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Background: Variations in renal veins are quite common, and most people do not experience issues due to them. However, these variations are important for healthcare professionals, especially in surgical procedures and imaging studies, as precise knowledge of vascular anatomy is essential to avoid complications during medical interventions. The purpose of this study was to expose the frequency of anatomical variations in the renal vein (RV) and detail their relationship with the retroperitoneal and renal regions. Methods: A systematic search was conducted in the Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception until January 2024. Two authors independently carried out the search, study selection, and data extraction and assessed methodological quality using a quality assurance tool for anatomical studies (AQUA). Ultimately, consolidated prevalence was estimated using a random effects model. Results: In total, 91 studies meeting the eligibility criteria were identified. This study included 91 investigations with a total of 46,664 subjects; the meta-analysis encompassed 64 studies. The overall prevalence of multiple renal veins was 5%, with a confidence interval (CI) of 4% to 5%. The prevalence of the renal vein trajectory was 5%, with a CI of 4% to 5%. The prevalence of renal vein branching was 3%, with a CI of 0% to 6%. Lastly, the prevalence of unusual renal vein origin was 2%, with a CI of 1% to 4%. Conclusions: The analysis of these variants is crucial for both surgical clinical management and the treatment of patients with renal transplant and hemodialysis.

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We present two cases of multiple anatomical variations of the renal and gonadal vessels. The first case presented duplication of the renal vein and the presence of an accessory renal artery. However, the most interesting fact, in this case, was that the right gonadal vein emptied into the inferior right renal vein instead of ending in the inferior vena cava as would typically be the case. In the second case, we also found an accessory renal artery and the right gonadal vein emptied at the exact junction between the right renal vein and the inferior vena cava. Clinicians and surgeons should be familiar with anatomical variations to provide an accurate diagnosis during preoperative studies and to avoid surprises in abdominal surgical procedures.

Este estudo apresenta dois casos de variação anatômica múltipla de vasos renais e gonadais. O primeiro caso apresentou uma duplicação da veia renal e a presença de uma artéria renal acessória. Porém, o fato mais interessante nesse caso foi a veia gonadal direita desembocar na veia renal direita inferior em vez de terminar na veia cava inferior, como seria o normal. No segundo caso, além de também encontrarmos uma artéria renal acessória, a veia gonadal direita desembocava no exato ponto de junção entre a veia renal direita e a veia cava inferior. Clínicos e cirurgiões devem estar familiarizados com a presença de possíveis variações dos vasos renais e gonadais, sendo um conhecimento imprescindível para obter um diagnóstico mais preciso e para evitar surpresas em procedimentos cirúrgicos abdominais.

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Knowledge of the anatomical variations of the visceral branches of the abdominal aorta is important information for planning any surgeries in the region. We present here a rare constellation of variations of visceral vessels around the kidneys with a brief review of the recent literature. On the right side, an accessory renal artery was observed originating just distal to the main renal artery. The middle suprarenal artery was absent on the right side and there were two inferior suprarenal arteries originating from a branch of the main right renal artery. On the left side, the testicular artery had an arched course anterior to the left renal vein mimicking an unusual variety of nutcracker phenomenon. The right kidney was drained by two renal veins into the inferior vena cava. Knowledge of the coexistence of such complex anatomical variations might be helpful for clinicians during diagnostic and therapeutic procedures.

O conhecimento das variações anatômicas dos ramos viscerais da aorta abdominal é uma informação importante para o planejamento de qualquer cirurgia nessa região. Neste relato, apresentamos um raro conjunto de variações de vasos viscerais ao redor dos rins, bem como uma breve revisão da literatura recente. No lado direito, foi observada uma artéria renal acessória originando-se distal à artéria renal principal. Não havia artéria suprarrenal média no lado direito, e havia duas artérias suprarrenais inferiores originando-se de um ramo da artéria renal direita. No lado esquerdo, a artéria testicular apresentava um curso arqueado anterior à veia renal esquerda, simulando uma variedade incomum do fenômeno do quebra-nozes. O rim direito era drenado por duas veias renais para a veia cava inferior. O conhecimento da coexistência de tais variações anatômicas complexas pode ser útil para os clínicos durante os procedimentos diagnósticos e terapêuticos.

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INTRODUCTION: Venous thromboembolism is widely recognized as a life-threatening complication in trauma, yet renal vein thrombosis (RVT) following trauma is particularly rare. PRESENTATION OF CASE: We report a case of a 67-year-old man who was brought to the emergency department after falling down a 14-step staircase at home which presented right kidney trauma (parenchyma laceration with a perirenal hematoma) on computed tomography, and hematuria. Considering the patient's hemodynamic stability, a non-operative treatment was initiated, and the patient was referred to the intensive care unit for close observation. On post-trauma day 3, a repeated CT revealed right renal vein thrombosis. After evaluation, it was decided to maintain prophylactic anticoagulation doses of enoxaparin (40 mg/day) due to the elevated risk of bleeding in high-grade renal trauma and planned an inferior vena cava (IVC) filter placement. In the following days, the hematuria resolved spontaneously and an IVC filter was placed. The patient progressed with no complaints, spontaneous diuresis, improvement in laboratory parameters, and cardiovascular stability, which led to his discharge on day 12 with rivaroxaban 10 mg/day. The patient was successfully treated with a non-operative approach, and the RVT disappeared after 35 days. DISCUSSION: Post-traumatic renal vein thrombosis is a rare occurrence, and due to the infrequent nature of these events, specific management guidelines are not fully established, particularly when thrombosis is confirmed in an acutely injured patient. CONCLUSION: Conservative therapy seems to play a meaningful role in trauma-related renal vein thrombosis treatment.

RESUMO

Abstract Knowledge of the anatomical variations of the visceral branches of the abdominal aorta is important information for planning any surgeries in the region. We present here a rare constellation of variations of visceral vessels around the kidneys with a brief review of the recent literature. On the right side, an accessory renal artery was observed originating just distal to the main renal artery. The middle suprarenal artery was absent on the right side and there were two inferior suprarenal arteries originating from a branch of the main right renal artery. On the left side, the testicular artery had an arched course anterior to the left renal vein mimicking an unusual variety of nutcracker phenomenon. The right kidney was drained by two renal veins into the inferior vena cava. Knowledge of the coexistence of such complex anatomical variations might be helpful for clinicians during diagnostic and therapeutic procedures.

Resumo O conhecimento das variações anatômicas dos ramos viscerais da aorta abdominal é uma informação importante para o planejamento de qualquer cirurgia nessa região. Neste relato, apresentamos um raro conjunto de variações de vasos viscerais ao redor dos rins, bem como uma breve revisão da literatura recente. No lado direito, foi observada uma artéria renal acessória originando-se distal à artéria renal principal. Não havia artéria suprarrenal média no lado direito, e havia duas artérias suprarrenais inferiores originando-se de um ramo da artéria renal direita. No lado esquerdo, a artéria testicular apresentava um curso arqueado anterior à veia renal esquerda, simulando uma variedade incomum do fenômeno do quebra-nozes. O rim direito era drenado por duas veias renais para a veia cava inferior. O conhecimento da coexistência de tais variações anatômicas complexas pode ser útil para os clínicos durante os procedimentos diagnósticos e terapêuticos.

RESUMO

Abstract We present two cases of multiple anatomical variations of the renal and gonadal vessels. The first case presented duplication of the renal vein and the presence of an accessory renal artery. However, the most interesting fact, in this case, was that the right gonadal vein emptied into the inferior right renal vein instead of ending in the inferior vena cava as would typically be the case. In the second case, we also found an accessory renal artery and the right gonadal vein emptied at the exact junction between the right renal vein and the inferior vena cava. Clinicians and surgeons should be familiar with anatomical variations to provide an accurate diagnosis during preoperative studies and to avoid surprises in abdominal surgical procedures.

Resumo Este estudo apresenta dois casos de variação anatômica múltipla de vasos renais e gonadais. O primeiro caso apresentou uma duplicação da veia renal e a presença de uma artéria renal acessória. Porém, o fato mais interessante nesse caso foi a veia gonadal direita desembocar na veia renal direita inferior em vez de terminar na veia cava inferior, como seria o normal. No segundo caso, além de também encontrarmos uma artéria renal acessória, a veia gonadal direita desembocava no exato ponto de junção entre a veia renal direita e a veia cava inferior. Clínicos e cirurgiões devem estar familiarizados com a presença de possíveis variações dos vasos renais e gonadais, sendo um conhecimento imprescindível para obter um diagnóstico mais preciso e para evitar surpresas em procedimentos cirúrgicos abdominais.

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Testut & Latarjet (1980), Bouchet & Cuilleret (1986), Latarjet & Liard (2005) y Rouvière & Delmas (2005) describen las relaciones intrínsecas del pedículo renal (PR) a partir de dos planos coronales, siendo la PER el elemento que limita entre ambos. Trivedi et al. (2011) demostró relaciones entre los elementos del PR que no coinciden con las descripciones aportadas por dichos autores.Conocer las posibles variantes en las relaciones intrínsecas del PR es de suma importancia en prácticas quirúrgicas como el trasplante renal (García de Jalón Martínez et al., 2003; Batista Hernández et al., 2010). Por lo tanto, el objetivo del presente trabajo fue analizar las variables relaciones entre los elementos que conforman el PR en la región yuxtahiliar del riñón. Se estudiaron 23 PR, formolizados al 10 % y provistos por el Equipo de Disección de la Segunda Cátedra de Anatomía de la Universidad de Buenos Aires. Se clasificaron los PR en dos grupos. En el Grupo I, las afluentes de origen de la vena renal (AOVR) se hallaban en el mismo plano coronal. En el grupo II, las AOVR se encontraban en diferentes planos coronales. Cada grupo fue subdividido en distintos patrones. Los patrones I y II, de mayor incidencia, fueron asociados al grupo I y los patrones III, IV y V al grupo II. En el patrón I, las AOVR eran anteriores a la pelvis renal (PER) y posteriores a la arteria prepiélica (APP). En el patrón II, las AOVR eran anteriores a la PER y a la APP. Los patrones I y II conforman el grupo I y presentaron mayor número de incidencia en nuestra investigación. Existen también variantes que inciden con menor frecuencia que dichos patrones, estas comprenden el grupo II de la clasificación planteada en el presente trabajo.

SUMMARY: Testut & Latarjet (1980), Bouchet & Cuilleret (1986), Latarjet & Liard (2005) y Rouvière & Delmas (2005) describe the intrinsic relationships of the renal pedicle (PR) from two coronal planes, the renal pelvis (PER) being the element that limits between both. Trivedi et al. (2011) showed relationships between the elements of the RP that do not coincide with the descriptions provided by these authors. Knowing the possible variants in the intrinsic relationships of the RP is of the utmost importance in surgical practices such as renal transplantation (García de Jalón Martínez et al., 2003). Therefore, the objective of this study is to analyze the variable relationships between the elements that make up the RP in the juxtahilar region of the kidney. 23 RP were studied, formalized at 10 % and provided by the Dissection Team of the Second Chair of Anatomy of the University of Buenos Aires. PRs were classified into two groups. In Group I, the tributaries of origin of the renal vein (RVOA) were in the same coronal plane. In group II, the AOVRs were in different coronal planes. Each group was subdivided into different patterns. Patterns I and II, with the highest incidence, were associated with group I and patterns III, IV and V with group II. In pattern I, the VROA were anterior to the renal pelvis (PER) and posterior to the prepelvic artery (PPA). In pattern II, AOVRs were prior to PER and APP. Patterns I and II make up group I and presented a higher number of incidence in our investigation. There are also variants that occur less frequently than these patterns, these comprise group II of the classification proposed in this work.

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Nutcracker syndrome (NCS) is a rare condition caused by compression of the left renal vein (LRV) between the aorta and superior mesenteric artery. Surgical treatment is reserved for patients with severe symptoms and failure of conservative treatment. A 31-year-old woman diagnosed in adolescence with NCS has had recurrent pain since age 15. For 30 days, she has had severe left flank pain and microhematuria. The patient underwent extravascular stent placement around the LRV with the Da Vinci Xi. In 30 months of follow-up, the patient has no pain and the LRV remained without compressions or thrombosis.

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Resumen Objetivo: describir la presentación clínica, el diagnóstico y el tratamiento quirúrgico de un paciente con síndrome de la arteria mesentérica superior o síndrome de Wilkie combinado con síndrome de cascanueces o síndrome de compresión de la vena renal izquierda, en un centro de alta complejidad de un país latinoamericano. Descripción del caso: paciente masculino de 25 años, procedente de Estados Unidos, quien consultó por un año de pérdida de peso y episodios de obstrucción intestinal de etiología desconocida tras múltiples estudios de imagen. Se le realizaron estudios endoscópicos sin hallazgos; en la sala de recuperación desarrolló dolor abdominal que requirió ingreso al servicio de urgencias. La enterotomografía mostró dilatación de asas de colon e intestino delgado, con disminución del ángulo aortomesentérico y la serie gastrointestinal con paso filiforme del medio de contraste. Se intentó el manejo conservador como terapia inicial, con intolerancia al soporte nutricional entérico. Finalmente, se optó por el tratamiento quirúrgico, con un proceso de recuperación tórpido inicialmente, pero al final con resolución de los síntomas y aumento de peso. Conclusión: el síndrome de Wilkie es una enfermedad rara y un desafío diagnóstico en pacientes con pérdida de peso y dolor abdominal. Describimos un caso de compresión de la arteria mesentérica superior en el que se logró el diagnóstico con múltiples estrategias diagnósticas y resolución completa luego del tratamiento quirúrgico. La disminución del ángulo aortomesentérico puede comprimir la arteria mesentérica superior, así como la vena renal izquierda, que en ese caso resultó en un síndrome combinado de Wilkie y de cascanueces.

Abstract Objective: to describe the clinical presentation, diagnosis, and surgical treatment of a patient with superior mesenteric artery syndrome or Wilkie syndrome combined with the nutcracker syndrome or left renal vein compression syndrome in a tertiary referral center in a Latin American country. Case description: a 25-year-old male patient from the United States who attended for a year of weight loss and intestinal obstruction episodes of unknown etiology after multiple imaging studies. Endoscopic studies were performed without findings. While in the recovery room, he developed abdominal pain requiring admission to the emergency service. The CT enterography showed dilation of the colon loops and small intestine with a decrease of the aortomesenteric (AOM) angle and the gastrointestinal series with the filiform passage of the contrast medium. Conservative management was attempted as initial therapy with intolerance to enteric nutritional support. Finally, we initially opted for surgical treatment, with a slow recovery process, but in the end, with a resolution of symptoms and weight gain. Conclusion: Wilkie syndrome is a rare disease and a diagnostic challenge in patients with weight loss and abdominal pain. We described a superior mesenteric artery compression case in which diagnosis was achieved with multiple diagnostic strategies and complete resolution after surgical treatment. The decreased aortomesenteric angle may compress the superior mesenteric artery and the left renal vein. In this case, it resulted in a combined Wilkie and nutcracker syndrome.

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A ruptured abdominal aortic aneurysm after endovascular aneurysm repair with an arteriovenous fistula between the aneurysm sac and a retroaortic left renal vein is an extremely rare complication. This case describes an 81-year-old man who developed an aorto-left renal vein fistula owing to a type IB endoleak 2 years after endovascular aneurysm exclusion. The leak was repaired with a left endograft limb extension. Endovascular techniques are attractive and feasible alternatives and can play an essential role in reinterventions. This report is the first of an aorto-left renal vein fistula owing a type IB endoleak after an endovascular aneurysm repair.

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Methicillin-resistant Staphylococcus aureus (MRSA) infections are cases of urgent management that often leads to hospitalizations in intensive care and prolonged management of antibiotic therapy. In this occasion, we present the case of a 38-year-old female patient with sepsis secondary to banal dermal infection due MRSA that complicates with infectious thrombus of the left renal vein associated with multiple foci of bilateral renal abscesses. As an extreme and exceptional measure, emergency bilateral radical nephrectomy was performed to save the patient's life.

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OBJECTIVE: We evaluated the frequency of significant left renal vein (LRV) compression, also called the nutcracker phenomenon (NCP), in a normal asymptomatic population. METHODS: The present retrospective descriptive anatomic study analyzed the data from high-definition renal computed tomography (CT) angiography of living kidney donors. A total of 324 CT examinations were evaluated for signs of LRV compression, including the beak sign, aortomesenteric angle <41°, LRV diameter ratio ≥4.9, and beak angle ≥32°. The presence of pelvic varicose veins and the left gonadal vein in the proximal and mid-portion (considered dilated if >0.5 cm) were also evaluated. Anthropometric and laboratory (urine erythrocyte count) data were collected from the medical records. Statistical inference was calculated using Fisher's exact test and Student's t test. RESULTS: The mean aortomesenteric angle was 53.1° in women and 58.7° in men (P = .044). The beak sign and beak angle were present in 15.3% and 9.8%, respectively, and both had a greater prevalence in the women (P = .01). An aortomesenteric angle <41° was identified in 30.5%, with a greater prevalence in women (P < .01). The diameter ratio was positive in 0.7% of the cases, with no difference between the sexes. A left gonadal vein >0.5 cm was more prevalent in women in both the proximal and the mid-portions (P < .01). Although analysis stratified by positive criteria (3 or 4) showed no difference between the sexes, a positive correlation was found with younger age (P < .01). The limitations included the absence of a nutcracker syndrome (NCS) population; the lack of a renocaval pressure gradient, because of the need for intervention; the absence of other types of imaging studies, such as duplex ultrasound scan; and the absence of female parity data. CONCLUSIONS: The NCP and NCS CT criteria were present with a high frequency in healthy individuals. Women and younger individuals showed a greater prevalence of compression findings in the aortomesenteric axis. Revision of the current NCP and NCS criteria with a distinct categorization between sex, age, and body mass index is recommended to better evaluate LRV compressive events.

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The nutcracker syndrome is caused by compression of the left renal vein by the superior mesenteric artery and aorta and is associated with characteristic symptoms, such as lower abdominal pain, varicocele, and hematuria. Diagnosis is often difficult and, therefore, is often delayed. Invasive treatment is controversial, particularly in pediatric patients. However, it is indicated in cases of gross hematuria associated with anemia, renal function impairment, severe pelvic pain, or ineffective conservative treatment. We report the case of a 12-year-old boy presenting with severe hematuria for 12 hours, with no abnormal findings at a first evaluation, who progressed with severe anemia and urinary retention. Further investigation provided images suggestive of nutcracker syndrome, and endovascular stenting (smart control stent) followed by balloon dilatation was the treatment of choice. Hematuria ceased after the procedure, and the patient is still asymptomatic at 5-year follow-up.

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Shunts between the superior mesenteric vein (SMV) and the right renal vein (RRV) are very rare. Here, we describe and depict the rare case of a liver transplant (LT) in the setting of shunt between SMV and RRV. A 67-year-old white man presenting with Child C cirrhosis secondary to hemochromatosis and persistent encephalopathy was listed for LT. Preoperative abdominal angiotomography revealed the presence of a large spontaneous shunt between the SMV and the RRV. The patient underwent LT by receiving a liver from a 17-year-old brain-dead deceased donor victim of trauma. A large shunt between the SMV and the RRV was confirmed intraoperatively. Although there was no portal vein (PV) thrombosis, the PV was atrophic and had a reduced flow. PV pressure was 22mmHg (an arterial line was inserted inside the PV stump, and this line was connected to a common pressure transducer, the pressure readings was expressed in the anesthesia monitor). After shunt ligation PV pressure increased to 32mmHg. There were no post-transplant vascular complications, and the patient was discharged home in good health. Preoperative study of all LT candidates with angio CT scan is mandatory. Whenever there is PV thrombosis, an attempt to remove the entire thrombus is warranted. After thrombectomy or whenever there is not PV thrombosis, all large shunts should be ligated. PV pressure and flow should be measured before and after shunt ligation. In the absence of PV thrombosis, ligation of the shunt should enable an increase in PV flow and pressure, as reported herein.

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Resumo A síndrome do quebra-nozes (ou síndrome de nutcracker) é causada pela compressão da veia renal esquerda pela artéria mesentérica superior e aorta, e está associada a uma sintomatologia característica, como dor no baixo ventre, varicocele e hematúria. O diagnóstico é frequentemente difícil e, portanto, demorado. O tratamento invasivo é controverso, especialmente nos pacientes pediátricos; no entanto, em casos de hematúria severa associada a anemia, insuficiência renal funcional, severa dor pélvica ou ineficácia de tratamento conservador, ele é indicado. É relatado o caso de uma criança do sexo masculino, 12 anos, com quadro de hematúria maciça por 12 horas, sem evidências de alterações à investigação inicial, que evoluiu com anemia intensa e retenção urinária. Investigações futuras evidenciaram imagens sugestivas da síndrome de nutcracker e foi optado pelo tratamento endovascular por implante de stent smart control seguido de balonamento. Paciente cessou a hematúria após o procedimento e permanece assintomático há 5 anos.

Abstract The nutcracker syndrome is caused by compression of the left renal vein by the superior mesenteric artery and aorta and is associated with characteristic symptoms, such as lower abdominal pain, varicocele, and hematuria. Diagnosis is often difficult and, therefore, is often delayed. Invasive treatment is controversial, particularly in pediatric patients. However, it is indicated in cases of gross hematuria associated with anemia, renal function impairment, severe pelvic pain, or ineffective conservative treatment. We report the case of a 12-year-old boy presenting with severe hematuria for 12 hours, with no abnormal findings at a first evaluation, who progressed with severe anemia and urinary retention. Further investigation provided images suggestive of nutcracker syndrome, and endovascular stenting (smart control stent) followed by balloon dilatation was the treatment of choice. Hematuria ceased after the procedure, and the patient is still asymptomatic at 5-year follow-up.

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A 37-year-old asymptomatic man presented with incidentally identified intra-abdominal venous aneurysms. Workup, which included venography, demonstrated an absent segment of the inferior vena cava between the inferior right and superior left renal vein, resulting in a 4.4-cm right renal vein aneurysm, dilated common iliac veins, and left external iliac vein aneurysm. Collateralization was robust. Given the limited natural history data and complexities of open reconstruction, we opted to observe this asymptomatic patient with serial imaging, which demonstrated no interval change. We present our case and a review of the literature pertaining to intra-abdominal venous aneurysms.

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Chronic pelvic pain is a debilitating disease that directly impacts on quality of life and generates costs for health services. Nutcracker Syndrome is an important cause of pelvic pain and consists of a set of signs secondary to compression of the left renal vein, most commonly between the superior mesenteric artery and the aorta. Treatment remains controversial and varies depending on the patient's clinical severity. However, endovascular treatment with renal vein stenting has achieved excellent results. We report the case of a 59 year-old female treated by endovascular repair with a self-expanding nitinol stent. Clinical data, details of the procedure, and follow-up results are presented. Technical success was achieved and there patient reported no postoperative complications. Short-term, there was relief from symptoms and follow-up imaging tests showed improvement.

RESUMO

Nutcracker syndrome is a vascular anomaly consisting in the compression of the left renal vein between the superior mesenteric artery and the aorta. Clinical features in nutcracker syndrome include pelvic pain, flank pain, haematuria, gonadal varices or simply asymptomatic. We are presenting two cases, one of them with macroscopic haematuria and flank pain and the other was studied for hypertension but with previous antecedents of left renal vein embolization in the setting of varicocele. We discuss the clinical presentation as well as diagnostic and therapeutic aspects related to this syndrome.

El síndrome del cascanueces es una anomalía vascular en la que se comprime la vena renal izquierda a su paso entre la unión de la aorta y la arteria mesentérica superior, debido a un ángulo muy cerrado entre ambas arterias. Clínicamente puede presentarse como hematuria macro o microscópica, dolor episódico en flanco izquierdo, dolor pélvico, várices gonadales o simplemente cursar de forma asintomática. Presentamos dos casos clínicos, uno de ellos con dolor abdominal tipo cólico nefrítico y hematuria macroscópica y otro estudiado por hipertensión pero con antecedentes de embolización de la vena renal izquierda por varicocele izquierdo. Discutimos los aspectos clínicos, diagnósticos y terapéuticos de este síndrome.

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RESUMO

El síndrome del cascanueces es una anomalía vascular en la que se comprime la vena renal izquierda a su paso entre la unión de la aorta y la arteria mesentérica superior, debido a un ángulo muy cerrado entre ambas arterias. Clínicamente puede presentarse como hematuria macro o microscópica, dolor episódico en flanco izquierdo, dolor pélvico, várices gonadales o simplemente cursar de forma asintomática. Presentamos dos casos clínicos, uno de ellos con dolor abdominal tipo cólico nefrítico y hematuria macroscópica y otro estudiado por hipertensión pero con antecedentes de embolización de la vena renal izquierda por varicocele izquierdo. Discutimos los aspectos clínicos, diagnósticos y terapéuticos de este síndrome.

Nutcracker syndrome is a vascular anomaly consisting in the compression of the left renal vein between the superior mesenteric artery and the aorta. Clinical features in nutcracker syndrome include pelvic pain, flank pain, haematuria, gonadal varices or simply asymptomatic. We are presenting two cases, one of them with macroscopic haematuria and flank pain and the other was studied for hypertension but with previous antecedents of left renal vein embolization in the setting of varicocele. We discuss the clinical presentation as well as diagnostic and therapeutic aspects related to this syndrome.

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Variations of the renal veins are well described in the literature, although variations concerning the ureter are considered a rare finding in cats. The circumcaval ureter is one of the rarest variations of the ureter and is characterised by a loop of the ureter posterior to the caudal vena cava. This variant is also known as preureteral vena cava and retrocaval ureter. It is thought to be caused by a deviation during embryonic development of the aforementioned vein. Due to its rarity, there are scarce reports of the circumcaval ureter in cats, and its association with two renal veins makes it less common as well. These variations should be preoperatively identified in order to avoid complications in kidney transplants, ureteral surgeries and cystoscopies, for instance. The present work aims to report two cases of a circumcaval ureter with two renal veins in two different Brazilian shorthair cats (Felis catus).

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