Anomalous left renal vein coursing behind aorta and draining into the left common iliac vein: A rare variant

Introduction: It is important to know the detailed anatomy and anomalies in the renal veins for various operative as well as venographic procedures. Retroaortic left renal vein joining the left common iliac vein is a rare congenital anomaly of inferior vena caval development. To our knowledge, only two cases have been reported till date. Case Report: We report a case of this rare anomaly in a 51-year-old male admitted with history of road traffic accident, without any symptoms pertinent to this anomaly. Conclusion: We highlight the significance of multidetector computed tomography (MDCT) showing a retroaortic left renal vein joining the left common iliac vein. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 5 No. 8, August 2014. ISSN – [0976-3198] Int J Case Rep Images 2014;5(8):553–557. www.ijcasereportsandimages.com Prakash et al. 553 CASE REPORT OPEN ACCESS Anomalous left renal vein coursing behind aorta and draining into the left common iliac vein: A rare variant Chandra Prakash, Sajad Ali, Samina Manzoor Khan


IntroDuctIon
Venous anomalies resulting from errors of embryological development are frequent observations. These vascular anomalies of retroperitoneal region have clinical implications, with respect to patient symptomatology and while considering renal surgery. A left renal vein coursing behind the aorta is termed retroaortic left renal vein (RLRV). This course of the renal vein behind the aorta is uncommon in the development of the inferior vena cava (IVC) and its collateral vessels occurring in 1.8-2.4% of the population [1].
Recent advances in computed tomography (CT) scan have made it possible to provide detailed visualization of the vascular structures.
Anomalous development of the IVC includes duplication of IVC, transposition of IVC, circumaortic (left ) renal vein, retroaortic left renal vein [1,2]. Further left renal vein anomalies are categorized into four types [3,4]. vein, to our knowledge only two cases have been reported so far and only one of them has appeared in radiology literature in which CT and 3D phase-contrast magnetic resonance venography (MRV) was used to detect this anomaly, but we could ascertain the same anomaly on a MDCT and report the same.

cAsE rEPort
A 51-year-old male presented to our hospital with history of road traffic accident. On routine imaging based on trauma protocol, incidentally, it was found that he had an anomalous course of the left renal vein which was coursing behind the aorta and joining the left common iliac vein.
On further eliciting the patient's past history he had one episode of hematuria in the past which had settled with antibiotics, apart from this he did not have any other symptoms related to this anomaly. The patient was managed conservatively and later he was discharged from the hospital in normal state of health with the advice to follow-up if he develops any symptoms like hematuria or flank pain or any other urological complaints.
On MDCT, the left renal vein was seen coursing obliquely and caudally behind the aorta and joining the left common iliac vein. The left renal vein was seen to join the left iliac vein at the level of L4-L5. The left renal was of normal caliber as seen in the three-dimensional volumerendering technique (3D-VRT) images (Figures 1 and 2) and maximum intensity projection (MIP) image ( Figure  3). Right renal vein was short in course and normal in caliber.

DIscussIon
Venous anomalies resulting from errors of embryological development are frequent observations. The development of renal veins is a part of the complex developmental process of IVC, anomalies of the IVC include, namely, duplication of IVC, transposition of the IVC, circumaortic (left) renal vein, retroaortic left renal vein having an incidence of 0.2-3.0%, 0.2-0.5%, 1.5-8.7%, and 1.8-2.4%, respectively [1].
The embryological development of the renal vein starts from the fourth week of conception and ends at about the eighth week. The IVC forms from a vast network of three pairs of parallel veins. The posterior cardinal vein, the subcardinal vein and supracardinal vein are in order of appearance [8,9].
Posterior cardinal veins are first to develop, they are the vessels of mesonephros and largerly disappear with the transitory kidneys. The subcardinal veins appear by the fifth week. The veins are in a plane ventral to aorta  The diagnostic methods for detecting IVC anomalies have been autopsy study, renal venography, color Doppler ultrasonography, computed tomography and magnetic resonance imaging. With the advances in computed tomography, MDCT has replaced other conventional angiography and venogram in most of the conditions [2].
The importance of knowledge of the renal vessels is emphasized as it is crucial for surgeons to recognize these anomalies and failure to do so can lead to severe hemorrhage and renal damage [11]. Symptoms such as hematuria can be caused due to increased pressure of the renal vein due to its abnormal course behind the aorta and leading to its compression and subsequent elevation in pressure and congestion in the kidney [2].
In our case, patient did not have any overt symptoms related to this pathology but its timely diagnosis will definitely benefit him in future if such symptoms occur.

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