Stenosis of the renal vein

The accumulated experience in the study of the venous renal system allows not only to establish stenosis of the renal vein that led to venous stasis in the kidney, but often also to determine the etiological factor of stenosis.

[1], [2], [3], [4]

Causes of the stenosis of the renal vein

Stenosis of the renal vein can occur as a result of the following reasons.

• Arterial aortosferential "tweezers", infringing the renal vein (orthostatic stenosis).
• Acquired stenosis of the renal vein: nephroptosis, posttraumatic and pyelonephritic pedunculitis, arterial fibrous ring, etc. (permanent stenosis).
• Pathological mobility of the kidney (orthostatic stenosis): one-sided, two-sided.
• Ring-shaped left renal vein (permanent stenosis).
• Multiple renal arteries compressing the renal vein (permanent stenosis).
• Retroaortal left renal vein (permanent stenosis).
• Extracaveral confluence of the left vein of the kidney, compression of the common iliac artery (permanent stenosis).

[5], [6], [7], [8]

Symptoms of the stenosis of the renal vein

Varicocele - varicose veins of the spermatic cord is one of the most common symptoms of stenosis of renal veins in urological practice. High pressure in the renal vein leads to the failure of the valves of the testicle vein and the development of a bypass with a reverse current of venous blood from the veins of the kidney along the testicle into a groinlike plexus. Further along the external seminal vein into the common iliac. The compensatory renocaval anastomosis is formed.

Stenosis of the renal vein (or its branches) leads, as a rule, to a disturbance of hemodynamics in the entire venous bed of the kidney. The degree of constriction, as well as its character (permanent or orthostatic), determines the severity of circulatory disorders in the renal venous system. Compensation of disorders is carried out due to the reservoir-capacity capabilities of intraorganic venous structures (venous plexuses of calyx arches) and the transformation of inflows of the veins of the kidney in the path of the round outflow.

Congestive venous hypertension in the kidney, slowing of the blood flow in the venous segment at the level of the microcirculatory bed, overfilling of the plexus plexus, extraordogenic venous collateralization, the pathophysiological basis of certain symptoms and (or) the symptom complex of renal vein stenosis (hematuria, varicocele, dysmenorrhea, etc.).

The nature of the relationship between the nature of renal venous stenosis and clinical symptoms is obviously the following. Varicocele develops more often with orthostatic stenosis of the vein (aortomethovenous "tweezers"). Hematuria for this type of stenosis is not typical. A transient and often recurring pressure increase in the renal vein is enough to disrupt the blood flow in the testicle and cause the failure of its valves. Developing in this case, the discharge of blood from the veins of the kidney into the groinlike plexus contributes to venous decompression, protects the forenips from excessive overflow, from ruptures and forecanic bleeding.

Similarly to the appearance of varicocele in men, stenotic lesions of renal veins in women lead to a violation of venous renal and ovarian hemodynamics, its distortion and development of ovarian varicose veins in a descending ovarivarwicocel. Characterized by dysmenorrhea, pain in the left side of the abdomen, dyspareunia (painful sexual intercourse), dysuria, hematuria and proteinuria. In such cases, it is advisable to radiocontrast study of the venous system of both kidneys.

When dysmenorrhea is combined with hematuria, oncological alertness requires the exclusion of a tumor in the kidney, bladder and upper urinary tract. In the presence of a tumor in the kidney, pathological arteriovenous shunting in the tumor tissue can lead to the appearance of fistulous hypertension in the renal venous system and the development of pathological reflux from the vein of the kidney into the venous plexus of the ovary, the development of ovarivaricoceles and symptomatic dysmenorrhea. In addition, a kidney tumor, having polyhormonal potential, can cause ovarian dysfunction.

Hematuria occurs with persistent vaginal hypertension due to the permanent (organic) stenosis of a vein acquired or congenital in origin. The hematuria arising from the orthostatic stenosis of the vein of the pathologically movable right kidney is explained by the pronounced and prolonged venous stasis in the right kidney, which, unlike the left one, has limited opportunities for a roundabout venous outflow.

The combination of varicocele and hematuria is possible only with persistent forms of stenosis of the renal vein.

Diagnostics of the stenosis of the renal vein

Diagnosis of stenosis of the renal vein and the definition of its etiology are made up of a complex of clinical, laboratory and radiographic studies. The features of the research and the transition from one method to another depend on the results obtained at the previous stage of diagnosis.

[9], [10], [11], [12]

Clinical diagnosis of renal venous stenosis

First, the presence of clinical signs of venous outflow from the kidney is revealed: hematuria, proteinuria, varicocele, dysmenorrhea, etc. The side of the symptom (left, right, both sides), its character (permanent orthostatic), combination with other symptoms. For example, a combination of hematuria and varicocele indicates the possibility of persistent and pronounced narrowing of the vein. The combination of hematuria with hydronephrosis, as a rule, is due to the presence of multiple venous trunks or an anomalous ring-shaped vein of the kidney. The combination of dysmenorrhea and hematuria testifies to a stenotic lesion of the veins of both kidneys with a simultaneous inflow of the right ovarian vein into the right renal.

Clinical manifestations and their evolution should be considered in connection with the patient's age. This allows us to foresee the probability of a particular cause of stenosis of the renal vein. Young age is characterized by congenital factors of stenosis: arterial "tweezers", multiple arteries, compressing the renal vein, ring-shaped vein. In elderly patients, the acquired lesions of the veins are more often observed due to nephroptosis, arterial fibrous ring, etc.

Important data may be family history of the presence of such symptoms in the patient's relatives, which suggests the congenital genesis of renal vein stenosis. An indication in an anamnesis for a trauma to the lumbar region or abdomen speaks in favor of acquired stenosis. Evaluation of prescription and dynamics of symptoms contributes to the establishment of the correct etiological and pathogenetic diagnosis. For example, if the orthostatic varicocele that has existed since childhood, with age turned into a permanent, you should think about the transformation of arterial "tweezers" in the arterial fibrous ring. If the cessation of hematuria in a patient who had previously bleeding from the left kidney coincided with the gradual development of the left-sided varicocele, then one can assume the formation of venous collaterals, which reduced venous stagnation in the kidney and changed the clinical picture of the disease.

Experience shows that the correct interpretation of clinical symptoms makes it possible not only to suspect the patient of stenosis of renal veins, but also to some extent to judge its etiology.

The examination begins with the examination of the patient. Determine the presence of varicose veins of the spermatic cord, the side of the lesion, the nature of the varicocele (changes in the filling of the veins of the groinlike plexus in the horizontal and vertical position of the patient). Demonstrative reception Ivanissevich: in the patient lying in the lying position, the spermatic cord at the level of the outer ring of the inguinal canal is pressed against the pubic bone. At the same time, the veins of the cord in the scrotum are not filled, when the patient is transferred to the vertical position, if the cords are not compressed, the veins do not fill up. If you stop pressure on the cord, the groin-like plexus immediately becomes filled, becomes heavier. Even when examining the patient, one can assume the nature of hypertension in the renal vein (persistent or transient), determine the presence and extent of testicular atrophy on the side of the lesion.

[13]

Laboratory diagnostics of renal vein stenosis

Laboratory diagnostic methods include urine analysis according to Almeida-Nechiporenko, determination of daily protein excretion, immunochemical examination of urine and blood.

These indicators are important not so much for diagnosis (although the extent and nature of proteinuria characterize the severity of renal hemodynamic disorders), how many to evaluate the result of the treatment undertaken on the dynamics of protein excretion, a change in the uroproteinogram.

Instrumental diagnosis of renal vein stenosis

One of the most modern methods of diagnosing stenosis of the renal vein is 3D spiral bolus computer phlebography with reconstruction of the vascular bed and high-field MRI with contrasting. These technologies make it possible to obtain exhaustive information about vascular architectonics without the use of invasive diagnostic methods.

Widely applied color Doppler mapping on modern ultrasonic devices by determining retrograde blood flow in the venous canal allows diagnosing the so-called subclinical forms of varicocele, especially in preschool and early school-age children.

Stenosis of the renal veins is diagnosed by venographic studies that determine the choice of the treatment method for this pathology.

Catheterization of the abdominal aorta, inferior vena cava and their branches is carried out according to Seldinger's method.

Methods of radiopaque examination of the inferior vena cava and its tributaries

• Lower wenokavagrafiya:
  • non-structural - antegrade and retrograde;
  • obturation - antegrade.
• Renal venovascular disease.
• Venous phase in renal arteriography.
• Non-structural:
  • selective retrograde renal venography;
  • selective retrograde renal venography with preliminary interruption or reduction of arterial influx (using a balloon, a pharmacological preparation, an embolizing agent).
• Reflaxive renal venography in the lower venocavagrafia after obturation of the renal artery by using a balloon, a pharmacological preparation, an embolizing substance.
• Two-sided refluxive renal venography with obturation lower kavography.
• Antegrade contrasting of the left vein of the kidney in left-sided testicularbiovenography.