins is a rare phenomenon. However, a few cases of duplication of gonadal veins have been reported. Here, I report a case of unusual formation and termination of the right testicular vein in an adult male cadaver. Five veins arose from the pampinniform plexus and entered the abdomen through the deep inguinal ring. The most medial among the five was large (3 mm in diameter) and it continued as a testicular vein and opened into the right edge of the inferior vena cava, 1 cm above the union of the common iliac veins. The other four veins were about 1 mm in diameter and they united to form two veins in front of the lower part of the right psoas and iliacus muscles (about 2 cm above the deep inguinal ring) and the two veins united to form upper testicular vein, 4 cm above the deep inguinal ring. This testicular vein was 3 mm in diameter and it opened into the inferior vena cava, 4 cm above the union of common iliac veins. Having five veins at deep inguinal ring might increase the chances of varicocele and decrease the chances of indirect inguinal hernia.

La duplicación completa de las venas testiculares es un fenómeno raro. Sin embargo, se han reportado algunos casos de duplicación de venas gonadales. En el presente trabajo se informa un caso de formación y terminación inusual de la vena testicular derecha en un cadáver de un hombre adulto. Cinco venas surgieron del plexo pampiniforme y penetraron en el abdomen a través del anillo inguinal profundo. El más medial entre los cinco fue de gran tamaño (3 mm de diámetro) y continuó como una vena testicular y se abrió hacia el margen derecho de la vena cava inferior, 1 cm por encima de la unión de las venas ilíacas comunes. Las cuatro venas restantes eran de 1 mm de diámetro aproximadamente, y se unieron para formar dos venas frente a la parte inferior de los músculos psoas e ilíaco derechos (aproximadamente 2 cm por encima del anillo inguinal profundo). Se unieron dos venas para formar la vena testicular superior, la cual medía 3 mm de diámetro y se abría hacia la vena cava inferior, 4 cm por encima de la unión de las venas ilíacas comunes. Cinco venas en el anillo inguinal profundo podrían aumentar las posibilidades de varicocele y disminuir las posibilidades de una hernia inguinal indirecta.

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.

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.

Uncommon drainage of the left testicular vein: a case report

An uncommon drainage of the left testicular vein (LTV) was observed during a routine cadaver dissection, where a lateral division of the LTV was found to drain into an abdominal (anterior) tributary of the second lumbar vein. Adequate knowledge of the LTV anatomical variation presents clinical importance in renal transplantation, renal and testicular vein surgeries, testicular color Doppler imaging, testicular venography, and others retroperitoneal therapeutic and diagnostic procedures. Therefore, surgeons, especially those who work in the retroperitoneal space, must be aware of left testicular vein abnormalities, which may be encountered during surgery

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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.

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.

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.

Bilateral Duplication of Gonadal Veins: a Case Report / Duplicación Bilateral de las Venas Gonadales: Reporte de Caso

The duplication of gonadal vessels is mainly found on the left side, with less numbers of bilateral cases. The objective of this work is describing a case of bilateral duplication of gonadal veins, where two veins were draining to inferior vena cava, being that the closest vein of kidney medial margin had a thickness of 2.68mm and was distant 64.41 mm of the organ. The second vessel had a thickness of 1.43mm and was distant 73.76mm. Two veins follow to left renal vein, being that the first vessel had a thickness of 2.7mm and was distant 21.8mm of the kidney medial margin; the other had a thickness of 1.64mm and was distant 35.13mm of the organ. The presence of variations on the local of drainage of gonadal vessels has clinical importance for comprehension of origin of varicocele cases, as well as the recurrence of them after surgical procedures.

La duplicación de las venas gonadales es más común en el lado izquierdo, con pocos casos bilaterales. El propósito de este reporte fue describir el caso de una duplicación bilateral de las venas gonadales, dos de las cuales desembocaban en la vena cava inferior. El vaso próximo del margen medial del riñon tenía un diámetro de 2,68mm y una longitud de 64,41 mm. La segunda vena tenía un diámetro de 1,43 mm y una longitud de 73,76 mm. Los dos vasos desembocaban en la vena renal izquierda. La primera vena tenía un diámetro de 2,7 mm y estaba a 21,8 mm del margen medial del riñon. La otra tenía un diámetro de 1,64 mm y se se localizaba a 35,13 mm del margen medial del riñon. La presencia de variaciones donde se produce el drenaje de los vasos gonadales tiene importancia clínica para la comprensión del origen del varicocele y la recurrencia del mismo, después de procedimientos quirúrgicos.

The inferior mesenteric vein to the left gonadal vein shunt for gastroesophageal varices and extrahepatic portal vein thrombosis after living donor liver transplantation: a case report.

This 59-year-old woman underwent living donor liver transplantation using a left lobe graft as an aid for autoimmune hepatitis in 2003. Splenectomy was also performed because of blood type incompatibility. Follow-up endoscopic and computed tomography examinations showed gastroesophageal varices with extra hepatic portal vein thrombosis in 2007 that increased (esophageal varices [EV]: locus superior [Ls], moderately enlarged, beady varices [F2], Blue varices [Cb], presence of small in number and localized red color sign [RC1] and telangiectasia [TE+], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderately enlarged, beady varices [F2], white varices [Cw], absence of red color sign [RC-]). Portal venous flow to the gastroesophageal varices was also confirmed from a large right gastric vein. The splenic vein was thrombosed. Blood flow to the liver graft was totally supplied from the hepatic artery. The graft was functioning well. Because these gastroesophageal varices had a high risk of variceal bleeding, we decided to proceed with a portal reconstruction of a surgical portosystemic shunt in 2008. Severe adhesions were observed around the portal vein. It was impossible to perform portal reconstruction. There were relatively fewes adhesious in the left lower side of the abdominal cavity. We decided to create an inferior mesenteric vein to left gonadal vein shunt. The portal vein pressure decreased from 31.0 to 21.5 cm H2O thereafter. The postoperative course was smooth without any complication. This patient was discharged on the postoperative day 15. Follow-up endoscopic study showed the improvement in the gastroesophageal varices (EV: Ls, F2, Cb, RC(-), GV: Lg-c, F2, Cw, RC-) at 3 months after the operation. We also comfirmed the patency of the shunt by serial computed tomography examinations.

Variation in inferior vena cava with persistence of left posterior cardinal vein. A case report.

Left sided single inferior vena cava is a rare developmental anomaly affecting clinical diagnosis, treatment and raising academic quest. Incidentally, a similar case was found in the museum of the Department of Anatomy of Nepal Medical College. Along with the anomaly, there were other associated vascular anomalies. The article discusses the possible causative situations.

Hematopoietic stem cell activity in the aorta-gonad-mesonephros region enhances after mid-day 11 of mouse development.

The E11.5 aorta-gonad-mesonephros (AGM) region is a site of hematopoietic stem cell (HSC) development prior to colonisation of the embryonic liver. The generation of HSCs in the embryo starting from E11 is very rapid. Here, we have assessed hematopoietic development in the AGM region during E11 at precise somitic ages. Although the numbers of committed hematopoietic precursors fluctuate throughout the day, the repopulation activity in the AGM region noticeably increases from mid (44 s.p.) to end (48 s.p.) day 11 of gestation. While prior to mid day 11 two thirds of AGM regions contain no definitive HSCs, shortly prior to liver colonisation, all older day 11 embryos contain definitive HSC. Nevertheless, all E11 AGM regions even at early somitic stages have the capacity to expand numbers of definitive HSCs ex vivo. Quantitative anatomical analysis confirmed preferential localization of intra-aortic clusters (IACs) to the ventral domain of the dorsal aorta during entire day 11 of development. No clear correlation was established between IAC numbers and the presence of definitive HSCs.

Mpl receptor defect leads to earlier appearance of hematopoietic cells/hematopoietic stem cells in the Aorta-Gonad-Mesonephros region, with increased apoptosis.

In a previous study, we underlined the functional role of the TPO receptor, Mpl, in the establishment of definitive mouse hematopoiesis, by demonstrating that the lack of Mpl led to a delayed production of definitive hematopoietic cells in the aorta-gonad-mesonephros (AGM) region, and resulted in the production of hematopoietic stem cells (HSCs) with an impaired activity at E11.5. In order to more accurately estimate the role of Mpl during generation of HSCs in the aorta, we performed an analysis of these AGMs at the time of the first HSC emergence (E10.5). Our results indicated that while Mpl-/- AGMs were found to contain more hematopoietic cells (HC) than C57Bl6 AGMs at E10.5, a defect in the expansion process of the HC/HSCs was detected in explant cultures of these AGMs, likely due to an increased apoptosis of these cells. To determine the molecular mechanisms by which invalidation of Mpl receptor affects the temporal distribution and expansion of HC/HSCs in the AGM, a study of the transcription level of of Mpl target genes was conducted. Expression of Runx1, a master transcription factor for the formation of hematopoietic progenitor (HP) cells and HSCs from the vasculature, as well as expression of Meis1 and HoxB4, known to play a role in self-renewal and expansion of HSCs, were found to be down regulated in E10.5 Mpl-/- AGMs. Our data indicate that Mpl is an active player during the first steps of definitive hematopoiesis establishment through direct regulation of the expression of transcription factors or genes important for the self-renewal, proliferation and apoptosis of HSCs.