A case of anomalous inferior vena cava with azygos continuation associated with situs inversus totalis and acquired mitral valvular disease

Leriche syndrome in a patient with situs inversus totalis

Situs inversus is a rare congenital defect defined by a mirror image anatomic variation of the thoracic and abdominal organs. In this situation, abdominal aortic surgery may become particularly challenging. This is the case of a 51-year-old man, who presented with an incapacitating lower limb claudication. On his workup, a complete occlusion of the infrarenal aorta requiring surgical revascularization was found. Additionally, a situs inversus totalis was identified along with a single horseshoe kidney. The patient underwent uneventfully a surgical aortobifemoral interposition. The sole modification to the standard procedure regarded the graft limbs tunneling, which was performed in a prerenal pathway in the retroperitoneal space, thus avoiding iatrogenic injury to the anteriorly positioned iliac veins. Although challenging, conventional aortic surgery can be safely accomplished in patients with situs inversus totalis.

Congenitally interrupted inferior vena cava without other features of the heterotaxy syndrome: report of five cases and characterization of a rare entity

Congenital interruption of the inferior vena cava (IVC) due to absence of its hepatic segment is usually found in patients with polysplenia. The occurrence without other features of the heterotaxy syndrome is rare, and the frequency of associated additional vascular and cardiac anomalies in these patients is not well known. We reviewed the literature and present 5 of our own patients to characterize this entity. All but 1 of the 67 known cases had visceroatrial situs solitus. There was 1 patient with interruption of the IVC in complete situs inversus. The interrupted IVC typically continued via the azygos system into the superior vena cava, but there were 4 cases without a direct connection between the infrahepatic IVC and the azygos system. Additional venous abnormalities or cardiac malformations were present in 47.8% and 31.4%, respectively. In contrast to the classical heterotaxy syndrome, heart defects with interrupted IVC and normal situs did not involve inversion of cardiac segments. The diagnosis can readily be made by echocardiography or magnetic resonance imaging. Failure to recognize this anomaly can result in various problems during invasive medical or surgical procedures. In our own patients, interventional procedures failed, necessitating an operation in all 5 cases. Careful analysis of systemic venous drainage should be performed in all patients prior to cardiac catheterization, pacemaker implantation, or surgery, even if the visceroatrial situs is normal.

Abdominal aortic aneurysm in situs inversus totalis

Situs inversus totalis refers to a mirror-image reversal of the normal position of the internal organs. The recognition of concomitant anomalies, such as in the cardiac, venous, gastrointestinal, and urinary systems, is extremely important because these anomalies may disturb the surgical procedure for the concurrent disease in situs inversus totalis. The authors describe a case of successfully repaired abdominal aortic aneurysm with a false aneurysm of the right external iliac artery in situs inversus totalis. The coexistence of abdominal aortic aneurysm has been seldom encountered. The presence of anatomical anomalies significantly increases operative risk. The surgical management of patients with abdominal aortic aneurysm in situs inversus totalis is discussed.