The fetal venous system, part I: normal embryology, anatomy, hemodynamics, ultrasound evaluation and Doppler investigation

Perinatal outcomes in cases of umbilical-portal-systemic venous shunts: experience of a tertiary center

BACKGROUND

The umbilical-ductal-portal system attracts significant interest due to its specific connections in fetal life. Advances in the detailed examination of hepatic circulation have further intensified this interest in recent years. Present study aimed to evaluate the obstetric and perinatal outcomes of patients diagnosed with umbilical-portal-systemic venous shunts (UPSVS) at our clinic.

METHODS

This study involved a retrospective analysis covering the period from September 2019 to June 2024. Detailed anatomical screening, fetal echocardiography, and invasive genetic testing (for patients who consent) were performed on cases of fetal UPSVS. Accompanying anomalies, ductus venosus, the intrahepatic portal system, and hepatic veins were examined in detail.

RESULTS

During the specified period, 20 patients were identified to have UPSVS, with a mean gestational age of 25 weeks at the time of diagnosis. Of these cases, five (25%) were classified as umbilical-systemic shunt (USS), three (15%) as ductus venosus-systemic shunt (DVSS), twelve (60%) as intrahepatic portal-systemic shunt (IHPSS). Ductus venosus was absent in 70% (n = 14) of the cases. Chromosomal analysis was conducted on 11 fetuses either prenatally or postnatally. Trisomy 21 was detected in two fetuses, 45,X0 in one fetus, a variant of Adams-Oliver syndrome in one fetus, and Adams-Oliver syndrome in another. Pregnancy was terminated in three cases due to chromosomal or additional congenital anomalies. In one case, intrauterine fetal death occurred at 22 weeks of gestation. Sixteen live births were recorded, of which two neonates died due to accompanying congenital anomalies, one at 2 h postnatally and the other on the 10 th postnatal day.

CONCLUSION

UPSVS are increasingly detected in the presence of major structural or chromosomal anomalies. The prognosis of isolated cases is generally favorable; however, the exact incidence remains unknown.

The Occurrence of Supernumerary Umbilical Cord Vessels: A Review for Practicing Clinicians

Background: The umbilical cord normally contains two arteries and one vein. The presence of supernumerary-four or five-umbilical cord vessels is a rare phenomenon, with few cases reported in the literature. The majority of cases are detected postnatally. However, given their potential association with developmental abnormalities, primarily severe cardiac anomalies and genetic disorders, the prenatal diagnosis of supernumerary umbilical cord vessels may have clinical relevance. Methods: A review of the clinical phenomenon of the four-vessel umbilical cord and its complications was conducted using case studies and literature reviews in PubMed from 1977 to the present and in Google Scholar from 1966 to the present. Results: Among the 24 reported cases, 7 cases were associated with malformations, 8 cases were detected antenatally, and 16 cases postpartum. Among the eight antenatally diagnosed cases, only one had a congenital malformation, hydrops fetalis. Among the postnatally diagnosed cases, six had congenital abnormalities: three were cardiovascular, two were associated with hydrops, urinary, gastrointestinal, and skeletal disorders, hypoplastic corpus callosum, and dysmorphic facial features. Conclusions: Four-vessel umbilical cords are more frequent than previously thought, as they can be easily overlooked during the mandatory ultrasound examination. A review of the literature revealed a correlation between supernumerary umbilical cord vessels and major congenital malformations, underscoring the significance of prenatal diagnosis; however, the four-vessel cord may not always be indicative of a serious condition.

Reduced fetal ductus venosus shunt fraction is associated with adverse perinatal outcomes in pregnancy with pregestational diabetes mellitus

PURPOSE

We aimed to determine fetal liver perfusion in PGDM and GDM pregnancies and to assess the relation of ductus venosus (DV) shunt fraction with adverse pregnancy outcomes.

METHODS

We conducted a prospective longitudinal observational study including 188 pregnant women: group I-patients with pregestational DM (PGDM, n = 86), group II-patients with gestational DM (GDM, n = 44), group III-control (n = 58). The patients included in the study underwent ultrasound examination at 30+0-40+0 weeks of pregnancy. We evaluated volumetric blood flow adjusted to EFW (Q, ml/min/kg) for umbilical vein, DV, left and main portal vein. The relative risk was calculated for adverse pregnancy outcomes.

RESULTS

In PGDM pregnancies, umbilical blood flow was redistributed to the fetal liver, increasing left portal and total liver volumetric blood flow (p < 0.001) compared with GDM and control groups. Pathological reduction in the DV shunt fraction (≤ 16.5%) was associated with an increased relative risk of preterm delivery (3.61 [95%CI 1.68; 7.71]), LGA-birth (1.64 [95% CI 1.26; 2.12]), neonatal adiposity (1.53 [95%CI 1.18; 1.98]), fetal hypoxia (3.47 [95%CI 1.34; 9.05]), emergency cesarean Sect. (1.93 [95%CI 1.26; 2.97]), and neonatal intensive care unit stay of more than 5 days (1.78 [95%CI 1.08; 2.93]).

CONCLUSION

Decreased DV shunt fraction reflects changes in fetal hemodynamics in PGDM-pregnancies and associated with an increased risk of adverse perinatal outcomes.

Double superior vena cava incidentally found during permanent catheter placement: A case report and literature review

A devastating admission to a tertiary hospital intensive care unit led to the discovery of a case of congenital duplicated superior vena cava (DSVC). Following the insertion of a temporary left internal jugular vein catheter, a subsequent chest X-ray indicated that the left catheter was not reaching the right heart. This resulted in a chest computed tomography scan with contrast, which confirmed the diagnosis of DSVC. The asymptomatic nature of these conditions reduces their prevalence. To date, there is no documented history of DSVC patients in Palestine. Therefore, it is important to report such a case to highlight the needs for larger studies in the future that aim to define the characteristics and varying features of patients with DSVC and the associated clinical findings.

The role of persistent right umbilical vein in the diagnosis of fetal genetic syndromes

INTRODUCTION

Persistent right umbilical vein (PRUV) is an embryonic vascular abnormality. Recent studies suggested that the perinatal outcome was good and the risk of aneuploidy was low in isolated forms. Our purpose in this study was to assess the relation of PRUV with genetic abnormalities and demonstrate concomitant malformations and perinatal outcomes of these fetuses.

MATERIALS AND METHODS

This was a retrospective study examining consecutive pregnancies diagnosed as having PRUV in our hospital between 2017 and 2022.

RESULTS

A total of 41 patients were diagnosed as having fetuses with PRUV during the study period. Additional ultrasound findings were detected in 26 fetuses (63.4%). The most common associated finding was fetal growth restriction, which was found in 15 (36.5%) of 41 fetuses. This was followed by cardiovascular findings in eight (19.5%) fetuses. Genetic anomalies were detected in five (12.1%) fetuses. Down syndrome was detected in two fetuses (4.8%), nail-patella syndrome in one fetus (2.4%), duplication of 7p was found in one fetus (2.4%), and Potocki-Lupski syndrome (2.4%) was diagnosed in one fetus.

CONCLUSION

In our study we found that even in isolated cases, genetic syndromes could coexist and fetal growth could be impaired so it should be closely monitored.

"Form follows function": the developmental morphology of the cardiac atria

Although the heart atria have a lesser functional importance than the ventricles, atria play an important role in the pathophysiology of heart failure and supraventricular arrhythmias, particularly atrial fibrillation. In addition, knowledge of atrial morphology recently became more relevant as cardiac electrophysiology and interventional procedures in the atria gained an increasingly significant role in the clinical management of patients with heart disease. The atrial chambers are thin-walled, and several vessels enter at the level of the atria. The left and right atrium have different structures and shape. In general, both atrial chambers have the venous part, the appendage, and the vestibule; different aspects of each part allow us to distinguish morphologically between the left and right atrium. The human atrial conduction system consists of the sinus node and the atrioventricular node with no histologically specialized conduction pathways in the atrial chamber and an interatrial connection. The data show that the propagation of the impulse depends mainly on the myocardial architecture in the atria and the orientation of the myocytes plays a significant role in conduction. To complete the picture, it is also important to know how the atria develop and what is the embryonic origin of its different structures, as this may play a role in the development of some pathological conditions such as atrial fibrillation or certain types of congenital heart defects. Functional impairment of the atria can in some situations severely compromise heart pumping function, and conversely, can support it if other areas are damaged, balancing the blood flow to the body for some time. Key words Morphology of atrial chambers, Pectinate muscles, Atrial function.

Fetal Growth Restriction: A Pragmatic Approach

An accurate diagnosis of fetal growth restriction relies on a precise estimation of gestational age based on a carefully obtained history as well as early ultrasound, since a difference of just a few days can lead to a significant error. There is a continuum of risk for adverse outcome that depends on the certainty of dates and presence or absence of comorbidities, in addition to the estimated fetal weight percentile and the umbilical artery waveform. The results of several studies, most notably the TRUFFLE trial, demonstrate that optimal management of fetal growth restriction with an abnormal umbilical artery waveform requires daily electronic fetal heart rate monitoring, and this monitoring does not require computerized interpretation. The role of ductus venosus waveform, biophysical profile, and middle cerebral artery waveform is less clear, and the results of these three modalities should be interpreted with caution. KEY POINTS: · A correct diagnosis of fetal growth restriction requires a very precise estimate of gestational age.. · In the presence of abnormal umbilical artery Doppler, the cornerstone of surveillance is daily electronic fetal heart rate monitoring.. · Surveillance with biophysical profile, ductus venosus waveform, and middle cerebral artery waveform are less important than daily electronic fetal heart rate monitoring..

Three-Dimensional Ultrasound for Physical and Virtual Fetal Heart Models: Current Status and Future Perspectives

Congenital heart defects (CHDs) are the most common congenital defect, occurring in approximately 1 in 100 live births and being a leading cause of perinatal morbidity and mortality. Of note, approximately 25% of these defects are classified as critical, requiring immediate postnatal care by pediatric cardiology and neonatal cardiac surgery teams. Consequently, early and accurate diagnosis of CHD is key to proper prenatal and postnatal monitoring in a tertiary care setting. In this scenario, fetal echocardiography is considered the gold standard imaging ultrasound method for the diagnosis of CHD. However, the availability of this examination in clinical practice remains limited due to the need for a qualified specialist in pediatric cardiology. Moreover, in light of the relatively low prevalence of CHD among at-risk populations (approximately 10%), ultrasound cardiac screening for potential cardiac anomalies during routine second-trimester obstetric ultrasound scans represents a pivotal aspect of diagnosing CHD. In order to maximize the accuracy of CHD diagnoses, the views of the ventricular outflow tract and the superior mediastinum were added to the four-chamber view of the fetal heart for routine ultrasound screening according to international guidelines. In this context, four-dimensional spatio-temporal image correlation software (STIC) was developed in the early 2000s. Some of the advantages of STIC in fetal cardiac evaluation include the enrichment of anatomical details of fetal cardiac images in the absence of the pregnant woman and the ability to send volumes for analysis by an expert in fetal cardiology by an internet link. Sequentially, new technologies have been developed, such as fetal intelligent navigation echocardiography (FINE), also known as "5D heart", in which the nine fetal cardiac views recommended during a fetal echocardiogram are automatically generated from the acquisition of a cardiac volume. Furthermore, artificial intelligence (AI) has recently emerged as a promising technological innovation, offering the potential to warn of possible cardiac anomalies and thus increase the ability of non-cardiology specialists to diagnose CHD. In the early 2010s, the advent of 3D reconstruction software combined with high-definition printers enabled the virtual and 3D physical reconstruction of the fetal heart. The 3D physical models may improve parental counseling of fetal CHD, maternal-fetal interaction in cases of blind pregnant women, and interactive discussions among multidisciplinary health teams. In addition, the 3D physical and virtual models can be an useful tool for teaching cardiovascular anatomy and to optimize surgical planning, enabling simulation rooms for surgical procedures. Therefore, in this review, the authors discuss advanced image technologies that may optimize prenatal diagnoses of CHDs.

An Aneurysm of the Internal Iliac Vein and Its Confluent Branches Due to Congenital Arteriovenous Communication: A Case Report

Iliac vein aneurysms are a relatively rare clinical medical case requiring careful management. In general, vessel aneurysms are always an intriguing entity to approach due to the various options for diagnosis and treatment, which are heavily dependent on the unique characteristics of the condition. Such features include etiology, location, and coexistence with other abnormalities. In this case report, we describe the case of a patient who presented with an aneurysm in his internal iliac vein, as well as its tributaries, as a result of congenital arteriovenous communication.

Unraveling fetal venous disorders: An integrated approach in fetal echocardiography and their clinical significance

OBJECTIVE

Fetal venous system malformations frequently coincide with cardiac or extracardiac anomalies. This study explores our experience with an integrated fetal echocardiography approach and analyzes the characteristics and outcomes of fetal venous system disorders.

MATERIALS AND METHODS

We conducted a retrospective study with 7048 pregnant women (7255 fetuses) who underwent complete two-dimensional (2D) fetal echocardiographic examinations. We primarily employed an integrated 2D approach. Three-/four-dimensional (3D/4D) spatiotemporal image correlation was supplemental. Fetal venous disorders were classified into 3 groups: cardinal (Group 1), umbilical and vitelline (Group 2), and pulmonary (Group 3) systems, based on embryological-anatomical considerations. Maternofetal data were recorded alongside imaging diagnoses.

RESULTS

Congenital venous malformations were identified in 98 fetuses, yielding a prevalence of 1.35% (98/7255). Six participants had coexisting venous disorders from different groups. Group 1 included 48 fetuses with persistent left superior vena cava (LSVC) and 3 others (unidentified brachiocephalic vein, left inferior vena cava (IVC), and interrupted IVC with azygous continuation to SVC). Group 2 had 39 fetuses with persistent right umbilical vein and 7 with umbilical-portal-ductus venosus disorders. Group 3 had 7 fetuses with pulmonary venous return disorders. Group 2 showed the most favorable outcomes (alive and without neonatal death), while Group 3 exhibited the poorest. Associated cardiac defects were observed in 43.1% of Group 1, 8.7% of Group 2, and 57.1% of Group 3 (P < 0.001), displaying a broad spectrum of non-specific anomalies. Meanwhile, Group 2 had a greater occurrence of a single venous disorder (93.5%) compared to Group 1 (88.2%) and Group 3 (57.1%) (P = 0.020).

CONCLUSION

Our approach offers an integrated strategy for assessing the fetal venous system during fetal echocardiography, providing multiple views to characterize venous anomalies. The presence of a fetal venous disorder may indicate the coexistence of more severe abnormalities, and the prognosis depends on associated anomalies or the venous disorders per se.

Prenatal Detection and Postnatal Outcome of Persistent Left Superior Vena Cava and Agenesis of Ductus Venosus Associated with Postnatal Bovine Aortic Arch

BACKGROUND

Isolated agenesis of ductus venosus (ADV) is usually a benign condition, but it may be associated with cardiovascular defects, hydrops, growth restriction, and chromosomal abnormalities. Additionally, persistent left superior vena cava (PLSVC) and bovine aortic arch are relatively common fetal anomalies. To the author's knowledge, this is the first report of prenatal detection of DV agenesis and PLSVC associated with the postnatal bovine aortic arch with a hypoplastic transverse aortic arch.

CASE

A 25-year-old, G2P1 woman was referred to our department at 31 weeks due to fetal growth restriction and short femur. On fetal echocardiography, DV could not be viewed via two-dimensional (2D) and Doppler ultrasound (US) imaging; there was also evidence of the co-occurrence of PLSVC and an aortic arch anomaly. We revealed the intrahepatic continuation of the umbilical vein. A weekly follow-up program was scheduled for the patient and the rest of the pregnancy was uneventful. Postnatal, thorax computer tomography and transthoracic echocardiography (TTE) demonstrated PLSVC and bovine aortic arch associated with hypoplastic transverse aortic arch. Routine echocardiographic examinations revealed that the blood flow of the aortic arch had increased gradually, and the male infant's aortic arch had significantly widened and reached the normal range until the baby was discharged from the hospital.

CONCLUSION

DV agenesis and PLSVC are usually benign conditions but underlying serious heart diseases may accompany them. Therefore, in situations like ours, a prenatal aortic arch evaluation is of capital importance. Postnatal hemodynamic changes should be taken into consideration in the management of these cases. This is the first example in the literature that these abnormalities co-existed in one case.

Evaluation of the type of fetal umblical-portal anastomosis in late-onset fetal growth restriction: A case-control study

PURPOSE

To evaluate the type of umbilical-portal anastomosis in late-onset fetal growth restriction (LO-FGR) and appropriate for gestational age (AGA) fetuses. To investigate the impact of the type of umbilical-portal anastomosis on the adverse outcomes in LO-FGR.

METHOD

This study observed 150 pregnancies with AGA fetuses and 62 pregnancies with fetuses with LO-FGR. In each case, the point of reference for measuring the abdominal circumference was established. The type of umbilical-portal anastomosis was evaluated as T-shaped, X-shaped, and H-shaped according to the shape of main portal vein and portal sinus. Incidences of the type of umbilical-portal anastomosis in AGA and LO-FGR fetuses were evaluated.

RESULTS

T-shaped anastomosis was the most common (56.7%) in the AGA group and X-shaped (66.1%) in the LO-FGR group. In LO-FGR, T-shape anastomosis was significantly lower and X-shape anastomosis was significantly higher than AGA (p < 0.001). X-shaped anastomosis was associated with LO-FGR and the RR was 2.3 (95% CI 1.5-3.6; p < 0.001). Incidences of admission to NICU and emergency C/S for fetal distress were higher in fetuses with X -shaped anastomosis in the LO-FGR (p < 0.05).

CONCLUSION

X-shaped umbilical-portal anastomosis have a prognostic significance in LO-FGR fetuses.

Percutaneous Correction of a Large Left Superior Vena Cava to Left Atrium Fistula

•Fistula between the PLSVC and the LA is a rare congenital condition. •Patients can present as adults with cerebrovascular accidents and dyspnea. •Percutaneous correction using a covered stent is feasible.

Absence of Ductus Venosus: A Comparison of 2 Distinctive Fetal Autopsy Cases and Embryologic Perspectives

In fetal circulation, oxygenated blood from the placenta flows through the umbilical vein into the ductus venosus (DV), then enters the inferior vena cava, and subsequently reaches the right atrium of the heart. The DV serves as a shunt, allowing this oxygen-rich blood to bypass the liver. The absence of the DV (ADV), also known as agenesis of the DV, is a rare congenital anomaly. Without a DV, blood from the umbilical vein must follow alternative routes to the heart. In ADV cases, blood from the umbilical vein must follow 1 of 2 primary drainage patterns: either an extrahepatic shunt or an intrahepatic shunt. This report details the antenatal ultrasound and postmortem findings of 2 fetuses diagnosed with ADV by prenatal imaging studies. The first case involved a fetus with a persistent right umbilical vein connected directly to the suprahepatic IVC, accompanied by early obliteration of the left umbilical vein and true agenesis of the DV. This fetus also had additional congenital anomalies. In contrast, the second case involved a fetus with a normal left umbilical vein that entered the liver. However, despite an ultrasound diagnosis of "absence" of the DV, a DV was present, though markedly hypoplastic and probably minimally functional or non-functional. In this case, blood from the umbilical vein likely followed an alternate intrahepatic route through the portal and hepatic veins, before reaching the heart (intrahepatic shunt). These contrasting cases emphasize the heterogeneity of vascular anomalies and embryologic origins captured by the term "ADV." Additionally, the terminology of "absence" or "agenesis" may be misleading in some purported ADV cases. Specifically, in the second case, the DV was not absent; it was markedly hypoplastic instead. This also appears to be the first reported case of a hypoplastic DV in a fetus. Both cases underscore the importance of effective collaboration and clear communication between maternal-fetal medicine specialists and pathologists.

In-utero evaluation of the fetal umbilical-portal venous system among fetuses with persistent right umbilical vein: Two-and three-dimensional ultrasonographic study

OBJECTIVE

The aim of this study was to describe the anatomy of the portal system in fetuses with persistent right umbilical vein (PRUV).

METHODS

Prospective observational study of fetuses diagnosed with PRUV. All patients underwent a comprehensive portal system anatomy scan supplemented by two-dimensional (2D) and three-dimensional (3D) color doppler modalities.

RESULTS

29 fetuses with PRUV were studied. We perceived an identical anatomical pattern in 28 fetuses. The right umbilical vein drains to the portal sinus (future right portal vein, RPV), which has a configuration of a left portal vein (LPV) in the normal left portal system, with three emerging branches: inferior (RPVi), medial (RPVm) and superior (RPVs). The RPV then courses to the left, towards the stomach to the point of the bifurcation of the main portal vein (MPV) to become the left portal vein. The LPV has an RPV configuration in a normal portal system with anterior (LPVa) and posterior (RPVp) branches. This anatomical layout mimics a mirror image of the normal anatomy of left portal system.

CONCLUSION

PRUV has unique umbilical portal venous anatomy, which is a mirror image of the normal left portal system. It can be demonstrated prenatally and serve as an additional tool for prenatal diagnosis of PRUV.

Retroperitoneal lymphoma with double inferior vena cava shown using a 3D visualization model: A case report and literature review

Cases of a retroperitoneal tumor with double inferior vena cava (IVC) are rarely reported. The present report documents a case of a retroperitoneal lymphoma with double IVC, and discusses its embryological, clinical and radiological significance. In addition, previous cases of a double IVC are reviewed. In the present report, a 52-year-old male patient was hospitalized for a retroperitoneal lymphoma tumor and double IVC. CT urography was performed, whilst a three-dimensional visualization model was also established based on CT data, to reveal a retroperitoneal tumor with double IVC. The present case involved a double IVC with interiliac vein, which was type 2b from the left IVC. The retroperitoneal tumor was identified to be a lymphoma measuring 116x83 mm by percutaneous puncture biopsy. Surgical treatment is generally not recommended for lymphoma. Therefore, this patient was transferred to the Hematology Department for treatment according to the lymphoma management guidelines. The size of the tumor was reduced after chemotherapy during the patient's follow-up. In conclusion, the three-dimensional visualization model can directly and accurately present the anatomical features of the double IVC and its surrounding tissue structure. In addition, variations in the features of IVC can have important clinical significance. It is also important for surgeons, interventional radiologists and clinicians to understand such abnormalities in anatomical features to avoid misdiagnosis and reduce the occurrence of serious intraoperative complications.

Persistent Left Superior Vena Cava and Inferior Vena Cava Dual Drainage to Coronary Sinus: A Case Report

Dilation of the coronary sinus is often a result of excessive volume overload from congenital anomalies of systemic venous return to the heart. These abnormalities are often discovered incidentally later in life when a patient requires cardiac imaging, cardiac catheterization, or thoracic surgery. The most common abnormality is a persistent left superior vena cava. Inferior vena cava malformation is less common, yet several different anomalies can arise. The presence of persistent left superior vena cava or inferior vena cava anomalies requires further evaluation to rule out congenital heart disease in infants. Knowledge of technically challenging systemic venous anatomy is beneficial prior to procedures necessitating central venous access such as a central line, cardiac catheterization, and intracardiac device implantation. We present an unusual case of persistent LSVC and IVC both draining directly into a severely dilated coronary sinus that was diagnosed by fetal echocardiogram and later confirmed postnatally by transthoracic echocardiogram and computed tomography angiography. To our knowledge this is the second reported case of IVC drainage into the CS and the first case that reports this as a prenatal diagnosis.

Prenatal ultrasonographic features and follow-up outcomes of 19 cases of congenital intrahepatic portosystemic venous shunts diagnosed during the foetal period

Background

To investigate the prenatal ultrasonographic features and case characteristics of the congenital intrahepatic portosystemic venous shunt (IHPSS) diagnosed during the foetal period and analyse its prognosis.

Methods

We conducted a retrospective cohort study of patients diagnosed with IHPSS between 2016 and 2021. IHPSS was defined as an abnormal connection between the foetal intrahepatic portal and the hepatic veins.

Results

In this study, 19 foetuses were identified, including 12 cases of single shunt and 7 cases of multiple shunts, with a gestational age of 33.8 ± 4.5 (range 25–40) weeks at diagnosis. In the single-shunt group, the origin position of the shunts was all from the left branch of the portal vein (LPV), whereas in the multiple-shunt group, the origin position of the shunts was from the LPV in six cases. Common concomitant intrauterine abnormalities of IHPSS include foetal growth restriction (47.4%) and foetal cardiac enlargement (21.1%). The postnatal manifestations of IHPSS include biochemical abnormalities (increased gamma-glutamyl transferase and bilirubin levels), neonatal hypoglycaemia, neonatal hyperammonaemia, pulmonary hypertension, multiple intrahepatic hyperechoic nodules, and cutaneous haemangiomas. Spontaneous closure of shunts occurred in ten cases, and the mean time to shunt closure was 8.1 months (1–28 months).

Conclusions

Most IHPSS found during the foetal period is located in the left branch of the portal vein, and the gestational age at diagnosis is usually in the late second or third trimester. Spontaneous closure of shunts can occur in most live births, and the prognosis is good.

Opto-ultrasound biosensor for wearable and mobile devices: realization with a transparent ultrasound transducer

Mobile and wearable healthcare electronics are widely used for measuring bio-signals using various fusion sensors that employ photoplethysmograms, cameras, microphones, ultrasound (US) sensors, and accelerometers. However, the consumer demand for small form factors has significantly increased as the integration of multiple sensors is difficult in small mobile or wearable devices. This study proposes two novel opto-US sensors, namely (1) a wearable photoplethysmography (PPG)-US device and (2) a PPG sensor built-in mobile smartphone with a US sensor, seamlessly integrated using a transparent ultrasound transducer (TUT). The TUT exhibits a center frequency of 6 MHz with a 50% bandwidth and 82% optical transparency in visible and near-infrared regions. We developed an integrated wearable PPG-US device to demonstrate its feasibility and coupled the TUT sensor with a smartphone. We measured the heart rates optically and acoustically in human subjects and quantified the oxygen saturation optically by passing light through the TUT. The proposed proof-of-concept is a novel sensor fusion for mobile and wearable devices that require a small form factor and aim to improve digital healthcare. The results of this study can form the basis for innovative developments in sensor-based high-tech industrial applications, such as automobiles, robots, and drones, in addition to healthcare applications.

Prenatal diagnosis of hepatic interruption of the inferior vena cava with azygos/hemiazygos continuation without structural heart defects: A case series

OBJECTIVES

To describe fetal spectrum and echocardiographic characteristics of interrupted inferior vena cava (IIVC) with azygos/hemiazygous continuation without other structural heart defects and to evaluate its association with visceral heterotaxy and isomerism, extracardiac and genetic anomalies, and to review neonatal outcome.

METHODS

This was a retrospective study of 14 fetuses with a confirmed diagnosis of IIVC with normal intracardiac anatomy. The following variables were collected; indication for referral, gestational age at diagnosis; associated isomerism and visceral heterotaxy, heart rhythm, genetic and extracardiac abnormalities, and fetal/neonatal outcome.

RESULTS

Among 36 fetuses with IIVC, 14 cases (38.8%) had normal intracardiac anatomy. These IIVC cases correspond to 0.19% (14/7250) of all fetal cardiac examinations, and to 1.5% (14/922) of all cardiac abnormalities. Six patients had visceral abnormalities. Atrial appendage morphology was clearly depicted in three fetuses, both appendages were left. One fetus had bradyarrhythmia revealing atrial ectopic rhythm. Six fetuses did not have any concomitant cardiac or visceral abnormalities, therefore regarded as isolated. All babies were delivered at term with a good prognosis.

CONCLUSION

Our study has shown that almost half of the IIVC cases without intracardiac structural anomalies displayed other findings of isomerism while the other half was isolated benign vascular variant. Therefore, prenatal diagnosis of IIVC should prompt a comprehensive evaluation for cardiac, situs, and visceral anomalies. The outcome is favorable.

Ductus Venosus Agenesis and Portal System Anomalies-Association and Outcome

To evaluate the prenatal diagnosis of agenesis of ductus venosus (ADV) and portal venous system (PVS) anomalies and describe the outcome of these cases, either isolated or associated. We evaluated the intrahepatic vascular system regarding the presence of normal umbilical drainage and PVS characteristics in the second and third trimester of pregnancy. The associated anomalies and umbilical venous drainage were noted. Follow-up was performed at six months follow-up. Ultrasonography was performed in 3517 cases. A total of 19 cases were prenatally diagnosed: 18 ADV cases, seven abnormal PVS cases, and six associations of the two anomalies. We noted an incidence of 5.1‱ and 1.9‱ for ADV and PVS anomalies, respectively. Out of the 18 ADV cases, 27.7% were isolated. Five cases (26.3%) presented genetic anomalies. PVS anomalies were found in 33.3% of the ADV cases. ADV was present in 85.7% of the PVS anomalies. DV and PVS abnormalities were found with a higher than reported frequency. Normal DV is involved in the normal development of the PVS. Additional fetal anomalies are the best predictor for the outcome of ADV cases. Evaluation of PVS represents a powerful predictor for ADV cases and addresses the long-term prognosis.

Prenatal Diagnosis and Outcome of Umbilical–Portal–Systemic Venous Shunts: Experience of a Tertiary Center and Proposal for a New Complex Type

Aims: To share our experience in the prenatal diagnosis of umbilical–portal–systemic venous shunts (UPSVS) and to study the prognostic factors for proper prenatal and perinatal management. Material and Methods: A five-year prospective study regarding the detection of UPSVS was conducted in two referral centers, Medgin Ginecho Clinic and the Prenatal Diagnostic Unit of the tertiary center, University Emergency County Hospital Craiova, Romania. We included in the analysis a series of agenesis of ductus venosus (ADV) cases previously reported by our center. We analyzed the incidence of the UPSVS types, their associations, and outcome predictors. Results: UPSVS were diagnosed in all 16 cases that were presented to our center at the time of first trimester anomaly scan, except one (94.12%). We diagnosed: 19 type I (61.2%), 4 type II (12.9%) and 5 type IIIa (16.1%) UPSVS. In three cases (9.6%) we noted multiple shunts, which we referred to as type IV (a new UPSVS type). Type IIIa-associated fetal growth restriction (FGR) was found in 60% of cases. Major anomalies worsened the outcome. Of the UPVSS cases, 57.1% were associated with PVS anomalies. Genetic anomalies were present in 40% of the tested cases. Conclusions: The incidence of UPSVS in our study was 0.2%. Early detection is feasible. The postnatal outcome mainly depends on the presence of structural, genetic and PVS anomalies. FGR may be associated. The new category presented a poor outcome secondary to poor hemodynamic and major associated anomalies.

Feasibility of Fetal Portal Venous System Ultrasound Assessment at the FT Anomaly Scan

Objective: To investigate the feasibility of the first trimester (FT) ultrasound scan (US) for the evaluation of the fetal portal venous system (PVS) anatomy, and to evaluate the potential of microcopy for a proper pathology evaluation for the PVS in the FT. Methods: We evaluated the PVS in 200 scan examinations performed in FT pregnancy. Half of the cases were scanned by two operators with extensive experience in obstetric ultrasound—Group I, and the other half was evaluated by two sonographers with less experience—Group II. Second-trimester US and autopsy in terminated pregnancies were used as follow-up. The pathologic evaluation was supported by microscopy. Results: all PVS features were successfully assessed by transabdominal ultrasound (TAUS) in 27% of the Group I cases and 14% in Group II. These rates increased to 88% in Group I and in 72% in Group II, after rescanning and using transvaginal ultrasound (TVUS). The conditions that led to rescanning and TVUS were: BMI greater than 24 in 26% cases, unfavorable fetal position (12.32%), retroverted uterus (12.32%), abdominal scar (10.96%), fibroids (4.11%), and combinations of the above (34.23%). The L-shaped UV confluence was identified transabdominally in 91% in Group I and in 79% in Group II and increased to 98% and 95%, respectively, following reevaluations. Microscopy represented a useful audit in all FT investigated cases. Conclusions: At the end of the FT, the visualization of a normal L-shaped UV confluence, that excludes major PVS abnormalities, is achievable in approx. 80%, indifferently the examiners experience. The sonographers experience, pregnant women BMI, and uterine anomalies as fibroids or retroversion significantly affect the rate of visualization, and necessitates vaginal approach and reexamination. The FT pathology, the audit of the ultrasound findings can only be performed microscopically, with relatively little resources involved and good results.

Ultrasound Pitfalls in a Complex Fetal Cardiac Malformation—Case Report of a New Arteriovenous Central Communication

Cardiac and cardiovascular malformations are of real interest in terms of definition, epidemiology, and means of early diagnosis by imaging. Although ultrasound examination reaches exceptional performance nowadays, unusual pathologies are still exposed to the risk of either incorrect acquired image or misinterpretation by the specialist in a routine scan. Herein, we present a case of a 20-week-old fetus (from an apparently low-risk pregnancy) with complex cardiac and vascular abnormalities, including an arteriovenous malformation along with ventricular septal defect, ductal coarctation of the aorta, aneurysm of a brachiocephalic vein, and dilation of the entire neck and upper mediastinum venous system, and the limitations that were encountered in the process of diagnosis and management of the case.

Fetal-TAPSE for Surveillance of Cardiac Function in Growth-Restricted Fetuses With a Portosystemic Shunt

OBJECTIVES

Congenital portosystemic shunt (CPSS) in a growth-restricted fetus may lead to cardiac overload and ultimately hemodynamic imbalance. The aim of the study was to describe the application of tricuspid annular plane systolic excursion (TAPSE) for surveillance of cardiac function in growth-restricted fetuses diagnosed with CPSS.

METHODS

The study group consisted of 7 fetuses with growth restriction diagnosed with CPSS between 2018 and 2020. Patients were followed longitudinally every 2 weeks. Sonographic fetal-TAPSE (f-TAPSE) was performed every 2 weeks. At each visit, the following parameters were recorded: estimated fetal weight, biophysical profile, nonstress test, Doppler flow indices, and fetal cardiothoracic index. Postnatal laboratory and imaging tests were retrieved from the medical files.

RESULTS

Mean gestational age at diagnosis of CPSS was 32 + 1 weeks. Cardiomegaly was observed in all cases. All portosystemic shunts were classified as intrahepatic. Values of f-TAPSE were above the 95th percentile in 6/7 fetuses at presentation and throughout follow-up. Gestational age at delivery ranged between 36 + 5 and 38 + 5 weeks. Postnatally, spontaneous closure of the shunt was noted in 2 infants. Transient hyperammonemia was diagnosed in 2 neonates, with no signs of the characteristic complication.

CONCLUSIONS

In growth-restricted fetuses diagnosed concomitantly with CPSS, f-TAPSE offers a practical sonographic tool for assessment of cardiac function and may serve as an additional clinical marker for follow-up. The appearance of cardiomegaly in growth-restricted fetuses should prompt a dedicated sonographic evaluation of the fetal portal system.

A new classification of congenital abnormalities of UPVS: sonographic appearances, screening strategy and clinical significance

The umbilical–portal venous system (UPVS) plays an important role in embryonic development, as well as a significant blood circulation system to ensure the normal blood supply of fetal heart and brain and other vital organs. Congenital anomalies of UPVS contain many subtypes with a broad spectrum of manifestations and prognoses. Furthermore, because of fetal small lumen of UPVS, the sonographic evaluation remains difficult in utero. Appreciation of normal embryology and anatomy of UPVS is essential to an understanding of sonographic characteristics of anomalies of UPVS and fetal sequential changes. Through reviewing previous references and our experience with congenital abnormalities of UPVS, a new comprehensive classification is proposed. The new classification identifies three types of congenital abnormalities of UPVS based on morphological abnormalities and shunts. The embryology and etiology, sonographic, clinical and prognostic characteristics of each subtype of the new classification are described in detail. Knowledge of congenital abnormalities of UPVS can give sonographers a clue and aid prenatal sonographic diagnosis. The purpose of this article is to help the sonographers to understand the new classification of congenital abnormalities of UPVS, master the sonographic characteristics of each subtype and prenatal ultrasonographic screening strategy, and guide subsequent appropriate counseling and management.

Incidental discovery of duplicated inferior vena cava in a septuagenarian: the radiologist's viewpoint

Duplication of the inferior vena cava is a rare malformation, normally without clinical impact, explained by abnormal development and regression of certain segments of the venous system during embryonic life. However, its presence and type should be systematically reported in the radiological report because of its potential implications for diagnostic and interventional procedures. This observation describes the case of a 77-year-old man with a complete asymmetric duplication of the inferior vena cava (type III IVC according to Natsis) that was incidentally discovered on CT-scan.

Prenatal Ultrasound Analysis of Umbilical-Portal-Systemic Venous Shunts Concurrent With Trisomy 21

OBJECTIVES

A classification termed umbilical-portal-systemic venous shunt (UPSVS) for an abnormal umbilical vein (UV), portal vein (PV), and ductus venosus (DV) was proposed recently. According to this classification, there are 3 types of UPSVSs: types I, II, and III. Trisomy 21 associated with UV-PV-DV anomalies has been described, but the incidence of trisomy 21 in UPSVS cases, the relationship between UPSVS types and trisomy 21, and the pregnancy outcome are poorly documented. This study aimed to address these issues.

METHODS

All UPSVS cases diagnosed at our department from 2016 to 2019 were retrospectively studied. The English literature describing UV-PV-DV anomalies and trisomy 21 from 2000 to 2019 was searched, and the retrieved cases were analyzed.

RESULTS

Four of 20 UPSVS cases identified by us also had trisomy 21, with 2 type I and 2 type II UPSVSs. Ultrasound markers of Down syndrome were observed in all 4 cases that underwent termination of pregnancy (TOP). The literature search retrieved 12 reports including 279 patients, with 29 also having trisomy 21, giving a pooled trisomy 21 incidence rate of 10.4%. Of the 29 cases, 16 had type I, and 9 had type II, whereas UPSVS types in 4 were undeterminable, and 22 cases underwent TOP.

CONCLUSIONS

There is a high incidence of trisomy 21 in UPSVS cases. Trisomy 21 is associated with a type I or II UPSVS. Most cases with the combined defect underwent TOP. These findings may be used to direct prenatal counseling and management of the combined condition.

The intra-hepatic umbilical-Porto-systemic venous shunt and fetal growth

OBJECTIVE

The fetal liver circulation has an important role in fetal growth. The intra-hepatic Umbilical-Porto-Systemic Venous Shunt (IHUPSVS) causes a reduction of the umbilical blood flow to the liver and has been reported to have a restrictive effect on fetal growth. The aim of this study was to evaluate the effect of IHUPSVS on fetal growth.

METHODS

We conducted a retrospective cohort study of IHUPSVS diagnosed between 2001 and 2019. IHUPSVS was defined as any abnormal communication between any branch of the portal vein and hepatic vein. Pre- and postnatal characteristics were collected from medical files and compared between cases with fetal growth restriction (FGR) and those appropriate for gestational age (AGA).

RESULTS

Twenty-five fetuses were included in the study. Eighteen (72%) had last estimated fetal weight and birth weight below the 10th centile, four (16%) of them between the third and fifth centile, and 11 (44%) below the third centile. Median gestational age at delivery was lower for FGR than AGA fetuses (37 vs. 38 weeks, p = 0.034) and rate of preterm delivery was higher (38.9 vs. 14.3, P = 0.24). Four cases had associated structural anomalies (2 in each group), and two had minor genetic aberrations (1 in each group).

CONCLUSIONS

Growth restriction is prevalent in fetuses with IHUPSVS, suggesting that fetal growth should be monitored. In equal measure, in cases with growth restriction, especially without other apparent cause, an intrahepatic shunt should be looked for.

Ultrasonic detection of fetal persistent right umbilical vein and incidence and significance of concomitant anomalies

BACKGROUND

Persistent right umbilical vein (PRUV) is characterized by atresia of the left umbilical vein while the right umbilical vein remains open. Given the limited sample size of most studies, the incidence of PRUV and the status of concomitant anomalies may not be fully reflected. Thus, we studied the incidence of fetal PRUV and its concomitant anomalies on a larger scale using our hospital database. This study hoped to address the following questions: Does PRUV increase the risk of fetal anomalies? If the PRUV fetus also has a single umbilical artery (SUA), does the risk of fetal anomaly increase further? What is the positive predictive value of PRUV for fetal anomalies?

METHODS

This retrospective study analyzed 756 cases of fetal PRUV at our hospital from January 2007 to April 2017. Prenatal ultrasound and color Doppler images were assessed. All PRUV fetuses underwent echocardiography and detailed ultrasound examinations of other systems. Newborn status was obtained via the database or by telephone follow-up.

RESULTS

A total of 435,428 pregnant women underwent prenatal ultrasonography at 16-40 weeks, the incidence of fetal PRUV was 0.17%, and 102 fetuses (13.5%) developed other anomalies. Two complicated cases had trisomy 18. PRUV was associated with a higher incidence of fetal anomalies. When fetal anomalies were classified by body systems, PRUV was associated with a higher incidence of cardiovascular, nervous, urinary, skeletal, digestive, and respiratory system anomalies. The positive predictive values of a PRUV for any fetal anomalies and cardiovascular anomalies were 13.5% (95%CI, 11.2-16.2%) and 5.4% (95%CI, 4.0-7.3%), respectively. SUA further increases the risk of PRUV fetuses with other anomalies and cardiovascular anomalies.

CONCLUSIONS

Detailed prenatal ultrasonography and echocardiography should be performed in fetuses with PRUV to rule out anomalies in other systems. When the PRUV is combined with SUA, echocardiography is particularly important. Fetuses with complicated PRUV should undergo chromosomal examination. Although isolated fetal PRUV prognosis is good, complicated PRUV prognosis depends on the type and severity of the concomitant anomalies.

Fetal Growth Restriction - Diagnostic Work-up, Management and Delivery

Fetal or intrauterine growth restriction (FGR/IUGR) affects approximately 5 – 8% of all pregnancies and refers to a fetus not exploiting its genetically determined growth potential. Not only a major cause of perinatal morbidity and mortality, it also predisposes these fetuses to the development of chronic disorders in later life. Apart from the timely diagnosis and identification of the causes of FGR, the obstetric challenge primarily entails continued antenatal management with optimum timing of delivery. In order to minimise premature birth morbidity, intensive fetal monitoring aims to prolong the pregnancy and at the same time intervene, i.e. deliver, before the fetus is threatened or harmed. It is important to note that early-onset FGR (< 32 + 0 weeks of gestation [wks]) should be assessed differently than late-onset FGR (≥ 32 + 0 wks). In early-onset FGR progressive deterioration is reflected in abnormal venous Doppler parameters, while in late-onset FGR this manifests primarily in abnormal cerebral Doppler ultrasound. According to our current understanding, the “optimum” approach for monitoring and timing of delivery in early-onset FGR combines computerized CTG with the ductus venosus Doppler, while in late-onset FGR assessment of the cerebral Doppler parameters becomes more important.

Congenital extracardiac venous system anomaly in two siblings with normal karyotype and increased nuchal translucency thickness: a case report

Previous studies have reported that congenital heart diseases (CHDs) develop in patients with genetic and environmental predisposition. Compared to CHDs, the significance of hereditary factors in the pathogenesis of congenital venous system anomalies remains unclear. Additionally, reports describing the pathogenic relationship between venous system anomalies and increased nuchal translucency (NT) are few. We report sibling recurrence of congenital venous system anomalies. In the prenatal periods of both siblings, increased NT without aneuploidy was confirmed. In the first sibling, the absence of ductus venosus (ADV) and umbilical vein-coronary sinus anastomosis was detected using prenatal ultrasonography. In the second sibling, abnormality of the pulmonary vein was suspected prenatally, leading to a final diagnosis of infracardiac total anomalous pulmonary venous return (TAPVR). This is the first report of extracardiac venous anomaly-associated recurrence of increased NT among siblings. We conclude that a hereditary factor may be responsible for the development of ADV and TAPVR.

Hepatic vein variations in 500 patients: surgical and radiological significance

OBJECTIVES

The purpose of the study was to assess the incidence of hepatic vein variations on multidetector CT (MDCT) for abdominal examinations.

METHODS

A retrospective analysis of 534 MDCT scans was performed in patients sent for various abdominal pathologies between January 2017 and April 2019. After excluding 34 patients, finally total of 500 patients (N = 500) were included in the study. For simplification, we classified the hepatic vein variations as classified by Soyer et al, Fang et al and Cheng et al.

RESULTS

Single right hepatic vein was seen in 458 (91.6%) out of 500 patients in our study. Two right hepatic veins were seen in 36 patients out of which 27 had common trunk and nine had independent drainage into the inferior vena cava (IVC). Common trunk of middle hepatic vein (MHV) and left hepatic vein (LHV) was seen in 405 (81%) and independent drainage of MHV and LHV into the IVC was seen in 95 (19%) of patients in our study. Amongst the segmental hepatic vein variations, most common drainage of segment IV vein was into LHV (333,66.6%) followed by MHV (148,29.6%) and IVC (19,3.8%).

CONCLUSION

Hepatic vein variations are commonly seen similar to variations in hepatic artery, portal vein and biliary anatomy. Knowledge of these variations is extremely important for transplant surgeons and intervention radiologists.

ADVANCES IN KNOWLEDGE

Awareness of the hepatic vein variations is essential for intervention radiologists and surgeons to reduce iatrogenic complications.

Anatomy of the Right Anterior Sector of the Liver and Its Clinical Implications in Surgery

BACKGROUND

Surgery remains the gold standard both for delimited hepatocellular carcinoma by selective anatomic liver segentectomy and for colorectal liver metastases by parenchymal sparing liver resection. Right anterior sector (RAS) (segments V-VIII; Couinaud) is the largest and most difficult sector to operate on. A better knowledge of its segmentation could prevent postoperative remnant liver ischemia and its impacts on patient's survival.

METHODS

A literature search was conducted in PubMed for papers on anatomy and surgery of the right anterior sector.

RESULTS

Segmentation of the RAS depended of the anatomic variations of the third-order portal branches. Cranio-caudal segmentation was the most commonly found (50-53%), followed by ventro-dorsal (23-26%), trifurcation (13-20%), and quadrifurcation types (5-11%). Ventral and dorsal partial or total subsegmentectomy seemed accessible in 47 to 50% of patients, including bifurcation, trifurcation, and quadrifurcation types, and could spare up to 22% of the total liver volume. The RAS hepatic vein was present in 85-100% of the patients and could be used as a landmark between RAS dorsal and ventral part in 63% of patients. Reported overall morbidity rate of RAS subsegmentectomy ranged from 33 to 59% among studies with a postoperative major complication rate (Clavien-Dindo ≥ III) ranging around 18% and a biliary leakage rate from 16 to 21%. In-hospital reported mortality rate was low (0-3%), and results were comparable to "classic" liver resections. RAS subsegmentectomy remains a complex procedure; median operating time ranged from 253 to 520 min and median intraoperative blood loss reached 1255 ml.

CONCLUSION

Better knowledge of RAS anatomy could allow for parenchymal preservation by using subsegmentectomy of the RAS, selective or as a part of a major hepatectomy.

Prenatal diagnosis of persistent right umbilical vein - Incidence and clinical impact. A prospective study

Background

Persistent right umbilical vein (PRUV) is usually an isolated finding but it may be accompanied by other fetal malformations.

Aims

We aimed to determine the incidence of prenatally diagnosed PRUV in a referral population, assess the neonatal outcome and discuss the findings together with those from previous publications.

Materials and methods

A total of 2360 women with low‐risk singleton pregnancies were examined in the second and third trimesters. A transabdominal convex volume transducer was used. B‐mode was applied in each patient. Scanning of the venous system included imaging of the target vessels with two‐dimensional colour Doppler mapping. The diagnosis of PRUV was made in a transverse section of the fetal abdomen. Three‐dimensional ultrasounds were performed as necessary, when anomalous cases were encountered.

Results

The incidence of PRUV in our population was 12/2360 = 0.5%, and it was higher than in other retrospective studies. In 75% (n = 9), PRUV was an isolated finding where delivery was uneventful and the postnatal outcome was favourable. In two cases PRUV was accompanied by omphalocele, and in one case by tetralogy of Fallot and single umbilical artery.

Conclusions

PRUV is an uncommon prenatal finding. Screening for this anomaly can be easily performed in all pregnant patients. A diagnosis of PRUV should be followed by a thorough fetal morphology scan in order to exclude any other malformations, especially those of the cardiovascular system.

Congenital absence of the portal vein in a cat

CASE SUMMARY

A 9-month-old female neutered domestic shorthair cat presented with a history of episodic ptyalism, lethargy and abnormal behaviour. The clinical signs together with elevated pre- and post-prandial bile acid concentrations were consistent with hepatic encephalopathy (HE). In the absence of a portosystemic shunt (PSS) on abdominal ultrasound, medical management of HE was established with a protein-restricted diet and lactulose and the neurological signs resolved. Following an episode of acute vomiting and haemorrhagic diarrhoea at 19 months of age abdominal ultrasonography was repeated. The portal vein could not be demonstrated ultrasonographically; instead, portal vein tributaries were tortuous and communicated with the caudal vena cava (CdVC) at the level of the left kidney. CT angiography (CTA) confirmed the absence of the portal vein. CTA demonstrated the tortuous terminations of the portal tributaries, and several systemic veins, draining into the CdVC via a large-diameter paracaval vessel at the level of the left kidney. Gastrointestinal signs were stabilised and medical management for HE of a protein-restricted diet and lactulose was re-established.

RELEVANCE AND NOVEL INFORMATION

Congenital absence of the portal vein has not been described previously in the cat and should be considered in cats presenting with signs suggestive of a PSS and HE. The portal vein in the cat can be demonstrated using ultrasound, but complex congenital vascular malformations of the portal or systemic abdominal veins should be characterised using CTA and further distinguished from other vascular anomalies that may present with similar ultrasonographic features.

Low-frequency high-definition power Doppler in visualizing and defining fetal pulmonary venous connections

PURPOSE

The use of low-frequency high-definition power Doppler in assessing and defining pulmonary venous connections was investigated.

METHODS

Study A included 260 fetuses at gestational ages ranging from 18 to 36 weeks. Pulmonary veins were assessed by performing two-dimensional B-mode imaging, color Doppler flow imaging (CDFI), and low-frequency high-definition power Doppler. A score of 1 was assigned if one pulmonary vein was visualized, 2 if two pulmonary veins were visualized, 3 if three pulmonary veins were visualized, and 4 if four pulmonary veins were visualized. The detection rate between Exam-1 and Exam-2 (intra-observer variability) and between Exam-1 and Exam-3 (inter-observer variability) was compared. In study B, five cases with abnormal pulmonary venous connection were diagnosed and compared to their anatomical examination.

RESULTS

In study A, there was a significant difference between CDFI and low-frequency high-definition power Doppler for the four pulmonary veins observed (P < 0.05). The detection rate of each pulmonary vein when employing low-frequency high-definition power Doppler was higher than that when employing two-dimensional B-mode imaging or CDFI. There was no significant difference between the intra- and inter-observer variabilities using low-frequency high-definition power Doppler display of pulmonary veins (P > 0.05). The coefficient correlation between Exam-1 and Exam-2 was 0.844, and the coefficient correlation between Exam-1 and Exam-3 was 0.821. In study B, one case of total anomalous pulmonary venous return and four cases of partial anomalous pulmonary venous return were diagnosed by low-frequency high-definition power Doppler and confirmed by autopsy.

CONCLUSIONS

The assessment of pulmonary venous connections by low-frequency high-definition power Doppler is advantageous. Pulmonary venous anatomy can and should be monitored during fetal heart examination.

Radiographic assessment of umbilical venous and arterial catheter tip location

Umbilical venous and arterial catheters are routinely used in the care of critically ill patients in neonatal intensive care settings. Providers caring for these vulnerable patients have a role in ensuring that catheter tips remain in an appropriate position. The ideal anatomic tip location for both types of umbilical catheters is reviewed, and the evaluation of this position via radiographic study is discussed. Umbilical venous catheters (UVCs) and umbilical arterial catheters (UACs) have their own different complications. Complications of a malpositioned catheter of either type can be life threatening; therefore, evaluation of catheter tip location is an important skill in the provision of neonatal intensive care.

Morphological and surgical overview of adolescent testis affected by varicocele

Varicocele is a common pathology of the testis frequently associated with infertility. For its management, a fine morphological study of the testis, both macroscopically and microscopically, and an accurate choice of surgical procedure are mandatory. The present review focuses its attention on the anatomic substrates of adolescent varicocele and its pathophysiologic modifications. The comprehensive assessment of all the reported alterations should be considered by the clinician before deciding the type of treatment and the timing.