Left Inferior Vena Cava With Infrahepatic Disruption, Azygos Continuation, and Retroaortic Left Renal Vein - A Complex, Symptomatic Caval Anomaly Managed With Endovascular Intervention

Background: Complex congenital anomalies of the inferior vena cava (IVC) are rare sequelae of inappropriate persistence or regression of embryological precursor veins. These anomalies are typically asymptomatic and generally do not warrant intervention. Case Presentation: Here we present a case of severely symptomatic left IVC with infrahepatic disruption, azygos continuation, and retroaortic left renal vein causing symptoms of severe pelvic congestion and recurrent miscarriages (8 total) in a 41 year old female. The patient was treated with stenting of the compressed retroaortic portion of the IVC/left renal vein. Four months post-procedure, the stent remained patent and the patient reported considerable improvement in their venous congestion symptoms. Most notably, as of the writing of this report, the patient is 38 weeks pregnant. Conclusions: The case is notable for its severe symptomatology of pelvic venous disease including recurrent miscarriage. More importantly, it represents the first documented case of successful retroaortic endovascular management of such a venous anomaly, in which the entirety of the typical IVC drainage occurred via a compressed left-to-right retroaortic crossover.

An anatomical variation during para-aortic lymphadenectomy

Failure to identify anatomical variations may contribute to surgical errors or perioperative complications during abdominal and oncological surgery. We report the case of an anatomical variation of the inferior vena cava revealed during para-aortic lymphadenectomy for advanced ovarian cancer. Due to renal insufficiency, preoperative CT-scan was performed without contrast injection and the variation was not clearly detected. Our clinical case underlines the importance of the preoperative diagnosis of anatomical variations and highlights the need to provide young surgeons with adequate technical training in para-aortic lymphadenectomy.

Partial Hepatectomy with Middle Hepatic Vein Reconstruction Using a Left Inferior Vena Cava Graft

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.

Coronary sinus aneurysm associated with multiple venous anomalies

Background

Congenital anomalies of the venous system are rare, involve the inferior vena cava (IVC), a persistent left superior vena cava (PLSVC), and the left hepatic vein (LHV), and can make cardiac diagnostic and therapeutic procedures difficult.

Case presentation

We present a 67-year-old woman without heterotaxy syndrome associated with interruption of the left IVC that continued with the hemiazygos vein system, a PLSVC, and an anomalous LHV draining the into coronary sinus (CS). The venous anomalies caused a CS aneurysm. The anomalies were demonstrated by echocardiography and the diagnosis was established by contrast-enhanced computed tomography. Three days later, a coronary artery bypass graft was performed, which confirmed the diagnosis. Half a month after surgery, the pain had been relieved and the patient was discharged from the hospital.

Conclusion

Echocardiography is a useful modality to diagnose and assess anomalies of the CS, including CS aneurysms. Congenital anomalies of the venous system in this case were all due to embryonic development abnormalities. Contrast-enhanced computed tomography provides a more comprehensive view of the entire course of abnormal veins.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0532-3) contains supplementary material, which is available to authorized users.

Duplication of the inferior vena cava from a division of the left external iliac vein

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.

Anterior Spinal Surgery Involving Variant Vascular Anatomy: A Case Report

STUDY DESIGN

Case report of an anterior approach to the spine in the setting of variant vascular anatomy.

OBJECTIVE

To highlight the importance of evaluating vascular anatomy before anterior lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

A 62-year-old woman with idiopathic scoliosis had thoracolumbar fusion in adolescence and subsequently developed symptomatic sub-adjacent segment breakdown. Vascular complications may be encountered during anterior approaches to the spine. Variation in vascular anatomy may compound the difficulty of an already meticulous dissection.

RESULTS

A patient with idiopathic scoliosis who had thoracolumbar fusion in adolescence and subsequently developed symptomatic sub-adjacent segment breakdown. She underwent a 2-stage posterior/anterior procedure. During the anterior retroperitoneal approach, an anomalous left inferior vena cava was encountered that required tedious dissection for safe and adequate exposure of the lumbar spine.

CONCLUSIONS

When planning anterior lumbar spine surgery, careful review of the vascular anatomy on imaging should be performed. This will help prepare the surgeon for more complex or anomalous anterior anatomy. If atypical vascular anatomy is identified, consideration of a pathologic cause should be investigated.

Klippel-Trenaunay syndrome with gastrointestinal bleeding, splenic hemangiomas and left inferior vena cava

Klippel-Trenaunay syndrome is a congenital vascular anomaly characterized by a triad of varicose veins, cutaneous capillary malformation, and hypertrophy of bone and (or) soft tissue. Gastrointestinal vascular malformations in Klippel-Trenaunay syndrome may present with gastrointestinal bleeding. The majority of patients with spleenic hemangiomatosis and/or left inferior vena cava are asymptomatic. We herein report a case admitted to the gastroenterology clinic with life-threatening hematochezia and symptomatic iron deficiency anemia. Due to the asymptomatic mild intermittent hematochezia, splenic hemangiomas and left inferior vena cava, the patient did not seek any help for gastrointestinal bleeding until his admittance to our department for evaluation of massive gastrointestinal bleeding. He was referred to angiography because of his serious pathogenetic condition and inefficiency of medical therapy. The method showed that hemostasis was successfully achieved in the hemorrhage site by embolism of corresponding vessels. Further endoscopy revealed vascular malformations starting from the stomach to the descending colon. On the other hand, computed tomography revealed splenic hemangiomas and left inferior vena cava. To the best of our knowledge, this is the first Klippel-Trenaunay syndrome case presenting with gastrointestinal bleeding, splenic hemangiomas and left inferior vena cava. The literature on the evaluation and management of this case is reviewed.

Radiofrequency catheter ablation of atrioventricular nodal reentry tachycardia in a patient with inferior vena cava anomaly

Curative radiofrequency catheter modification of the slow pathway is the recommended therapy for patients suffering from recurrent symptomatic atrioventricular nodal reentry tachycardia. This is usually performed via femoral vein and the inferior vena cava (IVC). Presence of venous occlusion or complex venous anomaly involving the IVC may preclude this approach. Here, we report a case with a complex venous anomaly involving the inferior vena cava, who underwent electrophysiological study and successful radiofrequency ablation by an alternative approach.