Minireviews Open Access
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hypertens. Feb 23, 2016; 6(1): 60-65
Published online Feb 23, 2016. doi: 10.5494/wjh.v6.i1.60
Renal venous hypertension
Makhmud Muslimovich Аliev, Rustam Zafarjanovich Yuldashev, Gulnora Srajitdinovna Аdilova, Аvazjon Аbdunomonovich Dekhqonboev, Department of Pediatric Surgery, Republican Specialized Scientific Practical Medical Centre of Pediatrics, Tashkent 100179, Uzbekistan
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: The authors declare no conflicts of interest regarding this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Rustam Zafarjanovich Yuldashev, MD, Department of Pediatric Surgery, Republican Specialized Scientific Practical Medical Centre of Pediatrics, District Olmazar, str. Chimbay № 2, Tashkent 100179, Uzbekistan. paediatric.surgery@yahoo.com
Telephone: +998-90-9575082 Fax: +998-371-2293873
Received: August 3, 2015
Peer-review started: August 3, 2015
First decision: September 29, 2015
Revised: October 30, 2015
Accepted: December 29, 2015
Article in press: December 31, 2015
Published online: February 23, 2016

Abstract

Renal venous hypertension usually seen in young, otherwise healthy individuals and can lead to significant overall morbidity. Aside from clinical findings and physical examination, diagnosis can be made with ultrasound, computed tomography, or magnetic resonance conventional venography. Symptoms and haemodynamic significance of the compression determine the ideal treatment method. This review of the literature discusses normal and pathological developmental aspects of renocaval venous segment and related circulatory disorders, summarizes congenital and acquired changes in left renal vein and their impact on development of renal venous hypertension. Also will be discussed surgical tactics of portosystemic shunting and their potential effects on renal hemodynamics.

Key Words: Renal venous hypertension, Nutcracker syndrome, Kidney, Portal hypertension, Splenorenal shunts

Core tip: Renal venous hypertension characterized by the presence of left renal vein dilatation, varicocele and hematuria. Being a rare cause of hematuria its etiology is diverse but of precise characteristics. Diagnosis is not easy and treatment requires ruling out its precise etiology and considering the intensity of the compression phenomenon because of interventionist attitudes have important implications and are not risk free.



INTRODUCTION

Renal venous hypertension (RVH) - venous insufficiency caused by inadequate drainage of blood through the renal vein[1]. There are two main reasons in the development of the RVH: Structural abnormalities of renocaval segment; acquired changes of the left renal vein.

Structural anomalies of renocaval segment and their clinical importance in the development of the RVH

Development of renocaval segment (inferior vena cava, renal, gonadal, adrenal and lumbar veins) - is a complex process in which there is consecutive regression and shifting of three venous structures, such as posterior cardinal, supracardinal and subcardinal veins[2-5]. Inferior vena cava (IVC) and its branches formed from different embryological structures; their segments formed from all three systems mentioned above. The formation of these veins can be impaired at any stage of development[2,3].

Among the developmental abnormalities of the IVC clinical significance in development of the RVH matters - left-sided IVC, with this type of abnormality abdominal aorta compresses IVC at the site of their contact, thus will cause congestion in left renal vein (LRV) and recurrent left sided hematuria[6,7].

Typical abnormality of the right renal vein is anomaly of their quantities, which is due to the fact, that the right renal vein embryogenesis does not undergo significant transformations. Essentially, the significance of these abnormalities in development of RVH negligible[2,3,8].

Clinically significant abnormalities often observed in the LRV, which related to its development. For example, retention of both limbs of the left portion of circumaortic venous ring leads to the formation of the circumaortic LRV, which occurs in 1%-17% of cases according to different authors[2,3,5,8-13]. In this type of anomaly there are pre-aortic and retroaortic limbs. In this situation, the pre-aortic limb usually receives the adrenal, gonadal, and phrenic veins; the retro-aortic limb receives the lumbar and the hemiazygous veins. The retroaortic limb passes obliquely and downward to reach the inferior vena cava at a lower level[8-13]. The clinical significance of this anomaly is that the impeded outflow from the retroaortic limb leads to congestive venous hypertension and increased blood flow in pre-aortic limb[8,9,11-13]. Knowledge of this anomaly is important for the angiographer performing renal and/or adrenal venography. In addition, it is of surgical importance when a left renal transplant and/or splenorenal shunt are considered. As for splenorenal shunt operations, opinions are contradictory. For example, some authors[14] recommend to perform splenorenal shunt, without the risk of RVH, while according to other researchers[15,16] the connection of splenic vein to retroaortic limb leads not only to inadequate drainage portal system with recurrent bleedings, but also the risk of development of RVH.

Another type of abnormality is retroaortic LRV (single or multiple). The retroaortic type of LRV occurs in approximately 2-6.6/cent[17-22]. When the ventral limb atrophies a retroaortic renal vein occurs. In this transformation, there are anatomical prerequisites for disorders of venous hemodynamics - the emergence of congestive venous hypertension, clinically manifested by proteinuria or hematuria and the development of the secondary varicocele[1,5,11,19,23]. Performing splenorenal shunt in this type of LRV is not advisable, since drainage of a large amount of blood from the portal system leads to RVH one hand and recurrent bleeding from gastroesophageal varices on the others[15].

Acquired changes of the LRV

Human body has anatomical preconditions, which may cause significant haemodynamic alterations that may lead to clinical symptoms and significant associated morbidity. The clinical manifestations of this predisposition is nutcracker syndrome[24]. In view of the insufficiency of symptoms during the first decade of life, specified condition practically have not described in pediatric patients, in most cases classified as associated finding. The nutcracker syndrome refers to compression of the LRV between the superior mesenteric artery and abdominal aorta. Obstruction of LRV occasionally causes clinically significant venous hypertension resulting in unexplained left flank, gross haematuria, with formation of periureteric and gonadal varices and varicocele in relatively young and previously healthy patients[25-29]. Other possible symptoms include pelvic congestion, chronic pediatric fatigue syndrome and orthostatic proteinuria[30-38].

Other rare acquired causes of RVH includes renal vein thrombosis, organic renal vein stenosis and arteriovenous fistula[39-41].

Well known that LRV mostly used in performing various types portosystemic shunts for portal hypertension. Issues related to presence of RVH in patients who underwent portosystemic shunting recent years draw increasing attention of researchers[15,16,42,43]. The data about the state of the left kidney after portosystemic shunting operation are very controversial. For example, some authors argue that performing end-to-end splenorenal shunt provides the venous drainage from the portal system to IVC without renal dysfunction[44-48]. But according to other data[14-16,42,43], impeded outflow of the left renal vein leads to not only venous hypertensive nephropathy, but can be cause of insufficiency of created anastomosis and therefore unsatisfactory results of surgical treatment. Furthermore, impeded outflow of LRV results in venous hypertension with the formation of intra- and extrarenal collaterals and/or the development of gonadal vein reflux resulting retrograde flow and has been implicated in the development of varicocele or ovaricocele[49]. According to experimentally induced extrahepatic portal hypertension[50-54] shunting end renal vein to side splenic vein (renosplenic) after ligation of the LRV lateral to the adrenolumbar tributary, leads to haemorrhagic necrosis of the left kidney. Thus, the ureteric, lumbar and pericapsular collaterals cannot adequately drain the left kidney. Ligation of the LRV on the medial side of the adrenolumbar tributary maintained a patent left renal vein in all cases[50,52,53].

Practical experience has shown that performing splenorenal anastomosis with ligation of the LRV proximal to the confluence of the adrenal vein - in one third of cases causes decreasing of renal function (according to the excretory urography), renal infarction, hematuria and proteinuria[52,53].

In addition, in the pathogenesis of the RVH renal arterial blood flow is essential[55]. High pressure in the renal artery in systemic arterial hypertension increases tone of sympathetic-adrenal system, which causes vasoconstriction in the cortex and increases medullary blood flow. Autoregulation mechanisms lead to increasing pressure in the renal venous system, which are the anatomical and functional characteristics of the vascular bed of the kidney. The diversity of intrarenal arteriovenous shunts, venous network ensures acceptance of a large amount of blood in the face of increasing its arterial delivery - this is the pathogenesis of RVH in systemic arterial hypertension[55]. On the other hand, congenital or acquired arteriovenous fistula leads to the restructuring of angioarchitectonics of kidneys and in this case pressure in renal veins increases due to shunting of blood through the abnormal arteriovenous communications. The blood from the arterial bed drains to venous rout bringing extraordinary pressure to the veins. Thus, developed the renal venous hypertension[55,56].

Diagnostics of RVH

In the evaluation of renal hemodynamics, intravascular pressure indicators are most important. Retrograde left renal venography and measurement of the pressure gradient between the left renal vein and the IVC are procedures of choice for diagnosing RVH. Normally, this gradient is determined in a horizontal position from a healthy child was equal to 0.13 ± 0.02 kPa, with individual variations 0.33 ± 0.05 kPa[57,58]. A number of studies indicated that the anomalies of the LRV (usually circumaortic and retroaortic LRV), the pressure gradient increases significantly (up to 0.86 kPa). However, these techniques are invasive and use of such invasive examinations is generally deemed imprudent in children, and non-invasive imaging studies are preferable. Recently progressive development of non-invasive imaging techniques led to that Doppler ultrasound (US) has become the method of choice in the diagnosis of RVH. During the last decade, increased the number of publications describing different ultrasound descriptions of renocaval segment anomalies[1,27-29,34-36,57-60]. Also in details described intrarenal arteriovenous shunts[61-63]. Recent publications dedicated in most cases for nutcracker syndrome[27-29,34-36,57-60]. Kim et al[58] suggested that a ratio of the AP diameter, and peak velocity (PV) between the hilar and aortomesenteric portions of the LRV of greater than 5.0 could be used as the cut-off level for the diagnosis of nutcracker syndrome with a sensitivity of 80% and a specificity of 94%. However, it has not yet been confirmed whether these criteria can be applied to children with clinically suspected nutcracker syndrome. In addition, detection of collateral veins around the left renal vein at color Doppler US is a reliable criterion for the diagnosis of nutcracker phenomenon[27]. However, the LRV flow patterns and collateral vein formations associated with nutcracker phenomenon depend on the degree and stage of the phenomenon[58]. In patients with early nutcracker phenomenon, LRV distention and high pressure gradients exist before collateral veins develop. Moreover, in patients with collateral veins, the presence of a distended left renal vein and hypertension of the left renal vein indicate that the nutcracker phenomenon is noncompensatory[58].

Regardless of the incidence angle, the resistances in the renal artery can be evaluated by measuring the resistive index and pulsatility index if the vessel is identified by colour Doppler. Increasing these rates in some cases may be indirect evidence of the venous outflow disturbances from LRV[15,16].

Recently, non-invasive methods such as computed tomography (CT) and magnetic resonance imaging (MRI) have been used in the diagnosis of nutcracker syndrome[10,12,41,64-66]. Performing of the study for our opinion, more appropriate to carry out not only for diagnostic purposes of RVH but also to assess the topographic anatomy course of renocaval segment and their relative position to the vessels of the v. porta and abdominal aorta in the planning of vascular surgery in the retroperitoneal space.

The clinical manifestations of RVH

The clinical presentation of RVH include the development of collateral blood flow and symptoms of renal function disorders[1,5,28,29,67]. The increased venous pressure within the renal circulation promotes the development of collaterals of the renal pelvis, and this plexus of abnormal hypertensive veins causes microhematuria or gross hematuria, orthostatic proteinuria[6,19,30-38]. Other possible symptoms include left flank pain, left-sided varicocele, pelvic congestion, chronic pediatric fatigue syndrome, and gastrointestinal symptoms[1,43,67].

Performing various types of splenorenal shunts using abnormally developed LRV due to portal hypertension can become a reason of unsatisfactory results with recurrent bleeding from gastroesophageal varices[14-16,42,43,68]. In addition, shunting the large amounts of blood from portal vein and its tributaries to abnormally developed LRV manifests as clinical signs of renal venous hypertension[14,16,69].

Different therapeutic methodologies have been used in treatment of RVH. In general, moderate manifestations may be controlled with conservative methods[70]. Nearly all surgical approaches aim to relieve the LRV outflow obstruction[70-85]. Surgical modalities including autotransplantation of the left kidney, LRV bypass with graft interposition and reanastomosis to the IVC anteriorly has been performed with satisfying results[73-75]. Renal autotransplantation may offer maximal efficiency in terms of normalizing renal venous circulation. In more severe cases with hematuria, significant stenosis of LRV, varicocele, left flank pain and pressure gradient more than 1.33 kPa preferable intervention on LRV. Lot of evidence of the efficacy of endovascular interventions - methods of stenting and balloon angioplasty[76-85]. Initially performed via a transperitoneal approach, an external stent can be wrapped around the renal vein to prevent its compression by the mesoaortic clamp. The procedure has now also been performed by laparoscopic surgery. External and internal stenting procedures by either minimally invasive or endovascular approaches are promising treatment options. However, the risk of erosion of adjacent structures and dislodgment of the stent has not been defined yet.

However, surgical treatment methods have certain disadvantages. Thus, venous vascular suture can be considered as a potential source of thrombosis[72,83]. Postoperative complications may even lead to nephrectomy[84]. Even traditionally performed safe operations intravascular stents placement - can have few complications[79-82].

CONCLUSION

There are reasonable basis for research on the status of renocaval segment for modern pediatric surgeons, urologists, specialists concerned in portal hypertension, liver kidney transplant surgeons. The presence of RVH should be considered on the basis of a thorough clinical examination in patients with hematuria, left flank pain, varicocele, and symptoms of pelvic venous congestion. Dilatation of LRV and its tributaries, anomalies, additional communications observed on ultrasonography, computed tomography CT, or MRI should alert the physician to consider the diagnosis. If the symptoms merit, in particular if cystoscopy demonstrates left ureteral hematuria, selective left renal venography with pullback determination of renocaval pressure gradient is the diagnostic test of choice and should be performed in all patients. At the same time, complexity of revealing the causes of RVH with above mentioned methods, it is feasible to study the role of arterial blood, not only because of their lack of data, but also well-known factors associated with abnormal blood supply, and it is widely performed operations of decompression of the portal system through the LRV. Despite numerous studies, reasonableness of performing various types of splenorenal shunts in portal hypertension with prerequisites for RVH remains debatable. Finally, it is not enough studied phenomenon of nutcracker syndrome after surgical and congenital splenorenal shunts.

Footnotes

P- Reviewer: Cheng TH, Tan XR S- Editor: Qiu S L- Editor: A E- Editor: Wu HL

References
1.  Mendizábal S, Román E, Serrano A, Berbel O, Simón J. Left renal vein hypertension syndrome. Nefrologia. 2005;25:141-146.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the inferior vena cava. Review of embryogenesis and presentation of a simplified classification. Br J Radiol. 1974;47:206-213.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the left renal vein: angiographic consideration. Br J Radiol. 1974;47:214-218.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Valentine RJ, Dougald C, Gillivray M, Charles Blankenship Gary G. Wew Variations in the anatomic relationship of the left renal vein to the left renal artery at the aorta. Clin Anat. 1990;3:249-255.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 3]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
5.  Turgut HB, Bircan MK, Hatipoğlu ES, Doğruyol S. Congenital anomalies of left renal vein and its clinical importance: a case report and review of literature. Clin Anat. 1996;9:133-135.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
6.  Lopatkin NA, Morozov AV, Lopatkina LN. Essential renal haemorrhages. Eur Urol. 1978;4:115-119.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Giordano JM, Trout HH. Anomalies of the inferior vena cava. J Vasc Surg. 1986;3:924-928.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 25]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
8.  Beckmann CF, Abrams HL. Renal venography: anatomy, technique, applications, analysis of 132 venograms, and a review of the literature. Cardiovasc Intervent Radiol. 1980;3:45-70.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 37]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
9.  Senecail B, Bobeuf J, Forlodou P, Nonent M. Two rare anomalies of the left renal vein. Surg Radiol Anat. 2003;25:465-467.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 14]  [Cited by in F6Publishing: 16]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
10.  Tatar I, Tore HG, Celik HH, Karcaaltincaba M. Retroaortic and circumaortic left renal veins with their CT findings and review of the literature. Anat. 2008;2:72-76.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 8]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
11.  Mathews R, Smith PA, Fishman EK, Marshall FF. Anomalies of the inferior vena cava and renal veins: embryologic and surgical considerations. Urology. 1999;53:873-880.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 112]  [Cited by in F6Publishing: 117]  [Article Influence: 4.7]  [Reference Citation Analysis (0)]
12.  Trigaux JP, Vandroogenbroek S, De Wispelaere JF, Lacrosse M, Jamart J. Congenital anomalies of the inferior vena cava and left renal vein: evaluation with spiral CT. J Vasc Interv Radiol. 1998;9:339-345.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 101]  [Cited by in F6Publishing: 107]  [Article Influence: 4.1]  [Reference Citation Analysis (0)]
13.  Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat. 1999;21:77-81.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 68]  [Cited by in F6Publishing: 73]  [Article Influence: 2.9]  [Reference Citation Analysis (0)]
14.  Ferzauli AN, Razumovskiy AY, Vodolazov YA. Renal venous hemodynamics after portosystemic shunting in children with extrahepatic portal hypertension. Annal Surg. 1997;1:12-16.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Aliev MM, Yuldashev RZ, Adilova GS, Yusupaileva GA. Renal blood flow before and after portosystemic shunt in children with portal hypertension. Pediatr Surg Int. 2014;30:295-299.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 2]  [Article Influence: 0.2]  [Reference Citation Analysis (0)]
16.  Aliev MM, Yuldashev RZ, Adilova GS. Portosystemic shunts and its influence on renal hemodynamics in patients with portal hypertension. Pediatr Sur. 2015;3:3-9.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Davis CJ, Lundberg GD. Retroaortic left renal vein, a relatively frequent anomaly. Am J Clin Pathol. 1968;50:700-703.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Thomas TV. Surgical implications of retroaortic left renal vein. Arch Surg. 1970;100:738-740.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 34]  [Cited by in F6Publishing: 36]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
19.  Gibo M, Onitsuka H. Retroaortic left renal vein with renal vein hypertension causing hematuria. Clin Imaging. 1998;22:422-424.  [PubMed]  [DOI]  [Cited in This Article: ]
20.  Karkos CD, Bruce IA, Thomson GJ, Lambert ME. Retroaortic left renal vein and its implications in abdominal aortic surgery. Ann Vasc Surg. 2001;15:703-708.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 39]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
21.  Minniti S, Visentini S, Procacci C. Congenital anomalies of the venae cavae: embryological origin, imaging features and report of three new variants. Eur Radiol. 2002;12:2040-2055.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 125]  [Cited by in F6Publishing: 133]  [Article Influence: 6.0]  [Reference Citation Analysis (0)]
22.  Lee SE, Park DS, Chung SY, Lee YT. Retroaortic renal vein. Korean J Urol. 2002;43:84-86.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Nam JK, Park SW, Lee SD, Chung MK. The clinical significance of a retroaortic left renal vein. Korean J Urol. 2010;51:276-280.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 34]  [Cited by in F6Publishing: 34]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
24.  Grant JCB Methods of Anatomy. Baltimore: Williams & Wilkins 1937; 158.  [PubMed]  [DOI]  [Cited in This Article: ]
25.  Sansilvestri MP, Rupin A, Badier-Commander C. Chronic venous insufficiency: dysregulation of collagen synthesis. Angiology. 2003;54:13-18.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 30]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
26.  Braedel HU, Steffens J, Ziegler M, Polsky MS, Platt ML. A possible ontogenic etiology for idiopathic left varicocele. J Urol. 1994;151:62-66.  [PubMed]  [DOI]  [Cited in This Article: ]
27.  Takebayashi S, Ueki T, Ikeda N, Fujikawa Aosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography AJR. 1999;172:39-43.  [PubMed]  [DOI]  [Cited in This Article: ]
28.  Takemura T, Iwasa H, Yamamoto S, Hino S, Fukushima K, Isokawa S, Okada M, Yoshioka K. Clinical and radiological features in four adolescents with nutcracker syndrome. Pediatr Nephrol. 2000;14:1002-1005.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 51]  [Cited by in F6Publishing: 52]  [Article Influence: 2.2]  [Reference Citation Analysis (0)]
29.  Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D. Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg. 2006;20:120-129.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 91]  [Cited by in F6Publishing: 92]  [Article Influence: 5.1]  [Reference Citation Analysis (0)]
30.  Lau X, Lo R, Chan FL, Wong KK. The posterior «nutcracker»: hematuria secondary to retroaortic left renal vein. Urology. 1986;28:437-439.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 50]  [Cited by in F6Publishing: 55]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
31.  Shaper KR, Jackson M, Williams G. The nutcracker syndrome: an uncommon cause of haematuria. Br J Urol. 1994;74:144-146.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 74]  [Cited by in F6Publishing: 68]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
32.  Challenger RJ, Scott Dougherty W, Flisak ME, Flanigan RG. Left renal vein hypertension as a cause of persistent gross hematuria. Urology. 1996;48:468-472.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 9]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
33.  Gibo M, Onitsuka H. Retroaortic left renal vein with renal vein hypertension causing hematuria. Clin Imaging. 1998;22:422-424.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 31]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
34.  Park SJ, Lim JW, Cho BS, Yoon TY, Oh JH. Nutcracker syndrome in children with orthostatic proteinuria: diagnosis on the basis of Doppler sonography. J Ultrasound Med. 2002;21:39-45; quiz 46.  [PubMed]  [DOI]  [Cited in This Article: ]
35.  Cheon JE, Kim WS, Kim IO, Kim SH, Yeon KM, Ha IS, Cheong HI, Choi Y. Nutcracker syndrome in children with gross haematuria: Doppler sonographic evaluation of the left renal vein. Pediatr Radiol. 2006;36:682-686.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 42]  [Cited by in F6Publishing: 43]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
36.  Ekim M, Bakkaloglu SA, Tümer N, Sanlidilek U, Salih M. Orthostatic proteinuria as a result of venous compression (nutcracker phenomenon)--a hypothesis testable with modern imaging techniques. Nephrol Dial Transplant. 1999;14:826-827.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 29]  [Cited by in F6Publishing: 29]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
37.  Cho BS, Choi YM, Kang HH, Park SJ, Lim JW, Yoon TY. Diagnosis of nut-cracker phenomenon using renal Doppler ultrasound in orthostatic proteinuria. Nephrol Dial Transplant. 2001;16:1620-1625.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 33]  [Cited by in F6Publishing: 36]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
38.  Faizan MK, Finn LS, Paladin AM, McDonald RA. A 14-year-old girl with recumbent proteinuria. Pediatr Nephrol. 2002;17:379-381.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 10]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
39.  Brill PW, Mitty HA, Strauss L. Renal Vein Thrombosis: A Cause of Intrarenal Calcification in the Newborn. Pediat Radiol. 1977;6:I72-175.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 8]  [Article Influence: 0.2]  [Reference Citation Analysis (0)]
40.  Calligaro KD, Dougherty MJ Renal artery aneurysms and arteriovenous fistulae.  In: Rutherford RB. Vascular surgery, 5th ed. Philadelphia: Saunders 2000; 1697-1706.  [PubMed]  [DOI]  [Cited in This Article: ]
41.  Gayer G, Zissin R, Rimon U, Guranda L, Apter S, Hertz M. Vascular lesions of the renal sinus. Emerg Radiol. 2003;10:135-141.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 6]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
42.  Polyaev YA, Sukhov MN, Garbuzov RV, Drozdov AV, Mylnikov AA Angiographic diagnosis of pathology associated with extrahepatic portal hypertension in children and its impact on surgical approach Detskaya bolnitsa. 2010;1:9-15.  [PubMed]  [DOI]  [Cited in This Article: ]
43.  Sukhov MN, Polyaev YA, Drozdov AV. Varicose veins of the small pelvis and varicocele in children with extrahepatic portal hypertension. Detskaya bolnitsa. 2011;1:13-18.  [PubMed]  [DOI]  [Cited in This Article: ]
44.  Simon JS, Brown AA, Ross HB. Ligation of the left renal vein in splenorenal anastomosis without impairment of renal function. Br J Surg. 1972;59:170-173.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 13]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
45.  Cohen D, Stephen M. Control of bleeding in extrahepatic portal hypertension - the reverse splenorenal shunt and portal-azygos disconnection Aust. Paediatr J. 1984;20:147-150.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
46.  Lee SG, Moon DB, Ahn CS, Kim KH, Hwang S, Park KM, Ha TY, Ko GY, Sung KB, Song GW. Ligation of left renal vein for large spontaneous splenorenal shunt to prevent portal flow steal in adult living donor liver transplantation. Transpl Int. 2007;20:45-50.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 79]  [Cited by in F6Publishing: 86]  [Article Influence: 5.1]  [Reference Citation Analysis (0)]
47.  Samson RH, Lepore MR, Showalter DP, Nair DG, Lanoue JB. Long-term safety of left renal vein division and ligation to expedite complex abdominal aortic surgery. J Vasc Surg. 2009;50:500-504; discussion 504.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 25]  [Cited by in F6Publishing: 26]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
48.  Slater RR, Jabbour N, Abbass AA, Patil V, Hundley J, Kazimi M, Kim D, Yoshida A, Abouljoud M. Left renal vein ligation: a technique to mitigate low portal flow from splenic vein siphon during liver transplantation. Am J Transplant. 2011;11:1743-1747.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 28]  [Cited by in F6Publishing: 27]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
49.  Schulte-Baukloh H, Kämmer J, Felfe R, Stürzebecher B, Knispel HH. Surgery is inadvisable: massive varicocele due to portal hypertension. Int J Urol. 2005;12:852-854.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 7]  [Article Influence: 0.4]  [Reference Citation Analysis (0)]
50.  Threefoot SA, Cabrera-Gil C, Pearson Jr JE. Collateral circulation, renal function and histology after experimental obstruction of renal veins. Chest. 1970;58:249-260.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 7]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
51.  Darewicz J, Cylwik B, Gruszecki W. Effect of clamping of the renal vein in dogs on certain biochemical and histopathological changes. Int Urol Nephrol. 1976;8:271-276.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 4]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
52.  Solomon MJ, Stening MR, Hargrave JC. The fate of the left kidney after end renosplenic shunt in experimentally induced extrahepatic portal hypertension. Aust N Z J Surg. 1990;60:545-548.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
53.  Effeney DJ, Stoney RJ.  Wylie’s atlas of vascular surgery. Venous disease and miscellaneous arteriopathies. Philadelphia: JB Lippincott Company Philadelphia 1993; 38-54.  [PubMed]  [DOI]  [Cited in This Article: ]
54.  Satyapal KS, Kalideen JM. The renal veins in the human cadaveric fetus: their importance as contributors to collateral flow. J Anat. 1995;186:405-409.  [PubMed]  [DOI]  [Cited in This Article: ]
55.  Lopatkin NA, Morozov AV, Jitnikova LN. Stenosis of renal vein. Meditsina. 1984;1:12-21.  [PubMed]  [DOI]  [Cited in This Article: ]
56.  Matsell DG, Jones DP, Boulden TF, Burton EM, Baum SL, Tonkin IL. Arteriovenous fistula after biopsy of renal transplant kidney: diagnosis and treatment. Pediatr Nephrol. 1992;6:562-564.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 26]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
57.  Carl P, Stark L, Ouzoun N, Reindl P. Venous pressure in idiopathic varicocele. Eur Urol. 1993;24:214-220.  [PubMed]  [DOI]  [Cited in This Article: ]
58.  Kim WS, Cheon JE, Kim IO, Kim SH, Yeon KM, Kim KM, Choi H. Hemodynamic investigation of the left renal vein in pediatric varicocele: Doppler US, venography, and pressure measurements. Radiology. 2006;241:228-234.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 32]  [Cited by in F6Publishing: 35]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
59.  Butros SR, Liu R, Oliveira GR, Ganguli S, Kalva S. Venous compression syndromes: clinical features, imaging findings and management. Br J Radiol. 2013;86:20130284.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 89]  [Cited by in F6Publishing: 101]  [Article Influence: 9.2]  [Reference Citation Analysis (0)]
60.  Mallat F, Hmida W, Othmen MB, Mosbah F. Mixed nutcracker syndrome with left renal vein duplication: A severe and exceptional presentation in an 18-year-old boy. Urol Ann. 2015;7:244-247.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 4]  [Article Influence: 0.4]  [Reference Citation Analysis (0)]
61.  Derchi LE, Martinoli C, Pontremoli R. Postbiopsy arteriovenous fistulas of the native kidneys diagnosed by Doppler US Eur. Radiol. 1993;3:186-189.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 2]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
62.  Deane C, Cowan N, Giles J. Arteriovenous fistulas in renal transplants: color Doppler ultrasound observations Urol. Radiol. 1992;13:211-217.  [PubMed]  [DOI]  [Cited in This Article: ]
63.  Ahn J, Cohen HI, Post renal biopsy complication: perinephric hematoma and arteriovenous fistula J.  Ultrasound Med. 1995;14:327-328.  [PubMed]  [DOI]  [Cited in This Article: ]
64.  Zerin JM, Hernandez RJ, Sedman AB, Kelsch RC. “Dilatation” of the left renal vein on computed tomography in children: a normal variant. Pediatr Radiol. 1991;21:267-269.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 27]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
65.  Kim KW, Cho JY, Kim SH, Yoon JH, Kim DS, Chung JW, Park JH. Diagnostic value of computed tomographic findings of nutcracker syndrome: correlation with renal venography and renocaval pressure gradients. Eur J Radiol. 2011;80:648-654.  [PubMed]  [DOI]  [Cited in This Article: ]
66.  Wong HI, Chen MC, Wu CS, Fu KA, Lin CH, Weng MJ, Liang HL, Pan HB. The usefulness of fast-spin-echo T2-weighted MR imaging in Nutcracker syndrome: a case report. Korean J Radiol. 2010;11:373-377.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 13]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
67.  Gupta R, Gupta A, Aggarwal N. Variations of gonadal veins: embryological prospective and clinical significance. J Clin Diagn Res. 2015;9:AC08-AC10.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 15]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
68.  Satran L, Amplatz K, Wolfson JJ, Leonarid AS, Sharp HL. Abnormal left kidney following splenorenal shunt. Amer Roentgen. 1969;106:92-96.  [PubMed]  [DOI]  [Cited in This Article: ]
69.  Yuldashev RZ, Aliev MM, Adilova GS. Impact of high portal pressure on renal hemodynamics in children with portal hypertension. J Hepat. 2015;62 Suppl 2:S820-821.  [PubMed]  [DOI]  [Cited in This Article: ]
70.  Menard MT. Nutcracker syndrome: when should it be treated and how? Perspect Vasc Surg Endovasc Ther. 2009;21:117-124.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 48]  [Cited by in F6Publishing: 52]  [Article Influence: 3.5]  [Reference Citation Analysis (0)]
71.  Lin WQ, Huang HF, Li M, Wang ZG, Chen JH, He XL, Zhou JQ. Diagnosis and therapy of the nutcracker phenomenon: long-term follow-up. Zhonghua Waike Zazhi. 2003;41:889-892.  [PubMed]  [DOI]  [Cited in This Article: ]
72.  Wang L, Yi L, Yang L, Liu Z, Rao J, Liu L, Yang J. Diagnosis and surgical treatment of nutcracker syndrome: a single-center experience. Urology. 2009;73:871-876.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 59]  [Article Influence: 3.9]  [Reference Citation Analysis (0)]
73.  Thompson PN, Farling RC, III , Chang BB. A case of nutcracker syndrome: treatment by mesoaortic transposition. J Vasc Surg. 1992;16:663-665.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 34]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
74.  Chuang CK, Chu SH, Lai PC. The nutcracker syndrome managed by autotransplantation. J Urol. 1997;157:1833-1834.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 1]  [Article Influence: 0.0]  [Reference Citation Analysis (0)]
75.  Marone EM, Psacharopulo D, Kahlberg A, Coppi G, Chiesa R. Surgical treatment of posterior nutcracker syndrome. J Vasc Surg. 2011;54:844-847.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 16]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
76.  Hohenfellner M, D’Elia G, Hampel C, Dahms S, Thuroff JW. Transposition of the left renal vein for treatment of the nutcracker phenomenon: long-term follow-up. Urology. 2002;59:354-357.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 81]  [Cited by in F6Publishing: 87]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
77.  Barnes RW, Fleisher HL 3rd, Redman JF, Smith JW, Harshfield DL, Ferris EJ. Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): repair by a new stenting procedure. J Vasc Surg. 1988;8:415-421.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 25]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
78.  Neste MG, Narasimham DL, Belcher KK. Endovascular stent placement as a treatment for renal venous hypertension. J Vasc Interv Radiol. 1996;7:859-861.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 75]  [Cited by in F6Publishing: 59]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
79.  Segawa N, Azuma H, Iwamoto Y. Expandable metallic stent placement for nutcracker phenomenon. Urology. 1999;53:631-633.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 49]  [Cited by in F6Publishing: 52]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
80.  Park YB, Lim SH, Ahn JH. Nutcracker syndrome: intravascular stenting approach. Nephrol Dial Trans. 2000;15:99-101.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 45]  [Cited by in F6Publishing: 49]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
81.  Takahashi Y, Sano A, Matsuo M. An effective “transluminal balloon angioplasty” therapy for pediatric chronic fatigue syndrome with nutcracker phenomenon. Clin Nephrol. 2000;53:77-78.  [PubMed]  [DOI]  [Cited in This Article: ]
82.  Zhang H, Zhang N. Li M. Treatment of six cases of left renal nutcracker phenomenon: surgery and endografting. Chin. Med J. 2003;116:1782-1784.  [PubMed]  [DOI]  [Cited in This Article: ]
83.  d’Archambeau O, Maes M, De Schepper AM. The pelvic congestion syndrome: role of the “nutcracker phenomenon” and results of endovascular treatment. JBR-BTR. 2004;87:1-8.  [PubMed]  [DOI]  [Cited in This Article: ]
84.  Wang X, Zhang Y, Li C, Zhang H. Results of endovascular treatment for patients with nutcracker syndrome. J Vasc Surg. 2012;56:142-148.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 59]  [Cited by in F6Publishing: 64]  [Article Influence: 5.3]  [Reference Citation Analysis (0)]
85.  Yih ND, Chyen LH, Cunli Y, Jaywantraj PS, Isip AB, Anil SA. Renosplenic shunting in the nutcracker phenomenon: a discussion and paradigm shift in options? A novel approach to treating nutcracker syndrome. Int J Angiol. 2014;23:71-76.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 5]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]