Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters.

METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up.

RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri-esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded.

CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.

Resolution of Large Azygos Vein Aneurysm Following Stent-Graft Shunt Placement in a Patient with Ehlers-Danlos Syndrome Type IV

Ehlers-Danlos syndrome (EDS) type IV is a rare connective tissue disorder associated with thin-walled, friable arteries and veins predisposing patients to aneurysm formation, dissection, fistula formation, and vessel rupture. Azygos vein aneurysm is an extremely rare condition which has not been reported in association with EDS in the literature. We present a patient with EDS type IV and interrupted inferior vena cava (IVC) with azygos continuation who developed an azygos vein aneurysm. In order to decrease flow through the azygos vein and reduce the risk of aneurysm rupture, a stent-graft shunt was created from the right hepatic vein to the azygos vein via a transhepatic, retroperitoneal route. At 6 month follow-up the shunt was open and the azygos vein aneurysm had resolved.

Azygos lobe associated with esophageal atresia: a trap for the unwary

Presence of an associated azygos lobe may cause problems during thoracotomy on the right side for esophageal atresia. Awareness of the anomaly allows its recognition and appropriate management.

Comparison of breath-hold 2D phase-contrast with non breath-hold cine phase-contrast MRA in the assessment of azygos venous blood flow in portal hypertension

Azygos venous blood flow as an index of blood flow through the gastroesophageal collaterals and varices is of value in the prediction of gastrointestinal bleeding. Measurement of azygos venous blood flow has been achieved by non breath-hold (NBH) cine phase-contrast magnetic resonance imaging. The objective of this study was to compare the faster breath-hold (BH) phase-contrast technique with the standard (NBH) cine phase-contrast technique in the measurement of azygos blood flow. Thirty-two cirrhotic patients with esophageal varices were examined by magnetic resonance imaging using a BH technique and a NBH cine phase-contrast technique to measure the flow velocity, flow volume and calibre of the azygos vein at the mid-right atrial level. The flow values were obtained on the velocity image of the phase-contrast study. Values obtained from the two methods were evaluated statistically for the strength and significance of correlation by the Pearson test. Measurement by the BH method performed at full-inspiration as well as end-expiration was also obtained in 15 healthy volunteers. The breath-hold phase-contrast method has significant but weak correlation with non BH cine phase-contrast method in the measurement of azygos venous blood flow volume (r = 0.55, p < 0.01) and flow velocity (r = 0.43, p = 0.01). However, the calibre of the azygos vein gave a strong correlation in these two methods (0.82). In the subgroup of patients whose azygos blood flow velocity was greater than 7.4 cm/s, the correlation of azygos blood flow volume is strong (r = 0.80, p < 0.01). The azygos vein calibre remains highly correlated between the BH and NBH method, in both high flow velocity (r = 0.73) and low flow velocity (r = 0.83) groups. Breath-hold sequence leads to higher values for flow velocity and flow volume in the cirrhotic patients and also the control group. In patients with portal hypertension, BH 2D phase-contrast (PC) magnetic resonance angiography (MRA) could give a comparable estimation of the calibre of the azygos vein as the NBH 2D cine PC MRA but not for azygos flow volume. In patients with high azygos flow velocity, the strong correlation in flow volume between the BH and NBH method suggests that the BH method may be a time-saving alternative to the NBH method.

Improvement of protein-losing enteropathy by coil embolization of the left azygos vein

We report a 17-year-old boy with double-outlet right ventricle, atrioventricular septal defect, pulmonary stenosis, and persistent left superior vena cava who developed a protein-losing enteropathy, which was cured by coil embolization of the left azygos vein, thereby interrupting the vein-to-vein shunt.

Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement

The purpose of this study was to determine the incidence of central vein stenosis and occlusion following upper extremity placement of peripherally inserted central venous catheters (PICCs) and venous ports. One hundred fifty-four patients who underwent venography of the ipsilateral central veins prior to initial and subsequent venous access device insertion were retrospectively identified. All follow-up venograms were interpreted at the time of catheter placement by one interventional radiologist over a 5-year period and compared to the findings on initial venography. For patients with central vein abnormalities, hospital and home infusion service records and radiology reports were reviewed to determine catheter dwell time and potential alternative etiologies of central vein stenosis or occlusion. The effect of catheter caliber and dwell time on development of central vein abnormalities was evaluated. Venography performed prior to initial catheter placement showed that 150 patients had normal central veins. Three patients had central vein stenosis, and one had central vein occlusion. Subsequent venograms (n = 154) at the time of additional venous access device placement demonstrated 8 patients with occlusions and 10 with stenoses. Three of the 18 patients with abnormal follow-up venograms were found to have potential alternative causes of central vein abnormalities. Excluding these 3 patients and the 4 patients with abnormal initial venograms, a 7% incidence of central vein stenosis or occlusion was found in patients with prior indwelling catheters and normal initial venograms. Catheter caliber showed no effect on the subsequent development of central vein abnormalities. Patients who developed new or worsened central vein stenosis or occlusion had significantly (p = 0.03) longer catheter dwell times than patients without central vein abnormalities. New central vein stenosis or occlusion occurred in 7% of patients following upper arm placement of venous access devices. Patients with longer catheter dwell time were more likely to develop central vein abnormalities. In order to preserve vascular access for dialysis fistulae and grafts and adhere to Dialysis Outcomes Quality Initiative guidelines, alternative venous access sites should be considered for patients with chronic renal insufficiency and end-stage renal disease.

[A case of unification anomalies of the superior vena cava and absence of the left brachiocephalic vein with dilated azygos and hemiazygos veins]

We report a case of dilated azygos vein simulating a tumor in the posterior mediastinum. The patient was a 47-year-old male who was found to have anomalies of unification of the superior vena cava and absence of the left brachiocephalic vein. He was admitted to our hospital because chest radiographs and computed tomography (CT) scans showed a well-circumscribed oval mass 2.5 cm in diameter, behind the bifurcation of the trachea. This lesion, which was markedly enhanced in chest CT, magnetic resonance imaging (MRI) and MR angiography (MRA) was diagnosed as a dilated azygos vein. An enlarged hemiazygos vein and collaterals were also recognized. Upon digital subtraction venography of both upper extremities, the right atrium and the left brachiocephalic vein could not been distinguished from the superior vena cava and the infraclavicular vein, respectively. Collaterals entering the azygos and hemiazygos veins were, however, recognized. It was considered that MRA and disital subtraction venography were very useful for confirmation of the diagnosis in this case.

Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices

BACKGROUND/AIM

The correlation between angiographic vascular patterns and endoscopic findings in portal hypertension is not sufficiently known, and knowledge of the vascular anatomy may contribute to an improvement in endoscopic embolization and transjugular retrograde obliteration procedures. We propose a new vascular map that should prove useful for this purpose.

METHODS

Between April 1985 and December 1997 we performed percutaneous transhepatic portography in a selected group of 75 patients (16 women and 59 men), aged 43-71 years, from whom informed consent was obtained. All patients had been diagnosed endoscopically as having either esophageal or isolated gastric varices. According to the Child-Pugh classification, class A, B, and C cirrhosis was seen in 19, 40, and 16 patients, respectively. We created a vascular map of esophageal and isolated gastric varices, based on the opacification of the portal venous collaterals on percutaneous transhepatic portography. We compared the patients in both variceal groups in terms of portal venous pressure, main blood supply, and drainage routes.

RESULTS

We found that the portal collateral system was divided into two systems: the portoazygos venous system and the portophrenic venous system. The former contributed to the formation of esophageal and cardiac varices and the latter to the formation of isolated gastric varices located at the fundus or at both the cardia and fundus. The left gastric vein participated as blood supply in 70% of the isolated gastric varices and in 100% of the esophageal varices (p < 0.01). The posterior gastric vein participated as blood supply in 70% of the isolated gastric varices and in 24% of the esophageal varices (p < 0.01). We classified the main blood drainage routes of isolated gastric varices functionally into three types: gastrorenal shunt (85%), gastrophrenic shunt (10%), and gastropericardiac shunt (5%). The portal venous pressure in patients with esophageal varices was 358 +/- 66 mm H(2)O, whereas in patients with isolated gastric varices it was 262 +/- 44 mm H(2)O (p < 0.01).

CONCLUSION

We suggest that this new vascular map will be useful in endoscopic embolization and transjugular retrograde obliteration procedures for esophageal and isolated gastric varices.

Thoracoabdominal intestinal duplication with absent inferior vena cava

We report a rare case of thoracoabdominal intestinal duplication with absent inferior vena cava (IVC). The patient was initially explored with a mistaken diagnosis of diaphragmatic hernia on the basis of a chest radiograph and barium meal. However, a subsequent computed tomography scan revealed a mediastinal mass with an air-fluid level, a hugely dilated azygos vein, and an absent IVC. Thoracoabdominal exploration was required to excise the duplication cyst arising from the jejunum. We believe that this is the first report of this association.

Giant aneurysm of the azygos anterior cerebral artery--case report

A 77-year-old female presented with a giant aneurysm of the azygos anterior cerebral artery (ACA) manifesting as acute onset of akinetic mutism caused by enlargement of the aneurysm resulting from rapid thrombus formation within the aneurysmal sac. Thrombus removal to obtain decompression of the aneurysmal bulk and tension was performed before parent artery occlusion to prevent thromboembolic events. The aneurysmal neck was completely clipped with preservation of the parent artery and all branches. This strategy for direct neck clipping of a giant thrombosed distal ACA aneurysm can reduce the possibility of ischemic sequelae.

Azygos vein diverticulum

A 47-year-old woman, diagnosed with a diverticulum of the arch of the azygos vein, underwent surgical treatment. With nonspecific symptomatology, she presented one of the most uncommon anomalies of the large veins.

Isolated azygos continuation of the inferior vena cava in the elderly

A 70-year-old woman with the isolated anomaly of azygos continuation of the inferior vena cava is presented. The interest in this anomaly lies in its presentation as a mediastinal mass on the chest roentgenogram. This article reviews the embryogenesis and the diagnostic testing of this venous anomaly.

Anomalous inferior vena cava demonstrated by contrast-enhanced magnetic resonance venography

We discuss the technique of contrast-enhanced magnetic resonance venography and its advantages over other methods of imaging the veins of the chest. An example is presented of the results of this technique in a patient with agenesis of the hepatic segment of the inferior vena cava and azygos continuation.

Clinical significance of azygos vein enlargement: radiographic recognition and etiologic analysis

Azygos vein enlargement can be detected in congestive heart failure, portal hypertension, inferior vena cava thrombosis, right atrial mural thrombosis, a pulmonary embolism, congenital azygos continuation to the inferior vena cava, and the arteriovenous fistula. Radiography, particularly computed tomography (CT), is very useful, not only in recognition of azygos vein enlargement, but also in evaluation of its etiology for the institution of the appropriate treatment of the diseases.

Azygos venous blood flow while fasting, postprandially, and after endoscopic variceal ligation, measured by magnetic resonance imaging

Using cine phase-contrast magnetic resonance (MR) imaging, we measured fasting and postprandial azygos blood flow in 15 cirrhotic patients with portal hypertension and 11 healthy controls. In 10 of the cirrhotics, measurements were made before and after prophylactic endoscopic variceal ligation therapy (EVL). Flow volume was measured in the azygos vein at the level of the midthoracic vertebra. Azygos blood flow was measured under basal fasting conditions and 30-40 min after ingestion of a 500 Kcal meal. Fasting azygos blood flow was 139 +/- 43 ml/min in controls vs 519 +/- 249 ml/min in cirrhotics (P < 0.01). Eating significantly increased azygos blood flow, by 38% in controls (P < 0.02) and by 27% in cirrhotics (P < 0.02), compared with fasting conditions. EVL markedly decreased azygos blood flow, by 25% compared with pre-EVL (P < 0.03). The cine phase-contrast MR velocity mapping method measured flow volume in the azygos veins. Azygos blood flow was markedly greater in the cirrhotics than in the controls. In the cirrhotics and controls, blood flow volume increased after eating. Azygos blood flow was significantly reduced by successful EVL.

Idiopathic saccular aneurysm of the azygos vein

Idiopathic saccular aneurysm of the azygos vein is a rare condition. We report the case of a 52-year-old man with saccular aneurysm of the azygos vein who underwent surgical resection. Preoperative dynamic computed tomography revealed strong and rapid enhancement of the chest mass. Magnetic resonance imaging showed a thoracic tumor with low signal intensity on the T1-weighted image and coexistence of low and high signal intensity on the T2-weighted image. Intraoperative findings showed cystic dilatation of the azygos vein. Although an accurate preoperative diagnosis of saccular azygos vein aneurysm is difficult, especially differential diagnosis between this anomaly and mediastinal tumors, a markedly enhanced mass shown by dynamic computed tomography was useful for the preoperative diagnosis of this anomaly.

Azygos continuation syndrome with aneurysm of the azygos vein: CT and MR appearances

We present a case of azygos vein continuation with aneurysm of the azygos vein simulating a tumor in the right upper mediastinum. The dynamic CT examination initially showed a structure of malignant appearance during the early arterial phase. Further dynamic CT revealed marked enhancement of the mass during the late venous phase, suggesting a vascular structure. Confirmation of diagnosis was made by MRI using a fast gradient echo imaging technique in cine mode, showing turbulent flow in the azygos aneurysm, and contrast-enhanced MR angiography, demonstrating a dilated azygos vein. Dynamic CT has a potential pitfall in the diagnosis of vascular structures.

[Dilatation of the azygos vein: an unusual cause of pulmonary mass]

Infrahepatic interruption of the inferior cava vein, is a rare congenital anomaly, usually associated with congenital heart and abdominal diseases. The systemic venous flow is accommodated by the dilated azygos. This dilated azygos arch accounts for the right paratracheal or mediastinal mass, and may be misinterpreted as a neoplasm. We report a case with this congenital vascular anomaly, associated with another of tracheobronchial tree.

[Pelvic and leg vein thrombosis in azygous and hemi-azygous vein continuity syndrome and complete agenesis of the inferior vena cava]

A patient with a complete agenesis of the inferior vena cava is presented. In this rare anomaly the blood of the pelvic veins is drained through the dilated venae lumbales, vena azygos and vena hemiazygos into the superior vena cava. The malformation was detected within the scope diagnostics of deep vein thrombosis. The diagnosis was made by sonography, computed tomography and magnetic resonance angiography.

Idiopathic saccular azygos vein aneurysm

We present a case of asymptomatic saccular aneurysm of the azygos vein. This abnormality is exceedingly rare. Dynamic computed tomography revealed strong enhancement of the mass, suggesting a vascular structure, which was very important for preoperative diagnosis. It is unclear whether the mass should be resected if the preoperative diagnosis has been made and the mass is not so large.