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Renal veins and CCSVI
by Mike Arata on Tuesday, August 30, 2011 at 2:16pm

I have been asked to share my thoughts on renal veins.

The jugular and azygous veins are the veins responsible for CCSVI. In the vast majority of cases this is from a malformed valve. When the flow in these veins is blocked the body has natural alternatives for draining the blood. In the jugular system the thyroidal and external jugular are the major alternative draining veins. The supreme intercostal vein and lumbar veins are the alternative veins for the azygous system. Less commonly the left renal vein provides alternative drainage. When the left renal is an alternative it is almost always in the setting of hemiazygos vein compression.

The important points are A)The renal veins do not directly cause CCSVI. B) The left renal vein is rarely involved with CCSVI, as an alternative. C) the left renal vein drainage is most often seen with hemiazygos vein compression.

Pathology of the left renal vein is quite unusual. Based on my evaluation with IVUS and review of literature it is not associated with a valve problem. Left renal vein abnormalities are caused by compression of the vein. When present it may cause flank pain or blood in urine.

Renal vein abnormalities are rare. I feel safe stating that I have treated as many hemiazygos compressions as anyone. In my experience hemiazygos compression is rare. Finding a patient with hemiazygos compression AND left renal vein compression is like finding the proverbial needle in a haystack!

So how would one identify when the renal vein is play a role, any role in ccsvi. Well first of all it would be evaluated last. What I mean by that is, you evaluate the azygous and hemiazygos veins. You correct any problems found in these veins. After treating the azygos and hemiazygos if you still have left renal drainage it means one thing. Blood is finding it easier to flow in the renal rather than the azygous. Logically one would try and search for the lesion blocking azygos/hemiazygos flow. If not found are able to be corrected I suppose one could make sure the left renal was wide open. Intuitively, this would be known since venous blood always flows in the direction of lowest pressure. The azygos blood draining into the left renal IMPLIES a normal renal.

For the sake of argument that all these rare events all came together in a single patient. Azygos/hemiazygos abnormality that could not be correct and alternative drainage into a left renal...that is abnormal. Well the treatment would be to stent the compressed renal vein. Balloon angioplasty of a compressed vein is not the standard of care for 2011.

So in summary. Renal vein involvement in CCSVI intuitively impossible and if it actually occurs exceedingly rare. If it ever were found it would be discovered after thorough treatment of the azygos/hemiazygos sytem. (renal vein treatment prior to azygos/hemiazygos should not EVER occur). In the off chance all this occurs, treatment of the left renal vein would be using a stent, NOT a balloon.

This is my opinion on renal veins and CCSVI. If another physician has a different opinion. I welcome a rebuttal on this page.

Dr. Arata:

Thank you for your comments on the relationship between the left renal vein and the azygous. I have had two treatments that have done nothing to help my gait and balance. I did see improvements in my vision, however. During first treatment, I saw the “HD effect” that others have reported. After the second, I could read the tiniest print on a medicine bottle.

I was treated in July 2010 at Georgetown University. The doctor missed my LIJV completely. He said my RIJV was widely patent. The azygous vein was extremely stenotic and then appeared to be totally occluded distally. He used a 6mm balloon by 20 in length to dilate the apex of the azygous vein, several dilations being performed from the proximal azygous vein around its apex into the distal descending portion. Then the balloon was used to dilate distally in the azygous vein to its first major collateral branch. He then said that the azygous was widely patent from the level of the first major collateral branch around the apex into the major venous drainage, and deemed it an excellent result.

I had a second procedure at another facility in April 2011. This time, the report said that the LCIV was 80% stenosed, and the left renal vein was 70% stenosed. Neither of these areas had been examined before. Both were successfully treated.

Then it was then noted that the azygous had retrograde flow with marked collaterals with a tight web-like stenosis and markedly delayed emptying. He used 8mmPTA of the azygous genu (70% stenosis) and a 6mmPTA of the thoracic vertical segment (70%) with marked improvement in drainage.

After that, LIJV was found to have 80% stenosis, the RIJV was 95% stenosed and both were described as successfully treated.

So this leads me to ask several questions.

First, why would two doctors describe such different conclusions? The first one said the RIJV was widely patent, but 9 months later, another doctor found it to be 95% stenosed. Again, the first doctor said the azygous was successfully treated, but the second described it was 70% stenosed with a web-like stenosis. Is it likely that these veins changed so much between the two treatments? Or is it more likely that diagnostics and techniques have become more effective?

Second, your comments seem to imply (to an uneducated “civilian” like me) that the findings and potential results would have been different if the left renal vein was looked at AFTER the azygous instead of before, as was the case in April. Is that what you meant?

I have images of both procedures if that would be helpful.

'gait and balance' are issues that interest me as well. I have also been treated twice, the second time much more thoroughly! After 2 valvular stenoses were opened in the ijvs, the azygous was checked with ivus and was good, then the renal veins and illiac veins were checked and also found to be good. I feel so much better--as long as I'm not trying to walk. I'm not fatigued all of the time either but my balance is lousy. Could core muscle weakness be part of the problem?

You are quoting a post by Dr Arata on Facebook, correct Dania?

I would love to see discussion about the renal veins here on TIMS. Anyone had their's checked? Anyone been found to have the nutcracker syndrome?

what is the nut cracker syndrome?

blossom wrote:what is the nut cracker syndrome?

[color=blue]Dr. Sclafani[/color] wrote:I now image the left renal vein in all cases because of the great blood flow within it. When there are outflow problems with this vein, a major collateral circuit is to the ascending lumbar vein (increasing flow through vertebral plexus) and to the hemiazygous vein (contributing greatly to the azygous system. There are two anomalies that typically obstruct left renal vein outflow: the nutcracker compression of the vein between the superior mesenteric artery and the abdominal aorta and retroaortic renal vein that can get compressed against the spine and back.



The image on the left shows the catheter going from the inferior vena cava into the left renal vein. There is an area of minimal xray dye in the middle of the renal vein. The gree curved arrow points to the ovarian vein. It is not common to see so much contrast media entering it. The next image shows that in addition to the gonadal vein, there is reflux into the ascending lumbar vein (orange arrow) and the hemiazygous vein (yellow arrow). THIS IS NOT NORMAL. The image on the right is an IVUS image of the renal vein. The renal vein is compressed (red arrows). I bet Nutcracker syndrome. Does treatment of this syndrome improve symptoms of ccsvi? I will review soon another patient who had already been treated for CCSVI (BUT NOT NUTCRACKER) who has already shown improvements of the prior CCSVI treatment.

NHE

I believe the patient he is referencing there is the same patient who, upon being treated for Nutcracker syndrome alone (after treatment for jugulars in a prior procedure), experienced improvements. While not definitive, this suggests that it is beneficial to treat this vein in CCSVI patients.

Nutcracker syndrome is compression of the renal vein, causing flow to reroute to the azygous, which complicates any flow issues there. Just adding that much flow to the azygous vein might slow down the cerebrospinal drainage into the azygous, so I think it could be a problem even in the absence of azygous stenosis.

Bumping this thread for a place to add some new info on renal veins and nutcracker.
Nutcracker syndrome is associated with chronic fatigue syndrome.

http://cat.inist.fr/?aModele=afficheN&cpsidt=1289948

Does severe nutcracker phenomenon cause pediatric chronic fatigue?

Auteur(s) / Author(s)
TAKAHASHI Y. (1) ; OHTA S. (1) ; SANO A. (2) ; KURODA Y. (2) ; KAJI Y. (3) ; MATSUKI M. (3) ; MATSUO M. (3) ;
Affiliation(s) du ou des auteurs / Author(s) Affiliation(s)
(1) Department of Pediatrics, Tenri Hospital, Nara, JAPON
(2) Department of Radiology, Tenri Hospital, Nara, JAPON
(3) MR center, Tenri Hospital, Nara, JAPON

Résumé / Abstract
Background: In the past five years we experienced 9 fatigued disabled children who were intermittently or persistently absent from school. Patients: They had been suspected to be burdened with psychosomatic disorders, having orthostatic hypotension, postural tachycardia, or other autonomic dysfunction symptoms. Results: Investigating the cause of moderate orthostatic proteinuria in some of them, we found by chance severe typical nutcracker phenomenon (NC), which was present in all 9 children complaining of chronic fatigue. Conclusion: Their symptoms filled the criteria of chronic fatigue syndrome or idiopathic chronic fatigue (CFS/CF). An association between severe NC and autonomic dysfunction symptoms in children with CFS/CF has been presented.

http://171.67.112.83/content/85/6/552.full

Chronic fatigue syndrome and fatigue symptoms have been associated with NCS with high LRV-IVC pressure gradients.19,66,68 Fatigue symptoms correlated positively with high peak velocity (PV) ratios by DUS and improved in some patients after surgery, balloon angioplasty, or aspirin therapy.3,68,69

http://www.ncbi.nlm.nih.gov/pubmed/10661488

Clin Nephrol. 2000 Jan;53(1):77-8.

An effective "transluminal balloon angioplasty" therapy for pediatric chronic fatigue syndrome with nutcracker phenomenon.

Takahashi Y, Sano A, Matsuo M.

http://www.ncbi.nlm.nih.gov/pubmed/17329037

Med Hypotheses. 2007;69(3):704-5. Epub 2007 Feb 27.

Can chronic fatigue symptoms associated with nutcracker phenomenon be treated with aspirin?

Shin JI, Lee JS.

More interesting info on renal veins:
http://lib.bioinfo.pl/pmid:644057

Radiology. 1978 May ;127 (2):351-6 644057 Cit:1

Renal vein valves: incidence and significance.

C F Beckmann, H L Abrams

Although autopsy studies have demonstrated valves in 28-70% of right and 4-36% of left renal veins, they have rarely been detected or described during life. In an analysis of 98 renal venograms, valves were found in 16% of patients on the right side and in 15% on the left, without predilection for any particular location. Angiographically, they appeared as thin, web-like structures which may block passage of the catheter or of contrast material, and hence cause poor venographic filling. Rarely, valves produce total obstruction to the retrograde flow of contrast material.

Renal veins have valves! Well, some do, anyway. A left renal vein obstruction by a malformed valve would have the same effects as a left renal vein obstruction due to compression.

And see that statement I bolded? It was known in 1978 that valves can produce total obstruction in the renal vein. Why didn't anyone know or care that valves could produce total obstruction in the jugulars as well?

Great find Cece!

For a while I have thought that my fatigue might be related to inadequate circulation . Once I get exercising I lose some fatigue, while remaining inordinately weak. I have been worse with both, since my heart attack. I have 3 artterial stents, and would have had 4 , except he could not get the wire through, and there was some collateral circulation sharing the load.