Imaging of Type I Retroaortic Left Renal Vein & Nutcracker Syndrome

Retroaortic left renal veins are an often overlooked, but no so rare anatomic anomaly that might cause a few aspecific symptoms and signs, especially flank or inguinal pain, microscopic or even gross hematuria; in the vast majority of cases it is, thought, totally asymptomatic. The nutcracker syndrome that might arise in the case of RLRV is mainly due to the re- duced space between aorta and the vertebral body and the consequent compression on the venal rein; this might in turn cause upstream hypertension, hematuria, varicocele, pain. The compression of RLRV leads to hematuria because of renal venous hypertension, consequent left renal congestion. This upstream venous congestion might result, in some cases, in left-sided varicocele in men and pelvic congestion syndrome in women. From a radiologic point of view, the presence of RLRV and the precise reporting its subtypes is mandatory.

Surgical removal of a foreshortened right innominate vein Wallstent causing venous outflow obstruction

Objectives: Stenting of central venous stenosis to preserve upper extremity hemodialysis access is well-described, though upper extremity complications secondary to these stents are less frequently discussed. Methods: We present the case of a 43-year-old male with a right brachiocephalic fistula who developed symptoms of venous hypertension following placement of a Wallstent for central venous stenosis. Workup demonstrated venous outflow obstruction secondary to stent foreshortening into the right subclavian vein. Results: The Wallstent was removed in a piecemeal fashion using an open surgical technique and a HeRO graft was placed for dedicated fistula outflow with complete relief of the patient’s symptoms. Conclusion: In situations where a stent has migrated and endovascular removal is not possible, individual Wallstent fibers can be removed through a limited venotomy.

Mimicking Amyotrophic Lateral Sclerosis: A Case of a Spinal Dural Arteriovenous Fistula

A number of conditions can mimic amyotrophic lateral sclerosis (ALS), which are in general excluded by neurophysiological and neuroimaging investigation. We present a novel mimicking disorder. A 58-year-old male, without relevant past medical history, presented with a 7-year history of progressive paraparesis. On examination, he had bilateral thigh atrophy, fasciculations, and asymmetric paraparesis (severe on the left side). Upper motor neuron signs were present in the lower limbs, with normal sensory examination. Needle EMG disclosed mild chronic neurogenic changes in the lower limbs. Brain and spinal cord neuroimaging was normal, namely, in the dorso-lumbar segment. Lumbar puncture showed mild hyperproteinorachia. Diagnosis of slowly progressive (possible) ALS was established. One year later, he required a bilateral support to walk, and neurological examination revealed weak tendon reflexes, abnormal pinprick, and proprioceptive sensation in the legs. Repeated lumbar MRI showed an extensive spinal cord oedema from T7 to the conus with multiple perimedullary vessel flow voids suggestive of a vascular malformation. Conventional angiography revealed a spinal dural arteriovenous fistula in L2–L3 with the left L4 lumbar branch as the afferent artery. Dural arteriovenous fistula is the most common vascular malformation of the spinal cord, despite being rare. It leads to arterialization of spinal veins, causing venous hypertension, spinal cord oedema, and ischaemia. The clinical picture includes a stepwise, sometimes fluctuant, myeloradiculopathy. In this case, EMG changes did not meet Awaji criteria. This case reinforces the need to critically follow atypical cases to ascertain clinical progression in patients with suspected ALS.

Dural arteriovenous fistula presenting as reversible dementia

DAVF is an abnormal connection between arteries and veins, where supply is mainly through branches arising from the external carotid artery. A 30 years old male had multiple episodes of seizures and progressive behavioral and cognitive decline, inattention and disorientation to time, place and person, along with ptosis and ophthalmoplegia in the right eye. DSA provided a definitive diagnosis of hypervascular Dural AV fistula at the right transverse sigmoid junction with significant cortical venous hypertension. Through femoral access, both underwent transarterial embolization through the Middle Meningeal branch of the right external carotid artery using onyx, resulting in complete occlusion of fistula and resolution of venous hypertension. Post embolisation, cognitive function assessment revealed increased attention span and improved orientation with time, place and person. Thus, DAVF can be one of the rare but reversible causes of dementia. Early diagnosis and treatment may help to dramatically improve patients’ clinical condition and minimize long-term disability.

Stasis Ulcers – The Unifying Concept

Chronic stasis dermatitis, usually confined to the lower legs, is a complication of longstanding interstitial edema and inflammation, due either to venous hypertension or disorders having in common excessive lymph overload. Heart failure, renal failure, liver cirrhosis, secondary and primary diseases of lymph vessels may complicate with stasis dermatitis. The same mechanisms causing stasis dermatitis can also generate skin ulcers superimposed on stasis dermatitis. In the appropriate context such skin ulcers are called "venous ulcers" or, in different situations, “stasis ulcers”. The distinction between venous and other stasis ulcers is usually possible at the bedside. Also, some general measures of therapy are similar for venous and other stasis ulcers: such are elastic compression, topical skin care and ulcer care. In having in common the pathophysiological mechanisms, in bearing clinical resemblance, and responding to similar therapies, a unifying concept may be opportune to comprise the spectrum of stasis dermatitis, venous and other stasis ulcers. The present work is an appeal to this aim.

Venous discirculation and cognitive impairment

This article considers the aging impact on the functional and structural integrity of venous cerebral circulation from the standpoint of potential mechanisms involved in the pathogenesis of neurodegeneration and cognitive decline. It was reported about venous collagenosis in the brain with apparent leukoaraiosis that demonstrates the participation of pathological re-structure of the venous wall in impairment of white matter both in natural aging and in Alzheimer’s disease. It is likely that due to an age-related decrease in elasticity, the internal jugular vein loses its compensatory ability to increase transmural pressure and therefore results in venous hypertension in the cerebral venous system. Diosminum increases the tone of venous and lymphatic vessels, decreases venous and lymphatic stasis, strengthens the capillary walls and reduces their permeability, has anti-inflammatory, antiedemic, and analgesic effects, improves microcirculation and tissue trophicity, prevents thrombosis. Hesperidin strengthens the walls of small vessels that reduces their permeability and therefore decreases the edemas.

Exercise Training as an Adjunctive Therapy for Chronic Venous Insufficiency Patients: Evidence from Research to Practice

Chronic venous insufficiency, which is defined as a condition relevant to persistent ambulatory venous hypertension, is a common cause of venous leg ulcers. Compression therapy is commonly used to relieve ambulatory venous hypertension and heal leg ulcers. Exercise is considered as adjunctive therapy, targeting calf muscle pump function, to additionally favor the compression treatment for facilitating the healing process. Different exercise training regimens for promoting wound healing and its relevant outcomes are reviewed and discussed in this study.

Increase Renal Tubular Pressure to Treat Congestive Renal Failure

Background: Congestive renal failure commonly result from cardiorenal syndrome related renal venous hypertension(RVH)，which is more linked to the renal venous pressure than mean arterial pressure and systematic vascular resistance. But its mechanism and treatment strategy is still being explored.Methods: We did an investigator-initiated,open-label study to explore a novel treatment strategy and mechanism of renal venous hypertension related acute kidney injury(AKI).A patient with acute kidney injury(AKI) due to cardiorenal syndrome related renal venous hypertension was enrolled.The estimated pressure of renal vein (ePrv) was measured by ultrasound. Prior to the trial,residual urinary was detected by bedside ultrasound so as to rule out lower urinary tract obstruction.A three-lumen catheter was inserted into bladder for elevating tubular pressure and monitor intrabladder pressure.In the first phase,pressure of intrabladder was maintained equal to ePrv+8mmHg for 3 hours.In the second phase, intrabladder pressure was adjusted and maintained equal to ePrv for 21 hours. The urine volume is equal to the fluid expelled from bladder minus infused 0.9% Sodium chloride.Result: 130 milliliter urine output was secreted in the first phase and 370 milliliter in the second phase.A total of 500 milliliter urine output was secreted during the trial period (24 hours). 5 days after treatment, the patient's creatinine level dropped significantly.Conclusions: We first proposed a new therapeutic exploration, acute kidney injury secondary to cardiorenal syndrome related renal venous hypertension can be treated by increasing tubular pressure.Tubular compressed or even collapsed under renal venous hypertension may be an important mechanism of acute kidney injury due to RVH.

Supra-systemic pulmonary hypertension after complicated percutaneous mitral balloon valvuloplasty: a case report and review of literature

Background The World Symposium of Pulmonary Hypertension in 2018, updated the definition of pulmonary hypertension (PH) as mean pulmonary artery pressures (PAP) > 20 mmHg. Pulmonary venous hypertension secondary to left-heart disease, constitutes the most common cause of PH, and the determination of a co-existent pre-capillary (primary) PH becomes paramount, particularly at the moment of evaluating and managing patients with heart failure. Pulmonary artery pressures above the systemic pressures define supra-systemic PH and generally leads to frank right ventricular failure and high mortality. Case presentation We present the perioperative management of a patient with rheumatic mitral valve disease, initially found to have severe PH due to pulmonary venous hypertension, who underwent percutaneous mitral balloon valvuloplasty complicated with mitral chordae rupture, severe mitral regurgitation and supra-systemic PH. Multiple medical therapies and an intra-aortic balloon pump were used as means of non-surgical management of this complication. Conclusions This case report illustrates the perioperative implications of combined pre- and post-capillary PH and supra-systemic PH, as this has not been widely discussed in previous literature. A thorough literature review of the clinical characteristics of PH, methods to determine co-existent pre- and post-capillary PH components, as well as concomitant right ventricular failure is presented. Severe PH has known detrimental effects on the hemodynamic status of patients, which can ultimately lead to a decrease in effective cardiac output and poor tissue perfusion.