BACKGROUND: Short harvested right renal veins (RV) are quite common in living donor kidney transplantation (KT). This technical difficulty might interfere implanting and increase warm ischemic time. Several techniques to overcome this problem have been applied, including iliac vein transposition, inverted transplant, synthetic graft, saphenous vein… Application of accompanying gonadal vein (GV), which is easily approachable and less time-consuming, has been recently published. This study aims to evaluate its effectiveness and safety.
METHODS: Retrospective study on KT using the gonadal vein to lengthen the short right renal vein at Viet Duc University Hospital from April 2019 to April 2022. The following data were gathered: baseline characteristics, vascular imaging in CT scan/after nephrectomy and after reconstruction (mm), reconstruction and surgical time, hospitalization days. The outcomes were determined by kidney function after transplantation (plasma creatinine, creatinine clearance) and related complications.
RESULTS: Twenty-five cases with procured right kidney with short RV from the living donor which were reconstructed and lengthened by the accompanying GV were collected. The additional length of RV was 15.9 ± 2.4 mm. Average cold ischemic time, venoplasty time, warm ischemic time were 60.4 ± 8.2, 21.2 ± 5.3, and 38.1 ± 5.6 min, respectively. The average hospital stay was 15.3 ± 3.2 days. Average follow-up time was 31 ± 5.2 months, creatinine clearance was around 60 ml/min after 1 year, no vascular or urologic complications was observed.
CONCLUSIONS: Accompanying GV from a living donor to lengthen short right RV in KT is a feasible, safe, and effective technique.

OBJECTIVE: Porous, radiolucent, shape memory polymer is a new technology available in discrete peripheral vascular embolization devices. Shape memory polymers can exist in two stable shapes; crimped for catheter delivery and expanded for vessel embolization. The expanded shape memory polymer in these new devices is hemostatic, and the porous polymeric scaffold has been shown to support tissue ingrowth and eventually bioabsorbs in preclinical animal studies. This report describes clinical experience with this novel material in vascular plug devices.
METHODS: a prospective, single-arm, safety study at a single center in New Zealand with longer term follow-up via retrospective imaging review. The study device was a pushable shape memory polymer vascular plug with a distal nitinol anchor coil and a proximal radiopaque marker.
RESULTS: Ten male patients were each implanted with a single shape memory polymer vascular plug. Three inferior mesenteric arteries and an accessory renal artery were embolized during endovascular aneurysm repair. An internal iliac artery was treated prior to the open surgical repair of aorto-iliac aneurysms. An internal iliac artery and a subclavian artery were embolized to treat/prophylactically address potential endoleaks. A profunda branch was embolized prior to tumor resection, and two testicular veins were embolized to treat varicoceles. Acute technical success of target vessel embolization was achieved in all implantation cases. Patients were followed for 30 days as part of the study, and no serious adverse events with a relationship to the study device occurred. No recurrent clinical symptoms attributable to treated vessel embolization or recanalization were documented. There was no evidence of recanalization on retrospective review of follow-up imaging through a mean of 22.2 months (range, <1-44 months) post-procedure.
CONCLUSIONS: Shape memory polymer vascular embolization devices were safe and effective over the follow-up period of this small safety study. Further experience and longer term follow-up will assess further applicability.

BACKGROUND: Nutcracker syndrome is a condition in which the left renal vein is pinched between the abdominal aorta and the superior mesenteric artery, resulting in an increase in renal vein pressure and certain symptoms. We report a very rare case of retroperitoneal hematoma caused by the rupture of varicose veins of the left ovary.
METHODS: A 77-year-old Japanese woman, para 7, experienced sudden left lower abdominal pain. She had no history of trauma or treatment complications. Computed tomography revealed a left retroperitoneal hematoma, but her abdominal pain subsided quickly; thus, urgent treatment was not required. We then scheduled her for an assessment regarding the cause of her bleeding. However, 6 days after the pain onset, abdominal pain symptoms recurred, confirming hematoma regrowth. Magnetic resonance imaging and three-dimensional computed tomography revealed an abnormal vascular network from the left side of the uterus to the left adnexa. Subsequent angiography revealed that the retroperitoneal bleeding originated from rupture of the distended left ovarian vein, which caused blood reflux from the left renal vein to the left ovarian vein. Although angiography confirmed a passage between the left renal vein and inferior vena cava, computed tomography showed obvious stenosis in the left renal vein. In accordance with these findings, we diagnosed the cause of the distention and rupture of the left ovarian vein as nutcracker syndrome. She underwent embolization of the left ovarian vein as hemostasis treatment, and had a good course thereafter.
CONCLUSIONS: This is the first report of a spontaneous rupture of the left ovarian vein caused by nutcracker syndrome. Nutcracker syndrome is not yet well known to clinicians and should be considered as part of the differential diagnosis when an abnormal vascular network in the pelvis is found.

Objectives Gonadal vein thrombosis is an uncommon but serious condition that can be fatal if it goes unnoticed. Up to 80% of cases occur in patients after delivery, hysterectomy, or lymphadenectomy for gynecological neoplasms. The objective of this study was to determine the incidence of gonadal vein thrombosis using computed tomography (CT) imaging at our center and to describe associated risk factors. Methods A retrospective, single-center, observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. Data were collected for all patients diagnosed with incidental gonadal-vein-thrombosis using contrast-enhanced computed tomography imaging of the abdomen and pelvis between January 2005 and December 2017. We included all patients with incidental findings of gonadal vein thrombosis and excluded those with incomplete data. Results In total, 58/68,268 (0.08%) patients were included. Fifty-seven patients were females, and only one was male. The mean age (years) of the patients was 50.0±15.0 (range 4-87). Thirty-four patients (59%) had right gonadal vein thrombosis, 20 (34%) had thrombosis on the left side, and four (7%) had bilateral thrombosis. Nineteen patients (33%) had undergone pelvic surgery previously. Forty-four patients (76%) had a malignancy at the time of diagnosis. Forty-two patients (72%) were treated with anticoagulants after the diagnosis. Conclusion Gonadal vein thrombosis is a rare clinical entity with vague clinical presentation. The incidence in the oncology population is similar to the reported incidence in the obstetric population. Initiation of anticoagulation therapy is important to treat this condition and limit complications.

Strictures of the ureter may occur from iatrogenic injury or impacted kidney stones. Complications from ureteroscopy may result in ureteral stricture in 0,5-2% of patients. New techniques are being described in order to minimize the morbidity associated with classic approaches. This is a step-by-step video of this novel technique: a successful laparoscopic ureteroplasty with gonadal vein graft for a iatrogenic long ureteral stenosis. A 16 year old female patient, with multiple previous ureteroscopies for ureteral stones, presented with severe left lumbar pain. An abdominal CT and a pyelography were performed showing a 3 cm left mid-proximal ureteral stricture with proximal hydronephrosis. The stenotic area was identified and an anterior left ureteral incision was made. Gonadal vein was removed and prepared, being sutured in the anterior surface of the ureter. Patient was discharged in the second post operative (PO). JJ stent was removed after 1 month. A 3 month PO pyelography was performed, showing no fistula and resolution of the stricture. Twelve months after surgery, the patient was painless with symptom resolution. The use of gonadal vein as a graft for ureteral strictures is a new possible approach, although more cases are necessary to evaluate its results.

Arterial reconstruction is one of the paramount procedures in kidney transplantation (KT) and greatly important if the procured kidney has multiple renal arteries (MRA). Despite various established techniques for arterial reconstruction, sometimes, the surgeon finds performing arterial anastomoses challenging in case of MRA. In our case, the donor\'s gonadal vein and recipient\'s internal iliac artery graft were used for arterial anastomoses, and 3 years after KT, the allograft did not present vascular complications.
A 34-year-old man underwent ABO-incompatible preemptive living KT. The allograft had three renal arteries and four renal veins. After donor nephrectomy, arterial reconstruction was performed on a back table. These arteries were reconstructed into one piece using the recipient\'s internal iliac artery graft. The two arteries at the middle of the renal hilum were reconstructed using the conjoined method. As the superior renal artery was too short to anastomose, the donor\'s gonadal vein was used for extension. The internal iliac artery graft was anastomosed to the original internal iliac artery. Intraoperative Doppler ultrasonography revealed that the blood flow in each renal artery was adequate, resulting in sufficient blood flow throughout the allograft. The allograft function was maintained with a serum creatinine level of approximately 0.9 mg/dL without vascular complications 3 years after KT.
The donor\'s gonadal vein can be a candidate for extension of the renal artery in the allograft with MRA. Further follow-up is needed for the assessment of long-term outcomes.

We illustrate the intravascular ultrasound (US) findings in the evaluation of left gonadal vein anatomic variations. During a 2-year period, 4 consecutive patients (mean age, 37 years; range, 28-45 years) with left-sided varicocele underwent embolization. Intravascular US examinations and retrograde venography were performed to assess varicocele anatomy. Anatomic variants were recorded and categorized. A comparison between intravascular US and fluoroscopic findings was performed. The Fisher exact test was used for statistical analysis (P < .05). Technical success was achieved in all cases. There was a statistically significant difference in the maximum gonadal vein diameter between venography and intravascular US (P = .0087). Intravascular US showed left gonadal vein anatomic variations and better ability in the evaluation of the vein diameter.

OBJECTIVE: To present anatomical variations of left internal spermatic vein and a comparison between treatments with hydrogel-coated and non-coated platinum coils in patients with varicocele.
METHODS: A total of 153 men (mean age, 27.5±6.7 [SD] years; range: 18-45 years) with left sided varicocele underwent coil embolization. Anatomic variants of gonadal vein were categorized into five subtypes (I-V). Additional venous collaterals were also recorded. Three types of coils were used (hydrogel coated platinum coils, fibered coils and non-coated platinum coils). Technical success, tolerance, efficacy and safety of hydrogel coated platinum coils were recorded. Comparison between different types of coils used was made. Fisher\'s exact test was used for statistical analysis.
RESULTS: Varicoceles were classified as type I (26.1%), type II (13.7%), type III (32.1%), type IV (18.3%) and type V (9.8%). The internal spermatic vein - renal vein angle ranged from 32°-128° (mean angle, 93.5°). Technical success was achieved in 145 patients (94.8%) without complications. The mean number of coils used was 3 (range: 1-6 coils). A total of 260 hydrogel coated platinum coils in 95 patients and 135 non-coated coils in 50 patients were deployed with no complications. No differences were noted between the different types of coils used regarding embolic efficacy and safety. A 6.2% (9/145) recurrence rate and a 33.3% (14/42) fertility rate were observed. Clinical success regarding symptom relief after painful varicocele embolization was 100% (36/36) for technically successful cases.
CONCLUSIONS: Varicocele embolization with the use of hydrogel coated or non-coated platinum coils is technically feasible and safe without complications. No superiority of one type of coil over the other was found.

A previously healthy 30-year-old man with a symptomatic varicocele underwent gonadal vein embolization using nickel vascular plugs. He developed a painful hypersensitivity to his nickel plugs and elected to pursue laparoscopic excision and proximal gonadal vein ligation. In the operating room, the gonadal vein was isolated from the ureter, and ligated proximal to the cephalad plug and distal to the caudal coil. His pain is completely resolved 5 months after surgery. Metal allergies are well documented in orthopedics and cardiology implants, but there are a limited number of case reports of metal allergies after varicocele embolization. Interestingly, nickel is the most common type of metal hypersensitivity.

To retrospectively evaluate the ability of computed tomographic (CT) findings to discriminate nutcracker syndrome (NCS) from asymptomatic nutcracker phenomenon (NCP) and to investigate the diagnostic value of CT findings in diagnosis of NCS.
From January 2014 to April 2015, 216 patients who underwent initial urographic CT were included. Initially, 216 patients were categorized as \"nutcracker\" or \"normal,\" based on the following CT criteria: (1) the presence of beak sign and (2) hilar-aortomesenteric left renal vein diameter ratio >4. Patients who satisfied both of these criteria were diagnosed with nutcracker. The nutcracker was then divided into \"NCS\" and \"asymptomatic NCP\" based on the presence of characteristic symptoms. CT findings in sagittal and axial scans of corticomedullary phase were evaluated. Multivariate analysis was used to identify significant factors among 30 NCS, 51 asymptomatic NCP, and 135 normal patients. Diagnostic performance and threshold using receiver operating characteristic (ROC) curve were calculated.
A total of 131 males and 85 females, with mean age of 38.6 years (range 18-89 years), were included. Multivariate analysis demonstrated superior mesenteric artery (SMA)-aortic angle (p < 0.001) and visualization of a dilated collateral vein with reflux (p = 0.001) were independent factors for distinguishing NCS from asymptomatic NCP. The combination of SMA-aortic angle <25° and visualization of a dilated collateral vein with reflux provided the greatest diagnostic accuracy (area under the ROC curve, 0.841).
The combination of SMA-aortic angle and visualization of a dilated collateral vein with reflux in multidetector CT can be useful to differentiate NCS from asymptomatic NCP.