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305
Case Report
Pericaliceal
Varices
Jonathan
Andrew
J. Trambert,1
A patient with intrarenal
Due to the Nutcracker
M. Rabin,1’2
vanices simulating
Kenneth
a transitional
L. Weiss,3
cell
carcinoma is described. The vanices presumably were related to venous hypertension caused by extrinsic compression of the left renal vein between the superior mesentenic artery and
the aorta
(the
nutcracker
phenomenon).
This
rare
entity
should be considered in the differential diagnosis of caliceal filling defects seen on IV urognaphy. MR imaging cleanly showed the vascular abnormalities in this patient, and therefore may be useful in the noninvasive evaluation of patients
suspected
Case
of having the nutcracker
phenomenon.
Report
A 44-year-old woman had a several-year history of intermittent left flank and abdominal pain without hematunia. An IV urogram showed a lobulated filling defect in the lower pole calix of the left kidney (Fig. 1 A).
No
pelvic
or
ureteral
notching
was
identified.
A
retrograde
pyelogram showed no abnormality, but specimens obtained by transureteral brushing of the renal pelvis initially were interpreted as suspicious for transitional cell carcinoma. On review, this impression was revised to dysplasia without definite evidence oftumor. Cytologic examinations of subsequent ureteral washings and voided urine samples showed no abnormal cells. CT with and without IV contrast material showed no discrete evidence of intrarenal mass, only questionable effacement of fat around the lower pole calix. In order to exclude neovascularity or vessel encasement caused by a small urothelial tumor, an arteriogram was performed, which showed neithen. However, the left renal vein was not visualized, and opacification of peniureteric and other retroperitoneal collateral veins was evident. There also was a suggestion of vanices within the lower pole of the Received
July 10, 1 989; accepted
after revision
September
Phenomenon
and Arnold
B. Tein4
Retrospective
evaluation
kidney.
ofthe
CT study raised
the possibility
of compression of the left renal vein between the superior mesenteric artery and the aorta. Small netroperitoneal densities that presumably corresponded to collateral veins also were noted on the CT scans. A left renal venogram showed a racemose plexus of varicose veins overlying
the
lower
pole
calix,
compression
of the
left
renal
vein,
and
filling of retroperitoneal collateral veins (Fig. 1 B). A pressure gradient of 4 mm Hg was measured between the left renal vein and the inferior
vena cava. The gradient between the right renal vein and the inferior vena cava was less than 0.5 mm Hg. Having been reassured that the lower pole caliceal filling defects were the result of extrinsic compression by venous varices rather than tumor, the patient agreed to return for MA, which clearly showed the retropentoneal and intrarenal varices, as well as the compression of the left renal vein between the superior mesenteric artery and the aorta (Figs. 1C and I D). The study was performed at 1 .5 T; superior and inferior saturation pulses were used, with respiratory compensation. The Ti -weighted spin-echo images (600/20) were the most informative.
Discussion
The nutcracker phenomenon has been recognized only recently in the literature [1 2]. The usual clinical presentation is hematunia with on without associated left flank pain, and sometimes left flank or back pain alone. IV unography is frequently normal, but the most common abnormal finding is ,
ureteral or pelvic notching due to extrinsic pressure from netnoperitoneal collateral veins. When hematuria is present, unilateral
bleeding
from the left uretenal
6, 1989.
orifice
is usually
noted
1 Department of Diagnostic Radiology, J. D. Weiler Hospital of the Albert Einstein College of Medicine, 1825 Eastchester Ad., Bronx, NY 10461 . Address reprint requests to J. J. Trambert. 2 Present address: Department of Diagnostic Radiology, The Mount Sinai Medical Center, One Gustav L. Levy Place, New York, NY 10029. 3 Department of Diagnostic Radiology, Magnetic Resonance Imaging Division, The Albert Einstein College of Medicine, 1201 Morris Park Ave., Bronx, NY 10461. 4
Department
AJR 154:305-306,
of Urology,
The Albert
Einstein
College
of Medicine,
February 1990 0361-803X/90/1542-0305
1 180 Morris
Park Ave.,
Bronx,
C American Roentgen Ray Society
NY 10461.
TRAMBERT
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306
A
ET AL.
AJR:154, February 1990
B
Fig. 1.-A, Tomographic image from an IV urogram shows lobular filling defects in lower pole calix and infundibulum (arrow). B, Selective left renal venogram shows intrarenal vances (arrow) corresponding to location of lower pole calix. Note penureteric veins and other retroperitoneal venous collaterals (arrowheads). C, Parasagittal MR image, 600/20, through medial aspect of left kidney shows tortuous retroperitoneal varices. LRV = left renal vein. D and E, Axial MR Images, 600/20, at level of renal vein (D) and lower pole calices (E) show compression of left renal vein (Xs) as it crosses between superior mesentenc artery (SMA) and aorta (Ao), retroperitoneal varices (black arrowheads), and intrarenal varices corresponding to those seen on venogram (white arrowheads). SMV = superior mesenteric vein; IVC = inferior vena cava.
on cystoscopy. The possibility of the nutcracker phenomenon in this patient was raised by the nonvisualization of the left renal vein and filling of netnopenitoneal collateral veins on selective arteniognaphy. The suspicion was reinforced by findings seen on the CT scans in retrospect and confirmed by selective renal venognaphy with pressure measurements. Beinart et al. [3] found a gradient of less than 1 mm Hg between the left renal vein and inferior vena cava in 49 of 50 normal subjects. The gradient of 4 mm Hg in our patient
therefore
can be considered
significantly
different
from non-
mal.
The differential
diagnosis
of irregular
caliceal filling defects
on IV unognaphy includes urothelial neoplasms; nadiolucent calculi; blood clots; and inflammatory conditions such as pyelitis cystica, tuberculosis, and leukoplakia. In this patient, the irregularity was caused by extrinsic pressure from pencaliceal vanices that probably provided collateral drainage between the upper part of the kidney and the lower-pressure penipelvic and peniunetenic veins. Rare cases have been re-
[4-6] in which intranenal vanices caused caliceal impressions simulating a neoplasm. In these cases, the intnarenal vanices apparently were considered to be idiopathic. To the best of our knowledge, this is the first case reported in which penicaliceal vanices have been attributed to the nutcracker phenomenon. ported
REFERENCES 1 . De Schepper A. Nutcracker fenomeen van de vena renalis en veneuze pathologie van de linker nier. J Beige Radio! 1972;55:507-51 1
2. Stewart BH, Aeiman G. Left renal venous hypertension “nutcracker syndrome. Urology 1982;20:365-369 3. Beinart C, Sniderman KW, Shozo T, et al. Left renal vein to inferior vena cava pressure relationships in humans. J Uro! 1982;127: 1070-1 071 4. Rosenthal JT, Costello P, Roth RA. varicosities of renal venous system. Urology 1980;15:427-429 5. Braedel HU, Haage H, Moeller JF, et al. Differential diagnostic importance of retrograde phlebography in cases of unusual ectasia and renal pelvic deformity. Radiology 1976;1 1 9: 65-68
6. Goswami AP. Anatomical variations of the renal veins with varicosity presenting as pseudotumor of the kidney. J Urol 1976;1 16:648-649
305
Case Report
Pericaliceal
Varices
Jonathan
Andrew
J. Trambert,1
A patient with intrarenal
Due to the Nutcracker
M. Rabin,1’2
vanices simulating
Kenneth
a transitional
L. Weiss,3
cell
carcinoma is described. The vanices presumably were related to venous hypertension caused by extrinsic compression of the left renal vein between the superior mesentenic artery and
the aorta
(the
nutcracker
phenomenon).
This
rare
entity
should be considered in the differential diagnosis of caliceal filling defects seen on IV urognaphy. MR imaging cleanly showed the vascular abnormalities in this patient, and therefore may be useful in the noninvasive evaluation of patients
suspected
Case
of having the nutcracker
phenomenon.
Report
A 44-year-old woman had a several-year history of intermittent left flank and abdominal pain without hematunia. An IV urogram showed a lobulated filling defect in the lower pole calix of the left kidney (Fig. 1 A).
No
pelvic
or
ureteral
notching
was
identified.
A
retrograde
pyelogram showed no abnormality, but specimens obtained by transureteral brushing of the renal pelvis initially were interpreted as suspicious for transitional cell carcinoma. On review, this impression was revised to dysplasia without definite evidence oftumor. Cytologic examinations of subsequent ureteral washings and voided urine samples showed no abnormal cells. CT with and without IV contrast material showed no discrete evidence of intrarenal mass, only questionable effacement of fat around the lower pole calix. In order to exclude neovascularity or vessel encasement caused by a small urothelial tumor, an arteriogram was performed, which showed neithen. However, the left renal vein was not visualized, and opacification of peniureteric and other retroperitoneal collateral veins was evident. There also was a suggestion of vanices within the lower pole of the Received
July 10, 1 989; accepted
after revision
September
Phenomenon
and Arnold
B. Tein4
Retrospective
evaluation
kidney.
ofthe
CT study raised
the possibility
of compression of the left renal vein between the superior mesenteric artery and the aorta. Small netroperitoneal densities that presumably corresponded to collateral veins also were noted on the CT scans. A left renal venogram showed a racemose plexus of varicose veins overlying
the
lower
pole
calix,
compression
of the
left
renal
vein,
and
filling of retroperitoneal collateral veins (Fig. 1 B). A pressure gradient of 4 mm Hg was measured between the left renal vein and the inferior
vena cava. The gradient between the right renal vein and the inferior vena cava was less than 0.5 mm Hg. Having been reassured that the lower pole caliceal filling defects were the result of extrinsic compression by venous varices rather than tumor, the patient agreed to return for MA, which clearly showed the retropentoneal and intrarenal varices, as well as the compression of the left renal vein between the superior mesenteric artery and the aorta (Figs. 1C and I D). The study was performed at 1 .5 T; superior and inferior saturation pulses were used, with respiratory compensation. The Ti -weighted spin-echo images (600/20) were the most informative.
Discussion
The nutcracker phenomenon has been recognized only recently in the literature [1 2]. The usual clinical presentation is hematunia with on without associated left flank pain, and sometimes left flank or back pain alone. IV unography is frequently normal, but the most common abnormal finding is ,
ureteral or pelvic notching due to extrinsic pressure from netnoperitoneal collateral veins. When hematuria is present, unilateral
bleeding
from the left uretenal
6, 1989.
orifice
is usually
noted
1 Department of Diagnostic Radiology, J. D. Weiler Hospital of the Albert Einstein College of Medicine, 1825 Eastchester Ad., Bronx, NY 10461 . Address reprint requests to J. J. Trambert. 2 Present address: Department of Diagnostic Radiology, The Mount Sinai Medical Center, One Gustav L. Levy Place, New York, NY 10029. 3 Department of Diagnostic Radiology, Magnetic Resonance Imaging Division, The Albert Einstein College of Medicine, 1201 Morris Park Ave., Bronx, NY 10461. 4
Department
AJR 154:305-306,
of Urology,
The Albert
Einstein
College
of Medicine,
February 1990 0361-803X/90/1542-0305
1 180 Morris
Park Ave.,
Bronx,
C American Roentgen Ray Society
NY 10461.
TRAMBERT
Downloaded from www.ajronline.org by 95.159.71.33 on 10/23/15 from IP address 95.159.71.33. Copyright ARRS. For personal use only; all rights reserved
306
A
ET AL.
AJR:154, February 1990
B
Fig. 1.-A, Tomographic image from an IV urogram shows lobular filling defects in lower pole calix and infundibulum (arrow). B, Selective left renal venogram shows intrarenal vances (arrow) corresponding to location of lower pole calix. Note penureteric veins and other retroperitoneal venous collaterals (arrowheads). C, Parasagittal MR image, 600/20, through medial aspect of left kidney shows tortuous retroperitoneal varices. LRV = left renal vein. D and E, Axial MR Images, 600/20, at level of renal vein (D) and lower pole calices (E) show compression of left renal vein (Xs) as it crosses between superior mesentenc artery (SMA) and aorta (Ao), retroperitoneal varices (black arrowheads), and intrarenal varices corresponding to those seen on venogram (white arrowheads). SMV = superior mesenteric vein; IVC = inferior vena cava.
on cystoscopy. The possibility of the nutcracker phenomenon in this patient was raised by the nonvisualization of the left renal vein and filling of netnopenitoneal collateral veins on selective arteniognaphy. The suspicion was reinforced by findings seen on the CT scans in retrospect and confirmed by selective renal venognaphy with pressure measurements. Beinart et al. [3] found a gradient of less than 1 mm Hg between the left renal vein and inferior vena cava in 49 of 50 normal subjects. The gradient of 4 mm Hg in our patient
therefore
can be considered
significantly
different
from non-
mal.
The differential
diagnosis
of irregular
caliceal filling defects
on IV unognaphy includes urothelial neoplasms; nadiolucent calculi; blood clots; and inflammatory conditions such as pyelitis cystica, tuberculosis, and leukoplakia. In this patient, the irregularity was caused by extrinsic pressure from pencaliceal vanices that probably provided collateral drainage between the upper part of the kidney and the lower-pressure penipelvic and peniunetenic veins. Rare cases have been re-
[4-6] in which intranenal vanices caused caliceal impressions simulating a neoplasm. In these cases, the intnarenal vanices apparently were considered to be idiopathic. To the best of our knowledge, this is the first case reported in which penicaliceal vanices have been attributed to the nutcracker phenomenon. ported
REFERENCES 1 . De Schepper A. Nutcracker fenomeen van de vena renalis en veneuze pathologie van de linker nier. J Beige Radio! 1972;55:507-51 1
2. Stewart BH, Aeiman G. Left renal venous hypertension “nutcracker syndrome. Urology 1982;20:365-369 3. Beinart C, Sniderman KW, Shozo T, et al. Left renal vein to inferior vena cava pressure relationships in humans. J Uro! 1982;127: 1070-1 071 4. Rosenthal JT, Costello P, Roth RA. varicosities of renal venous system. Urology 1980;15:427-429 5. Braedel HU, Haage H, Moeller JF, et al. Differential diagnostic importance of retrograde phlebography in cases of unusual ectasia and renal pelvic deformity. Radiology 1976;1 1 9: 65-68
6. Goswami AP. Anatomical variations of the renal veins with varicosity presenting as pseudotumor of the kidney. J Urol 1976;1 16:648-649
