Radiologic anatomy of duplication of the inferior vena cava: a trap in abdominal imaging. A report of 8 cases

Paraaortic Lymphadenectomy in Gynecologic Oncology—Significance of Vessels Variations

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.

Two level Anterior Lumbar Interbody Fusion (ALIF) in a patient with a rare vascular malformation, a duplication of the inferior vena cava

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.

Management of acute lower extremity deep venous thrombosis in a patient with duplicated inferior vena cava and contraindication to anticoagulation: case and review of the literature

Duplication of the inferior vena cava (DIVC) is an uncommon embryological anatomic phenomenon.We report a 63-year-old woman with extensive right leg deep vein thrombosis who required an IVC filter due to contraindications for anticoagulation, but was found to have DIVC which required the placement of two IVC filters with good result. This report will review and summarise past reports of DIVC management to provide a guide for future clinicians, and review the embryological development, diagnosis and IVC filter placement options as they are based on the type of anatomic malformation encountered.

Inferior Vena Cava Duplication: Incidental Case in a Young Woman

A case of a double inferior vena cava (IVC) with retroaortic left renal vein, azygos continuation of the IVC, and presence of the hepatic portion of the IVC drained into the right renal vein is reported and the embryologic, clinical, and radiological significance is discussed. The diagnosis is suggested by multidetector computed tomography (MDCT), which reveals the aberrant vascular structures. Awareness of different congenital anomalies of IVC is necessary for radiologists to avoid diagnostic pitfalls and they should be remembered because they can influence several surgical interventions and endovascular procedures.

Rare Anatomical Variation of Dual IVC with Left Sided IVC Draining into Hemiazygous Vein- A Case Report

Congenital anomalies of the Inferior Vena Cava (IVC) result from the persistence of the embryonic venous system. Knowledge of such anomaly is of great importance during abdominal surgery, liver and kidney transplantation, renal venous sampling and in the treatment of thromboembolic diseases. Here, we report a rare anatomical variation of dual IVC with normal course of right sided IVC and hemiazygous continuation of left sided IVC with interiliac communication in potential renal donor. Congenital abnormalities of the inferior vena cava are easily identified on Computed Tomography (CT) and should be considered when interpreting any CT of the abdomen or chest.

Angiojet thrombolysis and vena cava filter insertion in a case of a duplicated inferior vena cava

Objectives:

Duplication of the inferior vena cava (IVC) complicates interventional procedures. This case report aims to shed light on this unusual anomaly and the preoperative considerations necessary when treatment of venous thromboembolism is undertaken.

Methods:

An IRB approved case report of a 58 year old woman presented emergently with right lower extremity phlegmasia due to extensive thrombosis of her right iliofemoral and infrarenal portion of her duplicated IVC.

Results:

The patient underwent IVC filter placement and rheolytic thrombectomy with thrombolysis using the Angiojet device followed by venoplasty and stenting of the iliofemoral system and right IVC. Complete symptomatic and radiographic resolution on duplex imaging was achieved at 1 year follow up.

Conclusions:

With adequate preoperative awareness of IVC anomalies and treatment options available satisfactory results can be achieved and complications minimized for this unique patient population.

Use of a Trellis device for endovascular treatment of venous thrombosis involving a duplicated inferior vena cava

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.

Left sided inferior vena cava duplication and venous thromboembolism: case report and review of literature

The etiology of venous thromboembolism in young patients is frequently associated with hereditary coagulation abnormalities, immunologic diseases, and neoplasia. The advent of radiological advances, namely Computed Tomography (CT) scans and venography has identified vena cava malformations as a new etiologic factor worthy of consideration. In this case report, we describe the unusual occurrence of venous thromboembolism in association with a duplicated inferior vena cava. Duplications of the inferior vena cava (IVC) are seen with an incidence of 0.2% to 3.0% in the general population. Embryogenesis of the IVC is a complex process involving the intricate formation and regression of numerous anastomoses, potentially leading to various anomalies. We present a 23-year-old Caucasian woman with IVC duplication who developed a deep venous thrombosis and multiple pulmonary emboli. Anomaly of the IVC is a rare example of a congenital condition that predisposes to thromboembolism, presumably by favoring venous stasis. This diagnosis should be considered in patients under the age of 30 with spontaneous occurrence of blood clots.

Advanced gastric carcinoma combined with extra-adrenal pheochromocytoma resected after three courses of S-1 and cisplatin as neoadjuvant chemotherapy: report of a case

We herein describe the case of a patient with advanced gastric carcinoma combined with extra-adrenal pheochromocytoma who received a radical operation after undergoing neoadjuvant chemotherapy. A 48-year-old woman was referred to our hospital for gastric carcinoma. Computed tomography revealed an enlargement of the regional lymph nodes and a para-aortic lymph node. A diagnosis of advanced gastric carcinoma was made (cT3, cN3, cM0, cStage IV according to the Japanese Classification of Gastric Carcinoma, 2nd English edition). A reduction in size was observed in both the gastric tumor and the lymph nodes around the stomach after neoadjuvant chemotherapy. However, the paraaortic lymph node showed no remarkable change. We thus suspected this para-aortic tumor not to be a lymph node, but instead to be an extra-adrenal pheochromocytoma, because of the different response from the other regional lymph nodes. An endocrinological examination confirmed the diagnosis of extra-adrenal pheochromocytoma. A gastrectomy and a resection of the pheochromocytoma were thus performed.

Obstructive lesions of the inferior vena cava: clinical features and endovenous treatment

OBJECTIVE

Chronic obstructions of the inferior vena cava (IVC) are associated with many odd features. Even total occlusions may remain entirely silent or present late with acute symptoms. Renal dysfunction is rare. Many have chronic symptoms, but often only one limb is affected. We describe the clinical features in a series of 120 patients seen over a 10-year period and the results of successful stent placement in 99 limbs.

METHODS

Patients with acute onset of symptoms due to distal thromboses underwent catheter-directed thrombolysis. Patients with significant chronic symptoms were investigated by duplex, venous function tests, transfemoral venography and finally intravascular ultrasound (IVUS). Stenotic segments were balloon dilated and occluded segments were recannalized when feasible; stents were placed under IVUS control.

RESULTS

In the asymptomatic group, 10 patients with total occlusions had transient or no occlusive symptoms. In the acute symptom group, four patients with chronic IVC occlusions presented with acute onset of deep venous thrombosis distal to the occlusion but became asymptomatic when the clot was lysed. In the chronic symptom group, 97 patients (99 limbs) had symptoms of chronic venous disease of variable distribution and intensity. In two-thirds, limb symptoms were unilateral. Pathology was total occlusion in 14%, and the rest were stenoses. The lesion extended above the renal vein in 18%. Common iliac obstruction was concurrent in 93%. Distal reflux was present in 66%. Modifications of the basic stent technique were required in recanalization of total occlusions (four extending up to the atrium), two bilateral stent deployments, and nine IVC filter cases. Stent deployment across the renal and hepatic veins or the contralateral iliac vein had no adverse sequelae. Stent patency (cumulative) at 2 years was 82%. Complete relief (cumulative) of pain and swelling at 3.5 years was 74% and 51%, respectively. The cumulative rate of complete ulcer healing at 2 years was 63%. Overall clinical outcome was rated as good or excellent in 70%.

CONCLUSIONS

The unusual clinical features of IVC obstructions seem related to the rich collateralization, which has an embryonic basis. Common iliac vein patency seems to be a crucial link in collateral function, and its concurrent occlusion produces symptoms. Percutaneous stent placement has an emerging role in the treatment of IVC obstructive lesions, with good mid-term stent patency and clinical results.

[Duplication of the inferior vena cava: anatomical dissection and clinical implications]

The duplication of the inferior vena cava is often incidentally discovered during radiological studies. The presence of this anomaly can be mistaken for retroperitoneal adenopathy. Its knowledge allows to avoid hemorrhagic complications during retroperitoneal surgery. An anatomical dissection of a duplication of the inferior vena cava is presented. Embryogenesis and variations are described. Radiological and clinical implications are discussed.

Duplication droite de la veine cave inférieure

An infrarenal duplication of the inferior vena cava with both channels lying on the right side of the aorta was fortuitously found during an abdominal Computed Tomography performed on a 52 year-old woman. Only two same cases seem to be reported in the literature. This very uncommon abnormality probably results from persistence of the infra-renal part of the right subcardinal vein. Radiologists have to be aware of this right-sided ipsilateral duplication for it may be a trap in abdominal imaging as well as "classical" inferior vena cava duplication located on both sides of the abdominal aorta.

Approach to the educational opportunities provided by variant anatomy, illustrated by discussion of a duplicated inferior vena cava

Variant anatomy recognized during routine cadaveric dissection in the first year of medical school offers great learning potential by allowing students to gain enhanced understanding of an array of important subjects. It provides a framework for reviewing common morphology and embryogenesis of the structure in question, and through the help of appropriate faculty, yields insight into the potential medical, radiologic, and surgical implications. The frequency of clinically important anatomic variation is high enough to allow the gross anatomy laboratory to serve as an excellent teaching platform in this regard. Through anatomy, the student is introduced to the concept of patient individuality, and to the individualization of medical and surgical therapies. Recently, one of the variations encountered in our lab was a duplicated inferior vena cava. We describe our approach to such findings through a systematic discussion of the anatomy and embryology, as well as the radiologic and clinical correlates.

Pulmonary embolism with duplicated inferior vena cava

Congenital anomalies of the inferior vena cava (IVC) are common and usually of little clinical significance. We report the unusual cases of two patients with pulmonary embolism from thrombosis of part of a duplicated IVC. Both caval anomalies were easily identified with ultrasound, and the patients were successfully treated with anticoagulants. We encourage the reporting of similar cases since knowledge of the contribution of IVC duplication to thromboembolic disease is unknown.