Azygos Vein Aneurysm Mimicking a Mediastinal Mass

Azygos Vein Pseudoaneurysm After Trauma: A Case Report

High-speed motor vehicle collisions (MVCs) often result in severe musculoskeletal, neurological, and vascular injuries. Among these, azygos vein pseudoaneurysms (AVPs) are a rare and potentially life-threatening vascular complication. Our case study highlights an instance of an AVP arising from a high-velocity MVC, underscoring their critical significance in trauma scenarios. Additionally, this report delves into the complexities of managing AVPs, both traumatic and idiopathic, emphasizing the urgent need for intervention and the intricacies of their treatment.

CT Findings of Azygos Venous System: Congenital Variants and Acquired Structural Changes

The azygos venous system is a crucial conduit of the posterior thorax and potentially vital collateral pathway. However, it is often overlooked clinically and radiologically. This pictorial essay reviews the normal azygos venous anatomy and CT findings of congenital variations and structural changes associated with acquired pathologies.

Hemiazygos vein dilation as a radiological finding and multifactorial cause of dysphagia

Dysphagia is a common issue observed among the elderly, which can arise from various etiologies such as motility disorders and chronic neurologic conditions. Radiologists play a crucial role in diagnosing the cause of dysphagia, as they can identify anatomical abnormalities that may lead to the condition. One such anomaly is the hemiazygos vein, which is the left side equivalent of the azygos vein and can cause dysphagia if it crosses over the esophagus. To our knowledge, there are only 2 other recorded cases of azygos aneurysm/dilation causing esophageal dysphagia. In this context, we present a case report of a 73-year-old female with a 1-month history of weight loss and dysphagia due to a prominent hemiazygos vein. The case highlights the importance of thorough radiological evaluation in identifying the underlying cause of dysphagia and ensuring timely and appropriate treatment.

Single-port thoracoscopic removal of an azygos vein aneurysm: a case report and literature review

BACKGROUND

Azygos vein aneurysms (AVAs) are extremely rare. The majority of patients have no obvious clinical symptoms, so they are found by physical examination or by chance. There is limited clinical treatment experience that can be referred to, and there are no clear guidelines or research evidence standardizing the surgical and interventional therapy. Here, we report a patient with idiopathic AVA whose three-dimensional reconstruction of the tumor was completed before surgery. On the basis of three-dimensional reconstruction, single-port thoracoscopic resection of the AVA was successfully completed and reported for the first time. The previously reported cases are summarized to provide guidance for the diagnosis and treatment of patients with AVAs.

CASE PRESENTATION

A 56-year-old man was transferred to our hospital due to "dysphagia". The diagnosis of AVA was made after enhanced computed tomography, gastroscopy, fiberoptic bronchoscopy, and three-dimensional reconstruction. Congenital weakness or degenerative changes causes the vein walls to be extremely thin that the AVA had the risk of ruptur. Furthermore, the patient had symptoms of dysphagia, he received single-port thoracoscopic surgery. After the operation, his dysphagia disappeared. The postoperative pathology confirmed hemangioma. The patient was discharged 3 days after surgery without any complications.

CONCLUSIONS

AVAs are rare. Preoperative three-dimensional reconstruction can greatly help surgeons clarify the disease diagnosis, formulate the surgical plan, avoid damage to the surrounding vital organs, and reduce intraoperative bleeding. Thoracoscopic surgery to remove AVAs is difficult and has a high risk of bleeding, while more minimally invasive single-port thoracoscopic surgery is also safe and effective for the treatment of AVAs.

Refractory Chylothorax Secondary to Sizeable Azygos Vein Hemangioma: Tailored Multimodal Treatment of a Challenging Case Report

BACKGROUND

Mediastinal hemangiomas are rare, and their etiology remains unclear. Most patients affected have no pathognomonic clinical symptoms, and the diagnosis is often incidental. Due to the paucity of the available literature regarding the management of this disease, the choice and timing of treatment remains controversial.

CASE PRESENTATION

Herein, we report the case of a hemangioma of the azygos vein arch in a 66-year-old woman who presented with dyspnea, chest discomfort, dysphagia, and weight loss. A simultaneous right chylothorax refractory to conservative management was found. A CT-guided biopsy of the mass was performed, and it confirmed the vascular nature of the lesion. Therefore, the patient underwent an angiography followed by endo-vascular embolization. Three days later, thoracoscopic surgical resection of the mass and the repair of the chyle leakage were performed safely. The patient was discharged uneventfully on postoperative day seven, with complete resolution of all the presenting symptoms.

CONCLUSIONS

Treatment of symptomatic mediastinal hemangiomas could be mandatory, but a thorough multidisciplinary approach to these rare malformations is essential. Despite the risk of intraoperative bleeding, selective endovascular embolization followed by thoracoscopic surgery allowed for a complete and safe resection with a good outcome.

Thoracoscopic approach to the resection of idiopathic azygos vein aneurysm: a case report

BACKGROUND

Azygos vein aneurysm (AVA) is a rare thoracic pathological entity that mimics a posterior mediastinal mass. However, the pathogenesis of primary azygos vein aneurysms is not clear and its pathology is still being discussed. Some of the AVA are asymptomatic and usually discovered accidentally by routine physical examination.

CASE PRESENTATION

We report the case of a 37-year-old woman who had an azygos vein arch aneurysm with no obvious clinical symptoms. With the analysis of clinical features of the case and AVA morphological characteristics, the AVA was found by a chest computed tomography. Then, enhanced chest computed tomography showed a soft-tissue mass (4.9 × 3.7 × 3.2 cm) in the right posterior mediastinum, which was connected to the superior vena cava and significantly enhanced with contrast agent stratification. The density of the tumor in the delayed stage was the same as that in the azygos vein. The patient underwent video-assisted thoracoscopic surgery. Histopathological evaluation of the surgical biopsy specimen proved to be a completely thrombosed aneurism of the azygos vein arch.

CONCLUSIONS

AVA is a rare pathology that must be taken into consideration during the differential diagnosis of right posterior mediastinal masses. Thoracoscopic surgery is one of the most preferred treatment options for azygos vein aneurysm.

Presurgical assessment of flow variability in an azygos vein aneurysm using 4D-flow MRI

Azygos vein aneurysm (AVA) is necessary to prevent pulmonary embolism due to the outflow of a thrombus or rupture of the aneurysm. However, there is no established modality to assess the properties of AVA. Time-resolved three-dimensional phase-contrast magnetic resonance imaging (4D-flow MRI) has been used to examine the hemodynamics in various fields. We report a case of AVA to evaluate the flow variability and adhesions of surrounding tissues using 4D-flow MRI. The findings of the study suggested aneurysm turbulence and the absence of thrombi. The cine image, which showed a sliding wall synchronized to the heartbeat, indicated no adhesion to the superior vena cava. Based on these results, the thoracoscopic approach was deemed possible preoperatively. Thoracoscopic AVA resection was performed, and the postoperative course was uneventful. This study documented the utility of 4D-flow MRI for a detailed evaluation of AVA.

Necrotizing fasciitis of the chest wall: A clinical case report and literature review

Necrotizing fasciitis of the chest wall is a very rare pathology, but with significant mortality, representing a therapeutic challenge. All international reports indicate the need for early diagnosis and an aggressive medical-surgical attitude in order to improve the prognosis. In addition to a review of literature, we present a case developed secondary to a thoracic pleural drainage for pyopneumothorax associated with significant bronchopleural fistula in a destroyed tuberculous left lung. Along with medical treatment, extensive surgical debridement was required. Despite drainage incisions and negative pressure wound therapy (NPWT), the evolution of the fasciitis was difficult, due to bronchopleurocutaneous fistula. Thus, the Azorin procedure (transcervical mediastinoscopic closure of the left main bronchus) was performed. Once this procedure was completed, the inflammatory phenomena were controlled which allowed for a second step consisting of left pneumonectomy, with the application of specific methods for the prevention of bronchial fistula. The clinical case was a therapeutic challenge requiring a complex, staged, multidisciplinary approach due to both the immunocompromised terrain and the severity of the lesions. In conclusion, early recognition and aggressive and combined application of medical and surgical treatment methods can ensure therapeutic success.

A Large Thymoma Resected via Left Antero-lateral Thoracotomy

BACKGROUND/AIM

Thymomas are a rare type of mediastinal tumors with a slow growth rate. Because of this, they are well tolerated and patients usually present with large masses, which can extend in either of the thoracic cavities. The surgical approach for such tumors is dictated by the size and localization of the mass.

CASE REPORT

We present the case of a patient with a large thymoma, resected through surgery performed by left antero-lateral thoracotomy. The patient presented in our clinic with a persistent cough, dyspnea, chest pain and tightness. Standard thoracic X-ray revealed a bilateral increase in size of the mediastinal shadow, mainly on the left side, with well-defined margins and subcostal intensity. A thoracic computed tomography (CT) scan discovered a tumoral mass within the antero-superior mediastinum, with compression of the mediastinal organs; presentation being suggestive for a thymoma. Surgery was performed, removing a 15/13/10 cm thymoma with a weight of 1126 g. Pathological examination as well as immunohistochemistry confirmed our diagnosis of type AB thymoma, stage I Masaoka-Koga.

CONCLUSION

In conclusion, surgical treatment remains the main therapeutic option in thymomas, but it is often difficult to perform due to tumor size and local invasion. However, even in large thymomas of stages I and II, surgery can be performed using an antero-lateral thoracotomy.

Primary Leiomyoma of the Visceral Pleura: An Unexpected Occurrence

BACKGROUND/AIM

Leiomyoma is a rare benign tumor originating from smooth muscle fibres. In the respiratory tract, these tumors are rare and in the pleura, cases are exceptional, with only a few reported so far. This is the main reason we decided to present this case of primary leiomyoma of the visceral pleura.

CASE REPORT

We present a case of a 51-year-old asymptomatic patient who, during a routine medical examination using standard chest radiography, presented with a 3 by 2 cm homogenous mass in the right superior pulmonary area, tangent to the chest wall (same level with the 3rd rib). Further investigation using computed tomography (CT) in the chest confirmed the presence of a 31/18 mm solid mass in the right upper lobe, in contact with the parietal pleura. Surgery was performed for two reasons: i) removal of the tumoral mass and ii) establishing a histopathological diagnosis. Intraoperatively, a well-defined, homogenous, ivory white non-infiltrating mass was discovered in the right upper lobe on the visceral pleura and in close proximity to the minor fissure. The mass was removed with negative surgical margins and was left with healthy tissue. Histopathological examination and immunohistochemistry came as a surprise, establishing our diagnosis of leiomyoma.

CONCLUSION

Primitive pleural leiomyoma must remain a possibility when considering the differential diagnosis of pleural tumors. The main course of treatment is complete surgical resection. In our case, long-term follow up did not present any local recurrence.

Giant Intrathoracic Schwannoma: A Case Report

BACKGROUND/AIM

Thoracic neurogenic tumors are most frequently located in the posterior part of the mediastinum or on the chest wall, along the intercostal nerves. Schwannomas are very well tolerated for a long period, until the tumor reaches a large size and compression of the neighbouring mediastinal organs, chest wall or spine appears. The purpose of this article was to present a case of a giant right forth intercostal nerve Schwannoma, completely resected by a right antero-lateral thoracotomy. In addition, intrathoracic giant neurogenic tumors are a rarity.

CASE REPORT

The patient presented with only diminished tolerance to physical activity with no other obvious symptoms. Standard chest radiography revealed a well-defined opacity of subcostal intensity, occupying two thirds of the right hemithorax, forming a common body with the mediastinal shadow. Thoracic computed tomography (CT) identified a 21/11 cm solid mass that compresses the right lung and the right main bronchus with both a solid component and a central liquid area. Open surgery was performed in order to remove the tumor, which was 20.5/12.5/9 cm in size and weighed 1,830 g, well defined, with no invasion of the adjacent organs, having a solid-fibromatous aspect as well as a central necrotic area. The origin of the tumor was confirmed from the posterolateral part of the forth intercostal nerve. Pathology examination and immunohistochemistry confirmed the diagnosis of a benign Schwannoma.

CONCLUSION

Benign intrathoracic Schwannomas are asymptomatic for long periods and the main therapeutic option is complete surgical resection. The surgical approach, either open or video-assisted is dictated by the localisation of the tumor, local extension and most importantly the size of the neurogenic mass.

Multifactorial dysphagia: Azygos vein aneurysm (AVA) and esophagogastric junction outflow obstruction (EGJOO)

Introduction

Vascular impingement of the esophagus is a rare cause of dysphagia, and is most commonly due to aortic arch anomalies such as arterial lusoria. Dysphagia resultant from venous compression is even further less likely.

Presentation of case

We present a highly unusual case of dysphagia secondary to a large aneurysm of the azygous vein near its confluence with the superior vena cava, which was managed with endovascular modalities. Despite initial treatment success, patient reported some intermittent solid food dysphagia, and was also found to have esophagogastric junction outflow obstruction (EGJOO) on high resolution impedance manometry (HRIM) which was successfully managed with surgical myotomy and partial fundoplication.

Discussion

The azygos vein has an intimate anatomic relationship with the esophagus as it traverses the posterior mediastinum. Because of this anatomic association, the azygos vein may present a point of esophageal obstruction in the setting of significant pathology.

Conclusion

This case highlights the possibility of multifactorial causes of dysphagia, and that HRIM is a key aspect of this workup. Additionally we discuss the pertinent anatomy, diagnosis, and treatments for azygos vein aneurysm and EGJOO.

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Vascular impingement of the esophagus is a rare cause of dysphagia.

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This type of dysphagia is most commonly due to aortic arch anomalies such as arterial lusoria.

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The azygos vein may present a point of esophageal obstruction in the setting of significant pathology.

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Endovascular therapy in selected patients can provide resolution of dysphagia in patients with azygos vein aneurysm.

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There is possibility of multifactorial causes of dysphagia, and high resolution manometry is a key aspect of this workup.

Surgical therapy for hemangioma of the azygos vein arch under thoracoscopy: A case report

BACKGROUND

Azygos vein aneurysms are extremely rare, and their pathogenesis is not clear. The overwhelming majority of patients have no obvious clinical symptoms and are found to have the disease by physical examination or by chance. There are few reports on the diagnosis of and treatment strategy for this disease. Moreover, the choice of therapeutic schedule and the treatment window are controversial.

CASE SUMMARY

We report a case of azygos vein arch aneurysm in a 53-year-old woman. The patient had symptoms of back pain, chest tightness, and choking. Enhanced chest computed tomography showed a soft-tissue mass in the right posterior mediastinum, which was connected to the superior vena cava. The enhancement degree in the venous phase was the same as that of the superior vena cava. The patient received video-assisted thoracoscopic surgery. After the operation, her back pain disappeared, and her dysphagia and chest tightness were also significantly relieved. The postoperative pathology confirmed hemangioma. The patient was discharged on the seventh day after surgery without any comp-lications.

CONCLUSION

Some patients with hemangioma of the azygos vein arch may experience dysphagia and chest tightness caused by the tumor compressing the esophagus and trachea. Enhanced computed tomography scanning is vital for the diagnosis of azygos vein aneurysms. In addition, despite the difficulty and risk of surgery, thoracoscopic surgery for azygos vein aneurysms is completely feasible.