Cennet Şahin *, Özlem Kitiki Kaçira , Davut Tüney

Folia Medica 2014; 56(1): 38-42
Copyright © 2014 Medical University, Plovdiv
doi: 10.2478/folmed-2014-0006
THE RETROAORTIC LEFT RENAL VEIN ABNORMALITIES IN CROSS-SECTIONAL
IMAGING
Cennet Şahin1*, Özlem Kitiki Kaçira2, Davut Tüney3
1 Radiology Clinic, Tekirdağ State Hospital, Tekirdağ, 2Radiology Clinic, Sakarya Hendek State Hospital,
Sakarya, 3Radiology Department, Medical Faculty, Marmara University, Istanbul, Turkey
ОБРАЗНАЯ ДИАГНОСТИКА АНОМАЛИИ „РЕТРОАОРТАЛЬНАЯ
ЛЕВАЯ ПОЧЕЧНАЯ ВЕНА”
Сеинет Сахин1*, Йозлем К. Качира2, Давут Тюней3
больницан Tekirdağ, Радиологическая клиника Tekirdağ, 2Sakarya Hendek
Государственная больница, Радиологическая клиника, Sakarya, 3Радиологическое отделение,
Медицинский факультет, Marmara университет, Истамбул, Турция
1Государственная
ABSTRACT
OBJECTIVE: The normal anatomic course of the left renal vein (LRV) from the kidney to inferior vena cava (IVC)
is usually preaortic. It is called retroaortic left renal vein (RLRV) when located between the aorta and vertebra;
the circumaortic left renal vein (CLRV) has both a preaortic and retroaortic course. In this study, we aimed to find
the incidence and characteristics of LRV abnormalities in routine abdominal CT and MR examinations conducted
in our clinic. MATERIALS AND METHODS: A total of 2189 abdominal CT and MR examinations, performed between
April 2007 and June 2009, were reviewed retrospectively for retroaortic and circumaortic LRV abnormalities.
RESULTS: LRV abnormalities were detected in 50 (2.3%) examinations. Forty-four of these (2%) were RLRV and
6 (0.3%) were circumaortic LRV abnormalities. CONCLUSIONS: Preoperative knowledge of LRV abnormalities
facilitates the safe performance of surgery and reveals the clinical symptoms. It is easy to see LRV and its drainage way on routine CT and MR imagings.
Keywords: left renal vein, retroaortic, abnormality, radiologic imaging
Folia Medica 2014; 56(1): 38-42
Copyright © 2014 Medical University, Plovdiv
РЕЗЮМЕ
ЦЕЛЬ: Левая почечная вена в норме идет от почки к нижней полой вене, проходя перед аортой. Часть ее между
аортой и позвонком называется ретроаортальной левой почечной веной; кольцевидная левая почечная
вена может проходить перед, но и за аортой. Настоящее исследование ставит себе целью определить
частоту и характеристики аномалий левой почечной вены, обнаруженных во время проведенных в нашей
клинике рутинных компьютерной томографии исследований и ядерно-магнитного резонанса. МАТЕРИАЛ
И МЕТОДЫ: Ретроспективно изучено 2189 абдоминальных исследований, проведенных с помощью
компьютерной томографии и ядерно-магнитного резонанса. Исследования проведены в период: апрель
2007 – июнь 2009 г. с целью выявить аномалии ретроаортальной и кольцевидной левых почечных вен.
РЕЗУЛЬТАТЫ: Аномалии левой почечной вены обнаружены в 50 (2.3%) случаев, 44 (2%) из них оказались
аномалиями ретроаортальной почечной вены, а 6 (0.3%) - аномалиями кольцевидной левой почечной
вены. ЗАКЛЮЧЕНИЕ: Дооперативное знание аномалий левой почечной вены способствует безопасному
проведению оперативного вмешательства и раскрытию клинических симптомов. Левая почечная вена
и ее ход легко визуализируются рутинными исследваниями с помощью компьютерного томографа и
ядерно-магнитного резонанса.
Ключевые слова: левая почечная вена, ретроаортальный, аномалия, образная диагностика
Folia Medica 2014; 56(1): 38-42
© 2014 Все права защищены. Медицинский университет, Пловдив
Articles history:
38
Received: 10 January 2014;
Received in revised form: 3 February 2014;
Accepted: 23 February 2014
*Correspondence and reprint request to: C. Şahin, Tekirdağ State Hospital, Radiology Clinic, Tekirdağ,
E-mail: cennetsahin@yahoo.com; Mob.: +90 505 748 57 41
1 Kisim, Muratli Caddesi, 59000 Tekirdağ, Turkey
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The Retroaortic Left Renal Vein Abnormalities in Cross-sectional Imaging
The normal anatomic course of the left renal vein
(LRV) from kidney to inferior vena cava (IVC) is
usually preaortic. The retroaortic left renal vein
(RLRV) is defined as the left renal vein located
between the aorta and the vertebra on the drainage
way to IVC. When there is a renal collar of LRV that
is located both anterior and posterior to the aorta,
it is called a circumaortic left renal vein (CLRV).
RLRV abnormalities, although usually overlooked,
are not rare.1 The retroaortic and circumaortic left
renal veins are potentially hazardous anomalies of
the left renal vein. If these are left unrecognized
during abdominal surgery, they can cause severe
hemorrhage and severe renal damage, nephrectomy,
and even death.2 It is important to diagnose RLRV
prior to retroperitoneal surgery.
During the development of the IVC, anastomotic
communications develop between the subcardinal
and supracardinal channels, which process is called
subsupracardinal anastomosis.3 These connections
form a collar of veins that encircles the aorta. The
ventral portion of the circumaortic collar persists
as the normal left renal vein. If the dorsal portion
does not disintegrate it forms a retroaortic left
renal vein (Fig. 1).4
Left renal vein anomalies are generally categorized into four types.5,6 In type I, the ventral
preaortic limb of the left renal vein is obliterated,
but the dorsal retroaortic limb persists and drains
into the IVC in the orthotopic position.1,5-7 Type
II results from obliteration of the ventral preaortic limb of the left renal vein, and the remaining
dorsal limb turns into the RLRV which lies at the
level of L4 to L5 and joins with the gonadal and
ascending lumbar veins before draining into the
IVC. Type III is the circumaortic left renal vein
or venous collar. In type IV, the ventral preaortic
limb of the left renal vein is obliterated, and the
remaining dorsal limb becomes the RLRV which
courses obliquely and caudally behind the aorta to
drain into the left common iliac vein.1,5-7
Preoperative knowledge of the presence of major
venous anomalies facilitates the safe performance of
aortic surgery. A few cases showing clinical symp-
a
a
b
b
Figure 1. Retroaortic (a) and circumaortic (b) left renal
vein abnormalities, schematic illustration.
Figure 2. Contrast enhanced axial CT (compression
of the RLRV between the atherosclerotic aorta and the
vertebral body).
INTRODUCTION
Folia Medica 2014; 56(1): 38-42
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39
C. Şahin et al
toms with this abnormality have been reported in
literature. Compression of the retroaortic left renal
vein between the vertebral body and aorta (Figs 2a,
2b) can cause a number of urological symptoms
such as haematuria, proteinuria, varicocele, pelvic
congestion syndrome, and ureteropelvic junction
obstruction (UPJO).8-10
To find the frequency of RLRV abnormalities,
we retrospectively evaluated the existence of RLRV
on routine abdominal CT and MR examinations
performed in our clinic.
a
MATERIALS AND METHODS
A total of 2275 abdominal CT and MR imagings
were reviewed retrospectively by three radiologists
in our department on a 3-D workstation searching
for left renal vein abnormalities. Eighty-six of these
were excluded from the study: 84 were of poor
diagnostic quality and two - for left nephrectomy.
b
Figure 4. Circumaortic LRV on a non-contrast enhanced
T1-weighted out-of-phase sequence MR examination.
The left renal vein crossed the aorta anteriorly (a) and
posteriorly (b) (type III).
Figure 3. Type I of RLRV abnormality on a contrast
enhanced CT examination.
A total of 2189 abdominal CT and MR examinations were included in the study. We used slice
thickness of 5 mm for the CT scans (GE; HiSpeed
Dual SYS, Germany), and 3-mm-thick slices for the
MR examinations (1.5 T; Magnetom Symphony:
Siemens, Germany) in routine abdominal imaging
protocols. We looked for retroaortic and circumaortic left renal vein anomalies: a left renal vein that
crossed the aorta anteriorly and drained into the
IVC was designated as normal preaortic left renal
vein (LRV), and a left renal vein located between
the aorta and the vertebra draining into IVC was
defined as retroaortic LRV (type I and II). The LRV
that crossed the aorta anteriorly and also posteriorly,
making a ring around the aorta and draining into
the IVC at different levels was defined herein as
circumaortic LRV (Type III).
40
RESULTS
Retroaortic (type I and II) and circumaortic LRV (type
III) abnormalities were detected as left renal vein
abnormalities in our study. Of 2189 examinations in
this study, 1316 were CT scans and 873 were MR
examinations. We detected LRV abnormality in 50
(2.3%) examinations. Forty four of them (2%) were
RLRV (type I and II) (Fig. 3) and 6 (0.3%) were
circumaortic LRV abnormality (type III) (Fig. 4).
DISCUSSION
The left renal vein is longer than the right renal
vein (75 mm versus 25 mm). It has a complicated
embryological development. The left kidney is
preferred in renal transplantation because of the
greater length of the left renal vein. That is why it is
important in such a surgery to know what precisely
the course of the left renal vein is.4 When the aorta
is surgically exposed, not finding the anterior left
renal vein in the usual anatomic position raises the
Folia Medica 2014; 56(1): 38-42
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The Retroaortic Left Renal Vein Abnormalities in Cross-sectional Imaging
probability of a retroaortic left renal vein. Overlooking this anomaly during aortic and retroperitoneal
surgery can result in bleeding, nephrectomy, or
even death.5 Usually, no major venous abnormalities are found in patients undergoing retroperitoneal
and aortic surgery but preoperative assessment and
intra-operative awareness are important factors that
may prevent unexpected venous injuries.4,7
The incidence of the left renal vein abnormalities
has been reported in a wide range of variations in
many studies. Yi SQ et al. described in their study
three anatomic variations: circumaortic, retroaortic
left renal vein and retropelvic tributary of the renal
vein in Japanese cadavers. They found that the
median incidence of CLRV was 7% in examined
cadavers and 1.8% in examined clinical subjects.
The detection of circumaortic LRV abnormality
in CT/MDCT or angiography was relatively difficult compared with that by cadaver dissection.
The median incidence of RLRV was 1.7% and
2.2% in examined cadavers and clinical subjects,
respectively.11
Dilli A et al. found the incidence of left renal
vein abnormalities, RLRV and circumaortic left
renal vein abnormalities: 71/2644 (2.68%), 44/2644
(1.66%) and 27/2644 (1.02%), respectively.12 Satyapal et al. and Yeşildağ et al. found the incidence
of RLRV to be 0.5% (in a total of 1008 cases)
and 2.3% (in 984 cases) and of circumaortic left
renal vein abnormalities to be 0.3% and 0.9%,
respectively.13,14 Reed et al. included 433 cases
in their study: the incidence of the retroaortic
left renal vein abnormality was 1.8%, and that of
circumaortic abnormality - 4.4%.15 Trigaux et al.
included 1014 cases in their study: the frequency
rate of retroaortic left renal vein and circumaortic
left renal vein was 3.7% and 6.3%, respectively.16
The contingent size in this study was greater
than that in other studies, yet the incidence we
found of RLRV and CLRV anomalies (2% and
0.3%, respectively) was similar to the results reported in the relevant literature.
Also, it is important to differentiate RLRV
abnormality from retroperitoneal tumors, or retroperitoneal lymph nodes.5 A retroaortic left renal
vein can form a fistula to the abdominal aortic
aneurysm, but this occurs very rarely. Very few
cases (< 25 cases) with this pathology have been
reported in the relevant literature.17
Diagnosis of RLRV is important during renin
sampling from renal vein. The LRV can be catheterized by the femoral vein to measure renin
which is used in differential diagnosis of a renal
artery stenosis.18
The nutcracker syndrome is caused by the left
renal vein compression, most commonly between
the aorta and the superior mesenteric artery: this is
known as anterior nutcracker syndrome. Sometimes
a retroaortic position of the LRV also promotes a
compression, this time between the aorta and the
vertebral column - this is referred to as posterior
nutcracker syndrome. Posterior nutcracker syndrome
can result in left renal venous hypertension. Compression of the RLRV between the aorta and the
vertebra is known to be the cause of increased
pressure in the renal vein and of urological problems such as haematuria, anemia, proteinuria, hypertension, varicocele, pelvic congestion syndrome
and ureteropelvic junction obstruction (UPJO).9,10,19
As a limitation of our study we consider the
fact that we ignored the clinical symptoms of
the patients: the study was designed to find the
frequency rate of RLRV abnormality in routine
cross-sectional imagings performed for different
clinical conditions in different departments.
Radiological modalities such as ultrasonography
(US), color Doppler US, angiography, MRI and CT
can all be used to diagnose left renal vein abnormalities.14,20 Doppler US may show the turbulent
pattern of venous blood flow of the posterior LRV
branch behind the aorta. US and color Doppler
imaging modalities may be preferred because they
are relatively less expensive and noninvasive, but
they may be insufficient in overweight patients.
Nowadays, multi-detector CT (MDCT) has replaced
conventional angiography and venography in most
clinical conditions. MDCT is a reliable, easily applicable, and noninvasive tool for demonstration of
abdominal organs and vascular structures.1,9 Cadaver
studies can also be used to find the incidence of left
renal vein abnormalities.11 In our study, we used
routine abdominal CT and MR images. The age of
the patients was not taken into account because, as
it has been reported in many studies, there is no
statistically significant gender difference between
the ages and left renal vein variations.12,14 Also,
we included the non-contrast enhanced imaging in
the study. Although it was easier to see the renal
veins on contrast enhanced CT and MR images,
we could see all renal vein abnormalities on noncontrast enhanced images easily.
CONCLUSIONS
Preoperative knowledge of the presence of LRV
abnormalities facilitates the safe performance of
aortic surgery and reveals clinical symptoms such
Folia Medica 2014; 56(1): 38-42
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41
C. Şahin et al
as haematuria, proteinuria, venous renal hypertension, varicocele, pelvic congestion syndrome and
UPJO. In conclusion, the detection of RLRV, which
is an important vascular variation, is crucial to
avoid the complication of catastrophic hemorrhage
before aortic, renal, and retroperitoneal surgery. It
could be demonstrated by all radiological modalities mentioned above. It is easy to see LRV and its
drainage way on routine CT and MR examinations.
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