Vol. 50, No. 6
Printed in U.S.A.
THE AMERICAN JOURNAL OP CLINICAL PATHOLOGY
Copyright © 1968 by The Williams & Wilkins Co.
RETROAORTIC LEFT RENAL VEIN
A RELATIVELY FREQUENT ANOMALY
C H A R L E S J. DAVIS, J R . , L T C , M C , AND G E O R G E D . L U N D B E R G , M . D .
Pathology Service, Womack Army Hospital, Fori Bragg, North Carolina, and Department of
Pathology, University of Southern California School of Medicine, Los Angeles, California 90088
The increased frequency of surgical procedures involving the kidneys in renal
transplantation, lienorenal shunts, and primary surgery of the renal vessels and abdomnal aorta has shown a need for a reevaluation
of the normal renal vasculature and its
variations. Comprehensive anatomic dissections have shown that the simple form of
renal pedicle occurs in less than 25% of
individuals.1"4 The attention of one of us
(G.D.L.) was originally focused on the
retroaortic left renal vein in 1960 when, as a
result of surgical division of an unrecognized
limb of the left renal vein during surgery
on the abdominal aorta, hemorrhage occurred which resulted in prolonged shock,
renal failure, and death of the patient.
MATERIAL
During a 7-year span for one of us (G.D.L.)
and a 2-year span for the other (C.J.D.), all
autopsies performed personally at William
Beaumont and Brooke General Hospitals
included a careful observation of the main
trunk(s) of the left renal vein. This amounted
to 175 autopsies for the former and 95 for
the latter for a total of 270. Since results
were comparable, the studies are reported
as a single group.
the aorta. When entirely retroaortic, the
vessel lay at the usual level as did the left
kidney. When bifid, the preaortic limb
generally entered the inferior vena cava at
the usual level while the retroaortic limb
coursed several centimeters inferiorly as it
entered the cava. The bifid vein usually
united at the hilus of the kidney only to
bifurcate again to enter the kidney. The
retroaortic channel was not significantly
attenuated by the aorta and there was no
clinical or pathologic evidence of related
renal disease. In one instance a more complex vascular anomaly was found, the retroaortic limb communicating directly with a
persistent left supracardinal vein. All nine
cases were males, ranging in age from 1 day
to 78 .years. Associated anomalies included a
Meckel's diverticulum in one case and an
accessory left renal artery and a duodenal
diverticulum in another.
DISCUSSION
RESULTS
In 270 consecutive autopsies, the left
renal vein was entirely or partially retroaortic in nine instances for an incidence of
3.3%, or one in every 30 autopsies. In five
of these, the vessel was completely retroaortic (Fig. 1). In the other four, the vein
was bifid with essentially equally sized
halves running anterior and posterior to
Received J a n u a r y 10, 1968.
This paper was presented a t the interim meeting of the American Society of Clinical Pathologists in New Orleans, La., on March 26, 1968.
The retroaortic left renal vein results from
persistence of vessels that normally become
atrophic. Prior to the 6th week of embryologic development, the primary venous
drainage from the lumbar areas is through
the posterior cardinal veins.5 By the Sth
week, through a complex series of changes,
these have been entirely replaced at the
renal level by four longitudinal channels:
paired supracardinal veins which lie on a
plane posterior to the aorta and paired
subcardinal veins which lie on a plane
anterior to the aorta. 8 It is the anastomoses
between these four channels at the renal
level which form the circumaortic venous
ring or renal collar: the intersupracardinal
anastomosis, the intersubcardinal anastomosis, and the left and right suprasubcardinal anastomoses. Paired embryonic
vessels on each side unite the kidneys with
the latter anastomoses. The retroaortic
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Dec. 1968
RETROAORTIC LEFT RENAL VEIN
701
FIG. 1. The abdominal aorta has been sectioned, revealing a
retroaortic left renal vein.
components of the venous ring normally
atrophy, leaving a preaortic left renal vein
(Fig. 2). When the reverse occurs, the
definitive channel will be retroaortic (Fig.
3). With persistence of the entire ring,
permanent channels will be found both
anterior and posterior to the aorta.
From the medical literature one gains the
impression that a solitary retroaortic left
renal vein is a curiosity of unrecorded
frequency.6 Informal query of numerous
experienced pathologists has indicated an
almost total ignorance of this anomaly.
Anatomists, however, have reported incidences of solitary retroaortic left renal vein
of 3.46 %7 and 2.4 %8 and a circumaortic
venous ring as often as 16.8 %7 when considering even minute channels. A marked
male predominance existed.8 In the present
series, the frequency of the renal collar
was 1-5% and of the solitary retroaortic
left renal vein it was l.S%. Thus, this is one
of the most common of all congenital anomalies.
I t is generally stated that the left kidney
is preferred for transplantation because the
left renal vein is longer than the right (Fig.
2). 9 It may exceed that of the right by 5
times: the average length of the right renal
vein is 3.2 cm. (2.0 to 4.5 cm.), while that
of the left is S.4 cm. (6.0 to 11.0 cm.).3 The
solitary retroaortic vein, however, because
of fixation at the left aortic border, is no
more accessible for mobilization than the
right (Fig. 3). The circumaortic venous
ring also renders mobilization impossible
medial to the left aortic border, unless of
course the retroaortic limb is ligated and
sectioned. In addition to its usefulness in
shunts and transplants, a normally situated
preaortic vessel is utilized as a landmark
during surgery of the abdominal aorta. In
DAVIS AND LTJNDBERG
/
FIG. 2 (upper). The normally disposed, preaortic left renal vein is more accessible for mobilization than the right renal vein, and because of its greater length the
left kidney is usually preferred for renal transplantation. Compare with Figure 3,
where the vessel is retroaortic and these advantages are lacking.
FIG. 3 (lower). The surgical availability of the left renal vein is severely restricted when it occupies a retroaortic position. Its usable length is diminished to
the distance between the hilus of the kidney and the left border of the aorta.
Dec. 1968
RETROAORTIC LEFT RENAL VEIN
this regard, it is essential to realize that,
although usually overlooked or disregarded,
not uncommonly the left renal vein lies
behind the aorta.
2.
3.
SUMMARY
In 270 consecutive autopsies the left
renal vein was found to lie in a retroaortic
position in 3.3% of cases—in 1.8% entirely
retroaortic and in 1.5% circumaortic—
designating this as one of the most common
of all congenital anomalies. The surgical
significance of such occurrence lies principally in the fact that it restricts the availability of the left renal vein for mobilization
procedures and nullifies the advantages
which normally accrue from its greater
length.
REFERENCES
4.
5.
6.
7.
8.
9.
1. Anson, B. J., Cauldwell, E. W., Pick, J. W.,
and Beaton, L. E.: The blood supply of the
kidney, suprarenal gland, and associated
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structures. Surg. Gynec., & Obst., 84: 313320, 1947.
Anson B. J., Cauldwell, E. W., Pick, J. W.,
and Beaton, L. E.: The anatomy of the pararenal system of veins, with comments on the
renal arteries. J. Urol., 60: 714-737, 1948.
Anson, B. J., and Daseler, E. H.: Common
variations in renal anatomy, affecting blood
supply, form, and topography.
Surg.
Gynec. & Obst., 11%: 439-449, 1961.
Anson, B. J., and Kurth, L. E.: Common
variations in the renal blood supply. Surg.
Gynec. & Obst., 100: 157-162, 1955.
Arey, L. B.: Developmental Anatomy, Ed.
6. Philadelphia: W. B. Saunders Company,
1954, pp. 382-385.
Lord, J. W., Jr., Vigorita, J., and Florio, J.:
Fistula between abdominal aortic aneurysm
and anomalous renal vein. J. A. M. A.,
187: 535-536, 1964.
Pick, J. W., and Anson, B. J.: The renal vascular pedicle. An anatomical study of 430
body-halves. J. Urol., 44: 411-434, 1940.
Reis, R. H., and Esenther, G.: Variations
in the pattern of renal vessels and their
relation to the type of posterior vena cava
in man. Am. J. Anat., 104: 295-318, 1959.
Smith, G. T., Calne, R. Y., Murray, J. E.,
and Dammin, G. J.: Anatomic observations
on the renal vessels in man with reference
to kidney transplantation. Surg. Gynec. &
Obst., 115: 682-688, 1962.
CORRECTION
It has been brought to my attention that there is an error in my article "Antihemophilic Factor Assay" (Am. J. Clin. Path., 49: 657-661, 1968). The observation
that phosphatidylserine is more soluble in ether than is phosphatidylethanolamine
was inadvertently attributed to Doctor M. J. Silver. These relative solubilities were
inferred from the work of D. F. IT. Wallach et al. and should not have been attributed
to Doctor Silver.
A. WENDELL MUSSER, M.D.
Veterans Administration Hospital
Durham, ATorlh Carolina 27705