1
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Manjatika AT, Mazengenya P, Davimes JG. Bilateral duplicated inferior vena cava associated with aberrant internal iliac and gonadal veins: A case-based narrative review. Ann Anat 2024; 253:152223. [PMID: 38295909 DOI: 10.1016/j.aanat.2024.152223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/09/2023] [Accepted: 01/25/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND The left side anterior retroperitoneal approach is preferred for the management of lumbosacral spine disorders as there is reduced risk for vascular injury. The presence of multiple and uncommon venous variations on either side of the spine, like the bilateral duplicated inferior vena cava (DIVC), may complicate surgery in this region. The current study describes two rare cases of bilateral duplicated inferior vena cava associated with internal iliac and gonadal veins. METHODS The cases were identified during routine human dissections of the posterior abdominal wall of 89 (45 males, 44 females) individuals. The course, relations and morphometry of each duplicated inferior vena cava were examined and recorded. RESULTS Two (2.2%) of the 89 (1 male, 1 female) dissected individuals showed the presence of bilateral duplicated infrarenal segments of the inferior vena cava. In both cases, the pre-aortic trunk (vein) was the largest and the left inferior vena cava was the smallest. Both cases of bilateral DIVC presented with anomalous interiliac communicating veins, internal iliac veins, and drainage sites of the left gonadal veins. CONCLUSIONS The duplicated inferior vena cava may present with associated venous anomalies like those related to the gonadal and internal iliac veins. Knowledge of the duplicated inferior vena cava and its associated venous anomalies may be essential for accurately identifying and diagnosing vascular dysfunction and improving radiological interpretation across multiple surgical specialities.
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Affiliation(s)
- Arthur Tsalani Manjatika
- School of Anatomical Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa; School of Life Sciences, Anatomy Division, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Pedzisai Mazengenya
- College of Medicine, Ajman University, Ajman, United Arab Emirates; Center of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates; Faculty of Health Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa.
| | - Joshua Gabriel Davimes
- School of Anatomical Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa
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2
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Chiang CH, Tsai TY, Liu YC, Cheong KM. A Woman With Periumbilical Pain. Ann Emerg Med 2023; 82:e203-e204. [PMID: 37993234 DOI: 10.1016/j.annemergmed.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Cheng-Han Chiang
- Emergency Department, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Tou-Yuan Tsai
- Emergency Department, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Chang Liu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kar Mun Cheong
- Emergency Department, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
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3
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Abu Sabha MR, Bairmani ZA, Alfroukh KM, Nassar O, Albakri M. Extensive Deep Vein Thrombosis With Intraabdominal Extension Triggered by Oral Contraceptive Use in a Young Patient With Interrupted Inferior Vena Cava With Azygos Continuation: A Case Report. Cureus 2023; 15:e42690. [PMID: 37649933 PMCID: PMC10465072 DOI: 10.7759/cureus.42690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
Congenital malformations of the inferior vena cava (IVC) are rare and often asymptomatic, typically discovered incidentally during imaging. However, these anomalies can result in circulatory stasis, impede venous return, and serve as predisposing factors for thrombus formation. Here, we present a unique case of a 28-year-old female patient who was found to have interrupted IVC with azygos continuation, an exceedingly rare IVC anomaly, during a work-up of extensive bilateral deep vein thrombosis (DVT) with an intraabdominal extension which was triggered by recent combined oral contraceptive pills (OCP) use. This case highlights the importance of considering vena cava malformations as an underlying cause for extensive DVT, even in the absence of conventional risk factors. Clinicians should be aware of the potential association between congenital vena cava anomalies and thrombotic events, as early recognition and appropriate management are crucial for preventing complications such as pulmonary embolism.
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Affiliation(s)
- Mosa R Abu Sabha
- Internal Medicine, Faculty of Medicine, Al Quds University, Jerusalem, PSE
| | - Zinah A Bairmani
- Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University, Philadelphia, USA
| | | | - Osayd Nassar
- Internal Medicine Department, Al-Ahli Hospital, Hebron, PSE
| | - Mutaz Albakri
- Internal Medicine Department, Hebron University College of Medicine, Hebron, PSE
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4
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Abstract
The inferior vena cava (IVC) may develop abnormally because of its complex embryogenesis. An understanding of congenital variants such as duplication of the IVC is essential for clinical interventions, particularly those performed by surgeons and radiologists. We herein describe five patients who were diagnosed with duplication of the IVC by computed tomography or angiography and summarize their imaging and clinical features. All five patients were men aged 46 to 78 years. Two of the patients had pulmonary embolism and deep vein thrombosis and were treated by placement of an IVC filter and catheter-directed thrombolysis. The IVC in all patients ascended on either side of the abdominal aorta. All left IVCs terminated in the left renal vein, which crossed the aorta and joined the right IVC. The average follow-up time was 29 months (range, 14-46 months), and no patients developed venous thromboembolism or recurrence of thrombosis. Duplication of the IVC can be diagnosed by computed tomography and angiography. Its course and relationship with the renal vein must be identified for accurate planning of IVC filter placement in the setting of deep vein thrombosis and pulmonary embolism.
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Affiliation(s)
- Wen-rui Li
- Department of Vascular Surgery, Beijing Friendship
Hospital, Capital Medical University, Beijing 100050, China
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship
Hospital, Capital Medical University, Beijing 100050, China
| | - Lei Jin
- Department of Vascular Surgery, Beijing Friendship
Hospital, Capital Medical University, Beijing 100050, China
| | - Xue-ming Chen
- Department of Vascular Surgery, Beijing Friendship
Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-wen Zhang
- Department of Vascular Surgery, Beijing Friendship
Hospital, Capital Medical University, Beijing 100050, China
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5
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Mutavdzic P, Dragas M, Galun D, Mašulović D, Tomić I, Sladojević M, Zlatanović P, Davidovic L. Recurrent deep venous thrombosis of lower extremities as a result of compression of large horseshoe kidney cysts in double inferior vena cava - Successfully treatment with sclerotherapy. Vascular 2022; 31:603-607. [DOI: 10.1177/17085381221076332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Horseshoe kidney is a well-known congenital anomaly and the most common anomaly of the upper urinary tract. This condition is rarely associated with anomalous inferior vena cava (IVC). Polycystic horseshoe kidney is a very rare occurrence and however IVC anomalies common with polycistic disease are an increasingly recognized risk factor for iliofemoral deep venous thrombosis. Method We present a case of 75-year-old patient with recurrent deep vein thrombosis (DVT) of right leg as a result of compression of large horseshoe kidney cysts in double inferior vena cava. Results Large renal cyst were successful treated percutaneously punctured for the relief of compression and received injection of acidic solutions of 95% ethanol under ultrasound guidance for prevention against re-accumulation of cyst fluid. Conclusion Percutaneous aspiration with ultrasound guidance with injection of sclerosing solutions as a relatively simple procedure and can be the method of choice for treatment of renal cysts. Also, any recurrent deep vein thrombosis on lower extremity requires additional evaluation in the form of an ultrasound or multidetector computed tomography examination of the abdomen.
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Affiliation(s)
- Perica Mutavdzic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Dragas
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijel Galun
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Abdominal Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Dragan Mašulović
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Center for Radiology et MRI, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivan Tomić
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miloš Sladojević
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Petar Zlatanović
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Lazar Davidovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
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6
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Mansour MM, Hussein O, Saad B, Shinn A, Patel T. A Rare Case of Pulmonary Embolism in a Patient With Interrupted Inferior Vena Cava and Polysplenia. Cureus 2022; 14:e22323. [PMID: 35317044 PMCID: PMC8934036 DOI: 10.7759/cureus.22323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
Abstract
Interrupted inferior vena cava (IVC) with azygos continuation is one of the anomalies of the inferior vena cava (AIVCs) where venous drainage of the lower extremities is accomplished through a dilated azygos system and is usually accompanied by other congenital malformations such as polysplenia. AIVCs are more common in patients younger than 40 presenting with deep venous thrombosis (DVT). However, pulmonary embolism (PE) in association with AIVCs remains underreported. In this article, we describe a rare case of a 23-year-old male who presented with syncope secondary to sub-massive pulmonary embolism in the setting of an interrupted vena cava draining directly into the azygous vein.
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7
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Kostov S, Selçuk I, Yordanov A, Kornovski Y, Yalçın H, Slavchev S, Ivanova Y, Dineva S, Dzhenkov D, Watrowski R. Paraaortic Lymphadenectomy in Gynecologic Oncology—Significance of Vessels Variations. J Clin Med 2022; 11:953. [PMID: 35207226 PMCID: PMC8879527 DOI: 10.3390/jcm11040953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
Lymphadenectomy has been an essential part of the surgical treatment in surgical oncology, as the lymphatic channels and nodes are the main dissemination pathway for most of the gynecological cancers. Pelvic and paraaortic lymphadenectomy are frequent surgical procedures in gynecologic oncology. Paraaortic lymph node dissection facilitates staging, prognosis, surgical and postoperative management of patients. It is one of the most challenging retroperitoneal surgeries. A comprehensive knowledge of the paraaortic region is mandatory. Intraoperative bleeding is the most common complication during lymphadenectomy due to direct vascular injury, poor tissue handling, exuberant retraction and possible anatomical variations of the vessels in the paraaortic region. Approximately, one-third of women will have at least one anatomic variation in the paraaortic region. It must be stressed that anomalous vessels may be encountered in every woman who will undergo surgery. Consequently, detailed knowledge of anatomical vessels variations is required in order to prevent iatrogenic vessel injury. The importance of these variations is well described in urology, vascular and general surgery. Conversely, in oncogynecological surgery, there are few articles, which described some of the vessels variations in the paraaortic region. The present article aims to propose a surgical classification and to describe the majority of vessels variation, which could be encountered during paraaortic lymphadenectomy in gynecologic oncology. Moreover, surgical considerations in order to prevent anomalous vessels injury are well described.
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8
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Abstract
The inferior vena cava (IVC) is the largest vein in the body, draining blood from the abdomen, pelvis and lower extremities. This pictorial review summarises normal anatomy and embryological development of the IVC. In addition, we highlight a wide range of anatomical variants, acquired pathologies and a common pitfall in imaging of the IVC. This information is essential for clinical decision making and to reduce misdiagnosis.
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Affiliation(s)
- Simon J Li
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - Jean Lee
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jonathan Hall
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Tom R Sutherland
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
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9
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Spurzem GJ, Taddonio MA, Rubenzik TT, Bouvet M. Duplicate inferior vena cava complicating the evaluation of primary aldosteronism. BMJ Case Rep 2021; 14:14/1/e240093. [PMID: 33462066 PMCID: PMC7813361 DOI: 10.1136/bcr-2020-240093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
A 64-year-old man with a known duplicate inferior vena cava (D-IVC) and resistant hypertension presented to our emergency department in a hypertensive crisis. He had a longstanding history of hypertension and unexplained hypokalemia treated with oral potassium supplementation. The patient was diagnosed with primary aldosteronism and MRI of the abdomen revealed a left-sided adrenal adenoma. Adrenal venous sampling (AVS) lateralised aldosterone hypersecretion to the left adrenal gland. The patient subsequently underwent an uncomplicated laparoscopic left adrenalectomy. The patient's postoperative course was uneventful, and he was discharged on a single antihypertensive medication on postoperative day 1. D-IVC is one of several rare IVC anatomical variants that have been well described in the literature. Knowledge of this patient's unique abdominal venous anatomy enabled successful AVS and appropriate surgical management. It is necessary to identify potential anatomical variants of abdominal venous anatomy that may complicate these invasive procedures.
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Affiliation(s)
- Graham J Spurzem
- Surgery, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Michael A Taddonio
- Radiology, University of California San Diego, La Jolla, California, USA
| | - Tamara T Rubenzik
- Medicine, University of California San Diego, La Jolla, California, USA
| | - Michael Bouvet
- Surgery, University of California San Diego, La Jolla, California, USA
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10
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Cheung KT, Wong E. Duplicated Inferior Vena Cava in a Patient With Ampullary Adenocarcinoma: A Case Report and Literature Review of Anatomical Variations. Cureus 2020; 12:e11576. [PMID: 33364101 PMCID: PMC7749830 DOI: 10.7759/cureus.11576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Duplicated inferior vena cava (IVC) is a rare anatomical anomaly as a result of failed regression of the left supracardinal vein during the embryonic stage. This anatomical variation has certain surgical implications and could lead to potential catastrophe perioperatively. We hereby report a case of a 54 years old male in whom a whipple procedure was performed with type 1 duplicated IVC for ampullary adenocarcinoma. Review of current literature of such anatomical anomaly will also be discussed. This venous anomaly must be kept in mind in all surgical procedures involving the retroperitoneum to minimise the risk of incomplete lymph node dissection and life-threatening bleeding, and to guide management for deep vein thrombosis in the post-operative setting.
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Affiliation(s)
- King Tung Cheung
- Surgery, Eastern Health, Melbourne, AUS.,Surgery, Monash University Eastern Health Clinical school, Melbourne, AUS
| | - Enoch Wong
- Surgery, Eastern Health, Melbourne, AUS.,Surgery, Monash Univeristy Eastern Health Clinical School, Melbourne, AUS
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11
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Chapon R, Bousquet O, Beaurain J, Alixant P, Madkouri R, Grelat M. Two level Anterior Lumbar Interbody Fusion (ALIF) in a patient with a rare vascular malformation, a duplication of the inferior vena cava. Neurochirurgie 2020; 66:466-70. [PMID: 33127372 DOI: 10.1016/j.neuchi.2020.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/01/2020] [Accepted: 08/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Anterior Lumbar Interbody Fusion is now a well-established procedure to treat degenerative lumbar disease. This approach has its own risks and each spine surgeon must understand the pitfalls that can be encountered when dealing with an anatomy variation of the vessels in order to be able to perform the safest possible procedure. CASE DESCRIPTION We report the case of a 48 years old man with a rare vascular anatomy variation undergoing a two-levels L4-L5 and L5-S1 ALIF procedure through a right-sided retroperitoneal approach. The preoperative imaging planning revealed a duplication of the Inferior Vena Cava (IVC) located on each side of the aorta. CONCLUSION Preoperative Imaging evaluation and a detailed knowledge of the anatomy is the key of a safe and successful procedure as any variation can complicate the anterior approach. We believe that teaming up with a vascular surgeon for junior surgeons during the first anterior procedures and especially in the context of anatomical variation is recommended.
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12
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Alkashkari W, Al-Husayni F, Althobaiti M, Omeish A, Alqahtani SA. Transcatheter Intervention For Severe Aortic Coarctation in a Patient With Uninterrupted Left-Sided Inferior Vena Cava Presenting With Recurrent Abdominal Pain. Cureus 2020; 12:e8204. [PMID: 32455092 PMCID: PMC7243082 DOI: 10.7759/cureus.8204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We describe a case of a 17-year-old male patient who was admitted to the hospital for an evaluation of his recurrent postprandial abdominal pain and fatigue on exertion. He was discovered to have severe post-ductal aortic coarctation (CoA) and uninterrupted left-sided inferior vena cava (IVC) draining into the right atrium crossing anterior to the abdominal aorta. There were no signs of IVC compression. Patient symptoms improved dramatically after CoA stenting on follow up. The presence of uninterrupted left-sided IVC in this particular case created a diagnostic dilemma, and it was of great importance to know such anomaly before the procedure. This association of uninterrupted left-sided IVC with CoA is unusual, and to our knowledge, our case is the first to report such congenital association.
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Affiliation(s)
- Wail Alkashkari
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU.,Cardiology, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Faisal Al-Husayni
- Internal Medicine, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
| | - Mohammed Althobaiti
- Radiology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU.,Radiology, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Attafah Omeish
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Saad A Alqahtani
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
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13
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Hostiuc S, Minoiu C, Negoi I, Rusu MC, Hostiuc M. Duplication and transposition of inferior vena cava: A meta-analysis of prevalence. J Vasc Surg Venous Lymphat Disord 2019; 7:742-755. [DOI: 10.1016/j.jvsv.2019.01.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/27/2019] [Indexed: 12/26/2022]
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14
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Affiliation(s)
- Wei-Li Liao
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Yang Shih
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jiaan-Der Wang
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan,Center for Rare Disease and Hemophilia, Taichung Veterans General Hospital, Taichung, Taiwan,Tunghai University, Faculty of Medicine, Department of Pediatrics, Taichung, Taiwan
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15
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Garg MK, Satwik A, Bedi VS, Uppinakudru G, Agarwal S, Yadav A. Duplication of inferior vena cava and coagulation mutations with left-sided iliofemoral venous thrombosis. J Vasc Surg Cases Innov Tech 2019; 5:26-30. [PMID: 30619987 PMCID: PMC6313839 DOI: 10.1016/j.jvscit.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 09/18/2018] [Indexed: 11/22/2022]
Abstract
Duplication of the inferior vena cava (IVC) with coagulation mutations in the form of factor V Leiden and MTHFR mutations represents an unusual subset of patients. We are reporting a case of a 43-year-old man who presented with left iliofemoral deep venous thrombosis diagnosed on duplex ultrasound scan. At the time of catheter-directed thrombolysis with prophylactic IVC filter placement, a duplicated IVC system was observed. After thrombolysis, a stenotic lesion in the left common iliac vein and IVC was stented. IVC filters were retrieved after 6 weeks. On thrombophilia profile testing at 3 months, he was also found to have factor V Leiden and MTHFR mutations. After 12 months of follow-up, the patient is asymptomatic with a patent iliocaval venous system and is receiving lifelong anticoagulation.
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Affiliation(s)
- Mukesh Kumar Garg
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Ambarish Satwik
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Varinder S Bedi
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Gurunandan Uppinakudru
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Sandeep Agarwal
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Ajay Yadav
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India
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16
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Abstract
Venous compression syndromes are caused by extrinsic venous compression of anatomical structures, such as the adjacent arteries and bones. Chronic venous compression and pulsative vibratory arterial pressure accelerate the development of deep vein thrombosis. Herein, we report the first case of double venous compressions due to a duplicated inferior vena cava-induced right-sided common iliac vein thrombosis. The thrombus was induced by left-sided inferior vena cava entrapment and right-sided common iliac vein compression, resembling nutcracker syndrome and May-Thurner syndrome, respectively. Bypass flow of the right inferior vena cava rendered the right lower extremity asymptomatic. Once daily anticoagulation edoxaban was effective. Congenital venous anomalies and bypass formations should be considered when a common iliac vein thrombus without symptoms in the lower extremities is observed, and a lifelong periodical follow-up is mandatory, even after remission.
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Affiliation(s)
- Yuichi Mukai
- Department of Respiratory Medicine, National Hospital Organization Matsumoto Medical Center, Matsumoto, Nagano, Japan
| | - Shuhei Nozawa
- Department of Respiratory Medicine, National Hospital Organization Matsumoto Medical Center, Matsumoto, Nagano, Japan
| | - Toshiro Suzuki
- Department of Respiratory Medicine, National Hospital Organization Matsumoto Medical Center, Matsumoto, Nagano, Japan
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17
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Abstract
Duplicated inferior vena cava (IVC) is a rare congenital anomaly. We describe the utility of a new graft from the left IVC in a patient with duplicated IVC for reconstructing the middle hepatic vein (MHV) after partial hepatectomy with MHV resection. A 67-year-old woman with hepatitis C was found to have a liver tumor. Magnetic resonance imaging confirmed that the tumor, which was attached to the MHV, was hepatocellular carcinoma. Central bisectionectomy (S4, S5, and S8 resection) could not be tolerated because of poor liver function and a low future liver remnant volume. Therefore, partial hepatectomy with MHV resection was performed. The left IVC was harvested as a venous graft and was substituted for the resected MHV. She recovered uneventfully and was discharged on postoperative day 12. To the best of our knowledge, this is the first report of using the left IVC as a venous graft. The left IVC is a good candidate graft for the MHV or for portal vein reconstruction because of its length, diameter, and easy harvesting (it did not require an extra incision) in a patient with duplicated IVC.
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Affiliation(s)
- Yusuke Kawamoto
- Department of General Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yusuke Ome
- Department of General Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazuyuki Kawamoto
- Department of General Surgery, Kurashiki Central Hospital, Kurashiki, Japan
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18
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Sahin H, Pekcevik Y, Aslaner R. Double Inferior Vena Cava (IVC) With Intrahepatic Interruption, Hemiazygos Vein Continuation, and Intrahepatic Venous Shunt. Vasc Endovascular Surg 2017; 51:38-42. [PMID: 28100158 DOI: 10.1177/1538574416687734] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The duplication of the inferior vena cava (IVC) is a rare congenital anomaly, which also has some variations regarding the complex embryological development of the IVC. In the typical form, infrarenal IVC segments are duplicated and the left IVC joins the left renal vein, which crosses anterior to the aorta in the normal fashion to join the right IVC. In variant forms, the interruption of the intrahepatic segment of the IVC, azygos or hemiazygos continuation, or retroaortic course of the renal vein may be seen. An intrahepatic venous shunt accompanying a double IVC variant is an extremely rare anomaly. We report a case of 40-year-old female patient with double IVC, hemiazygos continuation, intrahepatic IVC interruption, and a transhepatic venous shunt.
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Affiliation(s)
- Hilal Sahin
- 1 Department of Radiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Yeliz Pekcevik
- 1 Department of Radiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ramazan Aslaner
- 2 Department of Radiology, Balıkesir State Hospital, Balıkesir, Turkey
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Tankruad S, Suwannakhan A, Suriyonplengsaeng C, Meemon K. Duplication of the inferior vena cava from a division of the left external iliac vein. Anat Sci Int 2016; 92:147-150. [PMID: 27401745 DOI: 10.1007/s12565-016-0356-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/30/2016] [Indexed: 10/21/2022]
Abstract
Duplication of the inferior vena cava was detected in a 71-year-old Thai male cadaver with unknown cause of death. Two inferior vena cavae located on each side of the lumbar vertebrae were identified. The right inferior vena cava was formed by fusion of the right and left common iliac veins and had a normal course, while the left inferior vena cava arose from the left branch of the left external iliac vein and ascended parallel to the abdominal aorta. To our knowledge, no similar case has been previously reported. The left inferior vena cava joined the left renal vein to become the preaortic trunk before joining the right inferior vena cava. Tributaries of the inferior vena cava were observed and followed. Development of the duplication of the inferior vena cava was reviewed. Anatomical and developmental comprehension of the duplication of the inferior vena cava is important for clinicians in planning for retroperitoneal surgery.
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Affiliation(s)
- Sirinad Tankruad
- Department of Anatomy, Faculty of Science, Mahidol University, Rama VI Rd., Bangkok, 10400, Thailand
| | - Athikhun Suwannakhan
- Department of Anatomy, Faculty of Science, Mahidol University, Rama VI Rd., Bangkok, 10400, Thailand.,Mahidol University International College, 999 Phutthamonthon 4 Road, Salaya, Nakhonpathom, 73170, Thailand
| | | | - Krai Meemon
- Department of Anatomy, Faculty of Science, Mahidol University, Rama VI Rd., Bangkok, 10400, Thailand.
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20
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Shaha P, Garg A, Sahoo K, Kothari N, Garg P. Duplication of Inferior Vena Cava with Associated Anomalies: A Rare Case Report. J Clin Diagn Res 2016; 10:TD01-4. [PMID: 27134964 DOI: 10.7860/jcdr/2016/18240.7406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/04/2016] [Indexed: 11/24/2022]
Abstract
Duplication of inferior vena cava is an uncommon abnormality and is important in daily today practice for vascular surgeons, radiologist and urologist especially during retroperitoneal surgeries and treatment of thromboembolic disease. Radiologically, Duplicated IVC can be mistaken for lymphadenopathy or left pyeloureteric dilatation. Crossed fused kidney with a single ureter defy the embryological theory of ureteric bud crossing the opposite side and induce nephron formation associated anomaly of Duplication of inferior vena cava and malrotation of gut are not reported in a same patient. On meticulous search of literature no such combination of abnormalities has been reported. In this case report we bring forward this rare type of combination of three congenital malformations that is Duplication of IVC, crossed fused kidney and malrotation of gut.
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Affiliation(s)
- Pramod Shaha
- Professor, Depatment of Radiodiagnosis, KIMS , Karad, Maharashtra, India
| | - Ashish Garg
- Post Graduate Student, Depatment of Radiodiagnosis, KIMS , Karad, Maharashtra, India
| | - Kulamani Sahoo
- Professor and Head of Department, Depatment of Radiodiagnosis, DMRD, KIMS , Karad, Maharashtra, India
| | - Nupoor Kothari
- Body Imaging Fellow, Depatment of Radiodiagnosis, LTMMC & LTMGH , Mumbai, Maharashtra, India
| | - Pooja Garg
- Senior Resident, Depatment of Medicine, Hindurao Medical College , Delhi, India
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21
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Nania A, Capilli F, Longo E. Left Inferior Vena Cava and Right Retroaortic Renal Vein. Case Rep Radiol 2016; 2016:1-3. [PMID: 26955497 PMCID: PMC4756163 DOI: 10.1155/2016/1270856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 01/18/2016] [Indexed: 11/17/2022] Open
Abstract
Nowadays, incidental anatomical variants are frequent findings, due to the widespread diffusion of cross-sectional imaging. This case report illustrates a fairly uncommon anatomical variant, that is, the copresence of left inferior vena cava and retroaortic right renal vein reported in a 46-year-old lady, undergoing a staging CT for breast cancer. Although the patient was asymptomatic, the authors highlight potential risks related to the above-mentioned condition and the importance of correct identification and diagnosis of the findings.
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Aycock KI, Campbell RL, Manning KB, Sastry SP, Shontz SM, Lynch FC, Craven BA. A Computational Method for Predicting Inferior Vena Cava Filter Performance on a Patient-Specific Basis. J Biomech Eng 2014; 136:1870705. [DOI: 10.1115/1.4027612] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 05/08/2014] [Indexed: 12/19/2022]
Abstract
A computational methodology for simulating virtual inferior vena cava (IVC) filter placement and IVC hemodynamics was developed and demonstrated in two patient-specific IVC geometries: a left-sided IVC and an IVC with a retroaortic left renal vein. An inverse analysis was performed to obtain the approximate in vivo stress state for each patient vein using nonlinear finite element analysis (FEA). Contact modeling was then used to simulate IVC filter placement. Contact area, contact normal force, and maximum vein displacements were higher in the retroaortic IVC than in the left-sided IVC (144 mm2, 0.47 N, and 1.49 mm versus 68 mm2, 0.22 N, and 1.01 mm, respectively). Hemodynamics were simulated using computational fluid dynamics (CFD), with four cases for each patient-specific vein: (1) IVC only, (2) IVC with a placed filter, (3) IVC with a placed filter and model embolus, all at resting flow conditions, and (4) IVC with a placed filter and model embolus at exercise flow conditions. Significant hemodynamic differences were observed between the two patient IVCs, with the development of a right-sided jet, larger flow recirculation regions, and lower maximum flow velocities in the left-sided IVC. These results support further investigation of IVC filter placement and hemodynamics on a patient-specific basis.
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Affiliation(s)
- Kenneth I. Aycock
- Department of Bioengineering, Applied Research Laboratory, The Pennsylvania State University, University Park, PA 16802 e-mail:
| | - Robert L. Campbell
- Department of Mechanical and Nuclear Engineering, Applied Research Laboratory, The Pennsylvania State University, University Park, PA 16802
| | - Keefe B. Manning
- Department of Bioengineering, The Pennsylvania State University, University Park, PA 16802
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA 17033
| | - Shankar P. Sastry
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT 84112
| | - Suzanne M. Shontz
- Department of Mathematics and Statistics, Department of Computer Science and Engineering, Center for Computational Sciences, Graduate Program in Computational Engineering, Mississippi State University, Mississippi State, MS 39762
| | - Frank C. Lynch
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA 17033
| | - Brent A. Craven
- Department of Mechanical and Nuclear Engineering, Department of Bioengineering, Applied Research Laboratory, The Pennsylvania State University, University Park, PA 16802 e-mail:
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24
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Tamizifar B, Seilani P, Zadeh MR. Duplication of the inferior vena cava and thrombosis: A rare case. J Res Med Sci 2013; 18:911-3. [PMID: 24497866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 02/10/2013] [Accepted: 04/09/2013] [Indexed: 10/30/2022]
Abstract
Duplication of inferior vena cava (IVC) is a rare finding in radiologic studies and its coincidence with thrombosis is even rarer. Here we described a rare case with duplication of IVC and symptomatic venous thrombosis of her lower extrimity.
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25
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Wang X, Chen Z, Cai Q. Catheter-directed thrombolysis for double inferior vena cava with deep venous thrombosis: A case report and literature review. Phlebology 2013; 29:480-3. [PMID: 23761872 DOI: 10.1177/0268355513490293] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Double inferior vena cava (DIVC) with deep venous thrombosis (DVT) is rare, and there is only one reported case of DIVC with DVT treated by catheter-directed thrombolysis. We report a case of a 32-year-old man with an extensive venous clot involving the infrarenal segment of a double IVC who received filter implantation and catheter-directed thrombolysis.
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Affiliation(s)
- Xiaodong Wang
- Department of vascular surgery, Tongde hospital of Zhejiang province, No. 234, Gucui road, Hangzhou, China
| | - Zhengxin Chen
- Department of vascular surgery, Tongde hospital of Zhejiang province, No. 234, Gucui road, Hangzhou, China
| | - Qianrong Cai
- Department of vascular surgery, Tongde hospital of Zhejiang province, No. 234, Gucui road, Hangzhou, China
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26
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Saettele MR, Morelli JN, Chesis P, Wible BC. Use of a Trellis device for endovascular treatment of venous thrombosis involving a duplicated inferior vena cava. Cardiovasc Intervent Radiol 2013; 36:1699-1703. [PMID: 23370490 DOI: 10.1007/s00270-013-0559-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 12/17/2012] [Indexed: 11/29/2022]
Abstract
Congenital anomalies of the inferior vena cava (IVC) are increasingly recognized with CT and venography techniques. Although many patients with IVC anomalies are asymptomatic, recent studies have suggested an association with venous thromboembolism. We report the case of a 62-year-old woman with extensive venous clot involving the infrarenal segment of a duplicated left IVC who underwent pharmacomechanical thrombectomy and tissue plasminogen activator catheter-directed thrombolysis with complete deep venous thrombosis resolution. To our knowledge this is the first reported case in the English literature of the use of a Trellis thrombectomy catheter in the setting of duplicated IVC.
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Affiliation(s)
- Megan R Saettele
- Department of Radiology, Saint Luke's Hospital, University of Missouri, Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA.
| | - John N Morelli
- Department of Radiology, Scott & White Clinic and Hospital, Texas A&M University Health Science Center, 2401 S 31st Street, Temple, TX, 76504, USA
| | - Paul Chesis
- Department of Interventional Radiology, Saint Luke's Hospital, University of Missouri, Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Brandt C Wible
- Department of Interventional Radiology, Saint Luke's Hospital, University of Missouri, Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
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Yang HJ, Gil YC, Jin JD, Cho H, Kim H, Lee HY. Novel findings of the anatomy and variations of the axillary vein and its tributaries. Clin Anat 2012; 25:893-902. [DOI: 10.1002/ca.22086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 03/13/2012] [Accepted: 03/19/2012] [Indexed: 11/06/2022]
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28
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Ang WC, Doyle T, Stringer MD. Left-sided and duplicate inferior vena cava: a case series and review. Clin Anat 2012; 26:990-1001. [PMID: 22576868 DOI: 10.1002/ca.22090] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/23/2012] [Accepted: 03/31/2012] [Indexed: 01/21/2023]
Abstract
Left-sided and duplicate inferior vena cava (IVC) are two major anatomical variants within the spectrum of IVC malformations, both of which are developmental abnormalities of the supracardinal veins. Four clinical cases are described to highlight the computed tomographic appearances of these vascular malformations and provide novel data on venous dimensions. A systematic review of the recent literature (2000-2011) was conducted focusing on the anatomy, demographics, and associated pathology (congenital and acquired) of isolated left-sided and duplicate IVC. A total of 73 relevant articles were retrieved, consisting of case reports and small case series. The prevalence of left-sided IVC is about 0.1-0.4% and that for duplicate IVC about 0.3-0.4%; both anomalies show a slight male preponderance. In each condition, there are documented variations in the course and tributaries of the IVC. The clinical importance of these anomalies lies in three principal areas: the potential for misdiagnosis on imaging; technical difficulties during retroperitoneal surgery (particularly abdominal aortic aneurysm repair and live donor nephrectomy); and their significance in relation to the etiology and management of venous thromboembolism.
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Affiliation(s)
- Wee Choen Ang
- Department of Anatomy, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
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29
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Sarlon G, Bartoli MA, Muller C, Acid S, Bartoli JM, Cohen S, Piquet P, Magnan PE. Congenital anomalies of inferior vena cava in young patients with iliac deep venous thrombosis. Ann Vasc Surg 2011; 25:265.e5-8. [PMID: 20889308 DOI: 10.1016/j.avsg.2010.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 06/23/2010] [Accepted: 07/01/2010] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism (VTE) in young patients is frequently associated with hereditary biological thrombophilia, autoimmune disorders, or neoplasia. Advances in venous ultrasound and contrast-enhanced computed tomography have allowed for the identification of inferior vena cava (IVC) anomalies as newly considered etiologic factor. We present two cases of VTE in young patients: the first case involves left IVC in a 22-year-old man and the second involves IVC atresia in a 39-year-old man. IVC anomalies should be identified in young patients with spontaneous VTE involving the iliac veins because they are at a high risk for thrombotic recurrence and adaptation to long periods of antithrombotic therapy.
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Affiliation(s)
- Gabrielle Sarlon
- Vascular Medicine and Surgery, Timone Hospital, Marseille, France.
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Jones O, Oweis D, Gedela VR, Mason PF. Duplicated inferior vena cava with associated ilio-femoral deep vein thrombosis. BMJ Case Rep 2010; 2010:2010/oct27_1/bcr0320102838. [PMID: 22791721 DOI: 10.1136/bcr.03.2010.2838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present the case of a fit and well 20-year-old gentleman who presented to our emergency department with unilateral lower limb pain and swelling. Subsequent imaging revealed a left ilio-femoral deep vein thrombosis, with associated duplication of his inferior vena cava. He was treated conservatively with a heparin infusion, warfarin and compression therapy prior to being discharged following a short inpatient stay.
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Affiliation(s)
- O Jones
- Department of General Surgery, Southport Hospital, Southport, UK.
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31
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Abstract
A agenesia da veia cava inferior é uma anomalia congênita rara, que foi recentemente identificada como um importante fator de risco para o desenvolvimento e a recorrência de trombose venosa profunda de membros inferiores em jovens. O objetivo deste trabalho foi relatar o caso de uma paciente que apresentou trombose venosa profunda dois meses após a realização de cirurgia de varizes. A angiotomografia computadorizada demonstrou a presença de anomalia venosa complexa com ausência da veia cava inferior.
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Abstract
Anomalies of the cardinal vein system (CVS) are uncommon but if unidentified can lead to life-threatening complications. We report a case with a novel malformation of the CVS. Autopsy with in situ dissection of heart and large vessels in a 25-day-old infant was performed. The infant was diagnosed with congenital heart disease, and systemic venous malformations were suspected by imaging. Correlation between premortem imaging and postmortem anatomy was performed. The superior and inferior left venous systems developed abnormally. A persistent left superior vena cava (PLSVC) drained into the right atrium via the coronary sinus. A persistent left inferior vena cava (PLIVC) continued with the hemiazygos vein (HV), which drained into the PLSVC. The innominate vein was absent. The left renal vein was connected to the HV. Two common iliac veins were identified. The left drained into the PLIVC and the right into the right inferior vena cava (IVC). Perinatal echocardiography identified only the dilated HV draining to an LSVC and a small IVC. Congenital heart disease included hypoplastic left ventricle with hypoplastic aortic arch and subaortic stenosis, which were diagnosed by fetal ultrasound. Remodeling of components of CVS takes place during development, and unknown mechanisms guide this process. Defects of this process can lead to variable malformations, as demonstrated by this case. To our knowledge, the combination of complex malformations of both superior and IVC systems that extends to the common iliac veins has not been reported. We recommend identifying vascular anomalies in situ during autopsy before anatomic relationships are altered.
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Affiliation(s)
- Eumenia C C Castro
- Department of Pediatric Pathology, Children's Hospital of UPMC, Pittsburgh, PA 15213, USA
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