Congenital anomalies of the IVC-embryological perspective and clinical relevance

Successful flutter catheter ablation through the azygos continuation due to an interrupted inferior vena cava

Inferior vena cava IVC is a crucial route for catheter access (both directly to the right heart and indirectly through a transeptal puncture to the left heart, used in most electrophysiological procedures). However, interrupted IVC is a real challenge to traditional arrythmia ablation approaches, compromising in certain cases the success of the procedure. A well-developed azygos continuation offers an alternative pathway, bypassing the interrupted segment of the IVC. We report the case of a 60 years old female, who underwent catheter ablation of a counterclockwise flutter. During the procedure, she was discovered to have an uncommon anatomical venous pathway from femoral access to the right heart chambers. She was diagnosed to have an interruption of the supra-renal segment of the inferior vena cava with azygos continuation. Radiofrequency ablation of the cavotricuspid isthmus was successfully performed through the azygos continuation.

Unveiling absent inferor vena cava in young patients: Case reports and clinical insights

INTRODUCTION

Inferior vena cava agenesis (IVCA), a rare congenital anomaly, contributes to approximately 5 % of deep venous thrombosis (DVT) cases lacking other risk factors. It can lead to chronic venous insufficiency and DVT when collateral circulation is insufficient, presenting diagnostic challenges due to its rarity.

CASE PRESENTATION

We present two cases of Absent IVC (AIVC) in young males. Case 1: a 22-year-old developed bilateral lower limb DVT post-appendectomy. Imaging revealed AIVC with azygos continuation. Treatment included Heparin and Rivaroxaban, achieving symptom resolution. Case 2: a 41-year-old with recurrent DVT and chronic venous insufficiency was diagnosed with AIVC via venography. Managed with warfarin and compression therapy, his symptoms stabilized.

CLINICAL DISCUSSION

These cases underscore the importance of recognizing AIVC in young patients presenting with unexplained DVT. Diagnosis often requires advanced imaging techniques like CT venography. Management typically involves long-term anticoagulation and compression therapy to mitigate the risk of recurrence and chronic venous complications.

CONCLUSION

Early identification of AIVC in young adults presenting with recurrent DVT is essential for appropriate management and prevention of long-term complications.

Heterozygosity for the Budapest 3 mutation in SERPINC1 in a family with thrombophilia and structural anomalies of the inferior vena cava

BACKGROUND

Atresia of the infrarenal inferior vena cava (IVC) is associated with thrombophilia and antithrombin (AT) deficiency (ATD) due to homozygosity for the so-called Budapest 3 variant, c.391C > T, in the gene, SERPINC1.

CASE PRESENTATION

We report on a father and his two sons that had severe thrombosis at a young age. One son had absence of, and the other had very gracile infrarenal IVC. The father had gracile vena iliaca. All had significant collateral building. AT activity was determined with four different methods and varied between moderately reduced and borderline normal values, depending on the method. While all were heterozygous for c.391C > T, the father was also heterozygous for a variant of uncertain significance in SERPINC1.

CONCLUSIONS

The findings support the association between c.391C > T in SERPINC1, thrombophilia, and atresia of the IVC system and indicate that even heterozygosity for c.391C > T may contribute to such anomalies. ATD detection was hampered by the varying sensitivity of methods used for AT activity measurement.

Adult intestinal malrotation presenting as caecal volvulus with incidental findings of duplicate inferior vena cava and other rare abnormalities: case report

Intestinal malrotation and duplication of the inferior vena cava are rarely diagnosed in adult patients; however, incidence is likely underestimated as they are usually asymptomatic. These congenital malformations have been previously reported in the same patient twice but never with colonic obstruction or ischaemia. A 25-year-old female presented with nausea, vomiting, obstipation, and abdominal pain, and on computed tomography of the abdomen and pelvis was diagnosed with a caecal volvulus and pneumatosis coli associated with intestinal malrotation requiring emergency right hemicolectomy. Incidentally, the patient was noted to have duplication of the inferior vena cava, azygos continuation of the inferior vena cava, and splenic fragmentation. This constellation of symptoms has not been reported in the literature previously. The pattern of malformations follows that of polysplenia syndrome. Although rare, awareness of these malformations can be useful to clinicians.

Case Report: Imaging features of a new type double inferior vena cava malformation and review

Background

Double inferior vena cava (DIVC) is a rare vascular malformation. With advances in radiological techniques and diagnosis, more and more types of DIVC were identified and diagnosed. Recognition of the variety of DIVC seen on imaging is essential for subsequent venous interventions.

Case presentation

A 77-year-old man presented with low back pain with left lower limb pain for 1 month. Scattered petechiae above the skin surface on the left lower leg, especially on the extensor surface, with flaking and mild tingling of the skin, were noted 3 weeks ago. Ultrasound revealed deep vein thrombosis (DVT) in the left lower limb. Computed tomography pulmonary angiography (CTPA) suggested no significant thrombus in the pulmonary artery. Computed tomography venography (CTV) of bilateral lower limbs showed that iliac vein compression syndrome with formation of deep and superficial venous traffic branches in bilateral lower limbs, predominantly on the left side. CTV of the inferior vena cava (IVC) suggested that the left common iliac vein crossed the common iliac artery bifurcation from dorsal to ventral and continued to travel cranially as a ventral vessel, and connected with the ventral IVC anterior to the right common iliac artery. The right common iliac vein extended cephalad as a dorsal vessel, which was narrowed at the level of 4th lumbar vertebra by compression of the hyperplastic bone and the osteophyte. The patient was discharged after right and left common iliac vein angiography and balloon dilation of bilateral common iliac vein.

Conclusion

The formation of both ventrally and dorsally aligned DIVC is rarer. It should be clarified the effects of DIVC on DVT formation, and the importance of imaging for preoperative planning.

Imaging of inferior vena cava normal variants, anomalies and pathologies, Part 1: Congenital

The embryology of the inferior vena cava (IVC) is complex, involving the sequential appearance and regression of multiple segments that ultimately form the IVC. Any alteration in this process during embryogenesis can result in congenital anomalies of the IVC. This study aimed to recognise common as well as rare anomalies of the IVC and associated veins, and their clinical implications. The anomalies tend to have diverse appearances based on the timing and segments involved. The development of the IVC is intertwined with the development of other veins like the renal vein, azygos vein and portal vein, and these veins may also be anomalous. Additionally, IVC anomalies are associated with various other congenital anomalies including cardiac anomalies, the recognition of which may be important for patient care. The IVC tends to have multiple normal variants and anomalies because of a complex process involving multiple segments contributing to the adult IVC. Knowledge of these variants is crucial for preoperative planning of procedures.

Contribution

This study would help in understanding the embryogenesis of the IVC and correlation with the imaging appearances and the clinical implications of each of these common as well as rare types of congenital anomalies.

A remarkable case report of an interrupted inferior vena cava with hemiazygos and transhepatic continuation

Inferior vena cava (IVC) interruption with azygos/hemiazygos continuation is an extremely uncommon congenital vascular anomaly, which may present with multiple variants. As a result, it is challenging to find in the literature the same anatomical variant. We report a unique case of an interrupted IVC with hemiazygos and transhepatic continuation in an 83-year-old female patient. The case was evaluated by performing Computed Tomography (CT) as imaging modality, with a multiphase protocol, able to detect accurately this complex vascular anomaly. The purpose of this case report is not only to present this remarkable case but also to briefly show the types of interrupted IVC, starting from the anatomy and the embryology of the IVC and the azygos system, and to discuss the value of imaging in detecting the vascular anomaly.

Orthostatic proteinuria due to inferior vena cava interruption without nutcracker phenomenon in an old obese female: a case report and literature review

BACKGROUND

Nutcracker syndrome (NCS) caused by left renal vein (LRV) entrapment, is one of the most common causes of orthostatic proteinuria. In stereotype, orthostatic proteinuria is often accompanied by left renal vein obstruction and is found in young and underweight individuals. Here, we report a rare case with orthostatic proteinuria in an old obese female caused by a rare type of congenital inferior vena cava (IVC) interruption.

CASE PRESENTATION

A 65-year-old obese woman, who suffered from fluctuated proteinuria, had been misdiagnosed as chronic glomerulitis for 30 years. Instead of having any sign of NCS, she had a unique type of IVC interruption. Most venous blood from infrarenal IVC and right kidney drained into her LRV, and then through the expanded communicating vessel, drained into the left ascending lumbar vein which extended as hemiazygos vein. To the best of our knowledge, this is one of the first cases reported of orthostatic proteinuria attributed to the subsequent hemodynamic irregularity caused by IVC interruption without nutcracker phenomenon.

CONCLUSION

Adult-onset orthostatic proteinuria is relatively rare, hard to be recognized and could be misdiagnosed as chronic glomerulonephritis. The case provided a novel differential diagnostic condition for those who suffered from fluctuated proteinuria of unknown causes.

Extensive Deep Vein Thrombosis With Intraabdominal Extension Triggered by Oral Contraceptive Use in a Young Patient With Interrupted Inferior Vena Cava With Azygos Continuation: A Case Report

Congenital malformations of the inferior vena cava (IVC) are rare and often asymptomatic, typically discovered incidentally during imaging. However, these anomalies can result in circulatory stasis, impede venous return, and serve as predisposing factors for thrombus formation. Here, we present a unique case of a 28-year-old female patient who was found to have interrupted IVC with azygos continuation, an exceedingly rare IVC anomaly, during a work-up of extensive bilateral deep vein thrombosis (DVT) with an intraabdominal extension which was triggered by recent combined oral contraceptive pills (OCP) use. This case highlights the importance of considering vena cava malformations as an underlying cause for extensive DVT, even in the absence of conventional risk factors. Clinicians should be aware of the potential association between congenital vena cava anomalies and thrombotic events, as early recognition and appropriate management are crucial for preventing complications such as pulmonary embolism.

Bilateral inferior venae cava combined with the persistent left superior vena cava and hemiazygos continuation of left inferior vena cava with drainage into right atrium: A case report

The persistent left superior vena cava (PLSVC) is a common venous abnormality. However, malformation of the bilateral inferior venae cava (IVC) is extremely rare, with an incidence rate of .3%. IVC malformation is associated most frequently with heart defects and isomerism and often has a poor prognosis. We presented a case of vascular malformations in the fetus of bilateral caval veins with the interruption of the left-sided venous return with hemiazygos continuation in presence of a right-sided inferior caval vein. Also noted were the PLSVC and a dilated right heart with a widened pulmonary trunk. In this case, there were no heart defects or chromosomal abnormalities, and the newborn postpartum was in a good condition.

Extensive deep vein thrombosis in a young girl with absent inferior vena cava and iliac veins: a case report

Congenital absence of inferior vena cava (IVC) and iliac veins is a rare anomaly that can predispose young patients to develop deep vein thrombosis (DVT). This case report highlights the importance of considering this anatomical abnormality in young patients with unprovoked DVT. We present the case of a 17-year-old girl who visited the emergency department (ED) complaining of right leg pain and swelling for 8 days. An ED ultrasound revealed extensive DVT in the right leg veins, and further investigation with abdominal computed tomography revealed that the patient's IVC and iliac veins were absent and showed the presence of thrombosis. The patient underwent thrombectomy and angioplasty by interventional radiology and was given a lifetime prescription for oral anticoagulation. When treating young, otherwise healthy individuals with unprovoked DVT, Clinicians should include absent IVC in their differential when treating young, otherwise healthy patients with unprovoked DVT.

Congenital absence of the left external iliac vein with anomalous venous connection in a pediatric patient

We report an interesting case of a 2-year-old boy with congenital absence of the left external iliac vein and an anomalous lower extremity venous connection. Magnetic resonance imaging was used to identify aplasia of the vessel and aid in the diagnostic algorithm. In the present report, we have discussed the relevant literature associated with congenital venous anomalies and their clinical presentations and treatment options. Our patient did not undergo surgical intervention for his vascular malformation.

Duplicated inferior vena cava-trifurcated portal vein: a rare anatomical variation encountered during Whipple procedure

The inferior vena cava (IVC) is the largest single vein in humans. However, during embryogenesis, abnormalities can occur resulting in a duplicated IVC. The portal vein (PV) offers the main blood flood to the liver, forming by the left and right PV. A number of anatomical variations are noticed, underlying the great importance of the pre-operative imaging workup. This case report presents a duplicated IVC and a trifucated PV that were incidentally found in an 82 year-old Caucasian male with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy (Whipple procedure). Although some anatomical variations, including the duplication of the IVC and the trifurcation of PV, may be rare to the general population, the suspicion of their existence should always be taken under consideration from surgeons during hepatobiliary or retroperitoneal operations.

Duplicated Inferior Vena Cava Thrombosis Mimicking Acute Pancreatitis in a COVID-19 Patient

An 86-year-old woman with a recent hospitalization for severe coronavirus disease 2019 (COVID-19) infection presented to the emergency department with abdominal discomfort and bilateral leg swelling. She was mildly tachycardic on physical exam, with superficial abdominal vessel dilation and bilateral lower extremity edema. Her laboratory results were significant for a mildly elevated lipase of 260 U/L (normal range: 0-160 U/L) and a positive COVID-19 PCR test. CT of the abdomen and pelvis did not show any pancreatic abnormality but revealed a duplicated inferior vena cava (IVC) with a thrombus located in the right IVC. The patient was subsequently placed on full-dose anticoagulation with the eventual achievement of clot lysis. It appears that the incidence of thrombosis, including IVC thrombosis, has been on the rise due to COVID-19-associated coagulopathy; therefore, a high index of clinical suspicion in these cases may prove to be lifesaving.

Inferior Vena Cava Agenesis: An Underrated Cause of Deep Venous Thrombosis

The absence of the inferior vena cava (IVC) is a rare abnormality reported in less than 1% of the population. The condition is usually the result of defects during embryogenesis. The collateral veins are enlarged with agenesis IVC, enabling blood transport to the superior vena cava. Although the alternate pathways enable venous drainage of the lower extremities, IVC agenesis (IVCA) may predispose to venous hypertension and complications, including thromboembolism. This report includes a case of a 35-year-old obese male who presented with deep vein thrombosis (DVT) in his left lower extremity (LLE) with no predisposing factors, which led to an incidental discovery of the inferior vena cava agenesis. Imaging showed thrombosis of the deep veins of the LLE, absence of the IVC, enlarged paralumbar veins, filling of the superior vena cava, and left renal atrophy. The patient responded to therapeutic heparin infusion, and catheter placement and thrombectomy were performed. The patient was discharged on the third day with medications and vascular follow-up. It is essential to recognize the complications of IVCA and its correlation with other findings, such as atrophy of the kidney. The agenesis of IVC is a highly under-recognized cause of DVT of the lower extremities in the young population without other risk factors. Hence, a complete diagnostic evaluation is necessary for this age group, including imaging for vascular anomalies, besides the thrombophilic screening.

Biliary atresia & choledochal malformation--Embryological and anatomical considerations

The two main biliary pathologies in paediatric practice, biliary atresia and choledochal malformations (CM), have their origins within prenatal life. Nevertheless, the actual mechanisms remain elusive with many unanswered questions. The extrahepatic bile duct develops as a funnel-like structure emerging from the foregut from about 3-4 weeks of gestation into the mesenchyme of the septum transversum. The cranial elements of this contain hepatoblasts - the precursors to the two key cell lines that will become hepatocytes and biliary epithelial cells. The intrahepatic bile ducts develop separately and emerge from a complex process involving the ductal plate surrounding the in-growing portal venous system from about the 7-8^th week of gestation. A developmental defect at some point(s) in this process may be the cause of at least some variants of BA - the Biliary Atresia Splenic Malformation syndrome particularly - though evidence in the more common isolated BA is much more circumstantial. Similarly, some types of choledochal malformation, specifically the cystic type of CM, are invariably present during prenatal life although again an actual aetiological mechanism remains elusive.

Developmental Anomalies of the Inferior Vena Cava and its Tributaries: What the Radiologist Needs to Know?

Inferior vena cava (IVC) can be involved by a wide gamut of developmental anomalies owing to its complex embryogenesis. Developmental anomalies of the IVC are not infrequent, seen in approximately 8.7% of the general population. Although most of the anatomical variations are asymptomatic, identification of these variations is important before planning any vascular surgery or interventional procedure in relation to the IVC to avoid inadvertent complications. Conventional venography has largely been replaced by noninvasive cross-sectional imaging modalities for detecting IVC abnormalities. Ultrasonography, often used for initial evaluation, is highly operator-dependent and the infrarenal part of IVC is often obscured by bowel gases. While magnetic resonance imaging is devoid of radiation risks, its use is limited due to limited availability and the frequent need for sedation. Computed tomography (CT) venography plays a pivotal role in the detection of these anomalies as it has an excellent spatial resolution along with availability of multiple postprocessing tools such as multiplanar reconstruction with generation of maximum intensity projection and volume-rendered images. This pictorial review focuses on the embryogenesis of IVC, various developmental anomalies of the IVC and its tributaries, their appearance on CT venography and conceivable clinical relevance.

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.

Is Fetus in Fetu a Reason for Vascular Anatomy Changes in the Host?

Fetus in fetu (FIF) is a rare congenital anomaly. Anomalies of inferior vena cava (IVC) in the host are rare and not reported in the literature. In this case report, the surgical management and the findings of a rare vascular anomaly of IVC in a 10-month-old male child with FIF are discussed. This case highlights the importance of antenatal ultrasonogram in the detection of FIF and to diligently look for structural anomalies of IVC in the host in such cases.

Rare case of concomitant juxtarenal aortic aneurysm and type 1 Inferior Vena Cava duplication: -intraoperative challenges to avoid catastrophe

Duplication of the inferior vena cava is a rare congenital anomaly, with an incidence of 0.2-3%. Despite being asymptomatic, anomalies of IVC are important in aortoiliac and retroperitoneal surgeries. Preoperative CT imaging is essential to identify any IVC anomaly and to prevent unexpected hemorrhage during surgery. Here, we report a case of a juxtarenal abdominal aortic aneurysm in which we encountered a type I IVC duplication anomaly intraoperatively while performing transperitoneal aneurysmorrhaphy and took precautions to avoid any iatrogenic injuries to either of the two trunks or the pre-aortic trunk of the anomalous duplicate IVC.

High penetrance of inferior vena cava system atresia in severe thrombophilia caused by homozygous antithrombin Budapest 3 variant: Description of a new syndrome

Atresia of inferior vena cava (IVC) is a rare congenital malformation associated with high risk of venous thrombosis that still has unknown etiology, although intrauterine IVC thrombosis has been suggested to be involved. The identification of IVC atresia in a case with early idiopathic venous thrombosis and antithrombin deficiency caused by the homozygous SERPINC1 c.391C > T variant (p.Leu131Phe; antithrombin Budapest 3) encouraged us to evaluate the role of this severe thrombophilia in this vascular abnormality. We have done a cross-sectional study in previously identified cohorts of patients homozygous for the Budapest 3 variant (N = 61) selected from 1118 patients with congenital antithrombin deficiency identified in two different populations: Spain (N = 692) and Hungary (N = 426). Image analysis included computed tomography and phlebography. Atresia of the IVC system was observed in 17/24 cases (70.8%, 95% confidence interval [CI]: 48.9%-87.3%) homozygous for antithrombin Budapest 3 with available computed tomography (5/8 and 12/16 in the Spanish and Hungarian cohorts, respectively), 16 had an absence of infrarenal IVC and one had atresia of the left common iliac vein. All cases with vascular defects had compensatory mechanisms, azygos-hemiazygos continuation or double IVC, and seven also had other congenital anomalies. Short tandem repeat analysis supported the specific association of the IVC system atresia with SERPINC1. We show the first evidence of the association of a severe thrombophilia with IVC system atresia, supporting the possibility that a thrombosis in the developing fetal vessels is the reason for this anomaly. Our hypothesis-generating results encourage further studies to investigate severe thrombophilic states in patients with atresia of IVC.

Anomalous Circumrenal Inferior Vena Cava Associated With Horseshoe Kidney

A 69-year-old male presented with periumbilical pain radiating across his abdomen, with associated nausea and emesis. CT imaging of his abdomen and pelvis revealed calculi in the right and left ureterovesical junctions with hydroureteronephrosis bilaterally. Furthermore, the imaging revealed that the patient had a horseshoe kidney with an associated anomalous inferior vena cava (IVC) that split superiorly to the horseshoe kidney at the L1 level and rejoined inferior to the horseshoe kidney at the L5 level. The IVC took on a "circumrenal" course, as it traversed the right kidney with an anterior and posterior portion. Furthermore, the patient's right ureter was compressed between the anterior portion of the IVC and the right kidney. We hypothesize that the development of the horseshoe kidney around the 7 to 8th week of gestation created a path of resistance for the forming of IVC around the same time. While surgical correction is not warranted, recognition of this circumrenal IVC variant could have major implications for planning of procedures, such as IVC filter placement.

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.

Unique triad of shunts in a patient with paroxysmal palpitations!

We present the case of a 34-year-old woman with a rare constellation of congenital cardiovascular defects. She presented with new-onset dyspnoea on exertion and intermittent palpitations. Extensive cardiac workup revealed anomalous drainage of the inferior vena cava and a large secundum atrial septal defect. She underwent surgical repair. Intraoperatively, an additional congenital venous anomaly was discovered, a partial anomalous pulmonary venous connection. Specifically, the right inferior pulmonary vein connected to the inferior vena cava, and together, they drained into the left atrium. On conducting a thorough literature review, we believe this is the first reported case in an adult female.

Aneurysm of the Communicating Vein Between the Left Renal Vein and Left Ascending Lumbar Vein Mimicking Retroperitoneal Lymphadenopathy: A Case Report

INTRODUCTION

Aneurysm of the communicating vein between the left renal vein and left ascending lumbar vein is extremely rare, with only anecdotal reported cases. Unless detected and recognized promptly, this rare condition may give rise to severe bleeding in patients undergoing retroperitoneal surgery. It may also closely mimic enlarged retroperitoneal lymph nodes, paragangliomas, adrenal masses, or renal artery aneurysms.

CASE REPORT

In this case study, we reported the imaging findings of this rare entity, which was falsely diagnosed as an enlarged retroperitoneal lymph node in an outside medical center, reported to be consistent with metastatic disease in a patient with newly diagnosed testicular cancer.

CONCLUSION

The aneurysm of the communicating vein should be considered in the differential diagnosis in patients with testicular cancer and other disease processes where lymph nodes are commonly affected.

Blunt Abdominal Trauma Leading to an Incidental Finding of Duplicate Inferior Vena Cava (DIVC): A Case Report and Literature Review

BACKGROUND With a prevalence of about 2% to 3%, duplication is the most common anomaly associated with the inferior vena cava (IVC). In general, systemic venous anomalies are being more frequently diagnosed in asymptomatic patients. We report the case of a young man with an incidental finding of an asymptomatic duplicated IVC, along with a literature review. CASE REPORT A 36-year-old man was brought to our Emergency Department (ED) following a high-speed motor vehicle collision (MVC), reporting right flank and hip pain. Upon examination, the "seatbelt sign" was noticed, along with abrasions over his right side. He sustained a small-bowel mesenteric injury, for which he was admitted and was treated conservatively. A CT scan incidentally revealed a duplicate IVC (DIVC). He later underwent a laparotomy with limited right hemi-colectomy and was discharged home in good condition. CONCLUSIONS Undiscovered and asymptomatic DIVCs pose a potential risk to patients during clinical interventions. Advancements in diagnostic imaging contribute greatly to the incidental discoveries of inferior vena cava duplication.

A Particular Infantile Scimitar Syndrome Variant with Anomalous Systemic Arterial Supply-Inferior Vena Cava Fistula

Scimitar syndrome is a rare congenital cardiovascular malformation that includes a partially anomalous drainage of the pulmonary veins in the inferior vena cava, right pulmonary hypoplasia, and systemic-pulmonary collaterals originating from various segments of the aorta. We present a case of Scimitar syndrome with associated intracardiac lesions and a large arterial conduct supplying the right lung, originating from the abdominal aorta and draining in the inferior vena cava.

Klippel-Trenaunay syndrome in a young patient with the involvement of gastrointestinal and genitourinary tracts: an unusual and rare presentation

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder characterised by capillary and venous malformations and soft-tissue hypertrophy with or without lymphatic malformation. The involvement of the gastrointestinal tract and genitourinary tract is uncommon in KTS. We present a case of a young adult who presented to us with bleeding per rectum and varicosities of the left lower limb. The patient was evaluated and diagnosed to have KTS. The patient was managed conservatively. To best of our knowledge, this is the first case report in literature where KTS was associated with atypical varicose veins of the left lower limb with mild hypertrophy of the lower limb, localised hypertrophy of the right gluteal region with involvement of pelvis, rectum, bladder and seminal vesicle.

Inferior vena cava-syndrome

Inferior vena cava syndrome (IVCS) is caused by agenesis, compression, invasion, or thrombosis of the IVC, or may be associated with Budd-Chiari syndrome. Its incidence and prevalence are unknown. Benign IVCS is separated from malignant IVCS. Both cover a wide clinical spectrum reaching from asymptomatic to highly symptomatic cases correlated to the underlying cause, the acuity, the extent of the venous obstruction, and the recruitment and development of venous collateral circuits. Imaging is necessary to determine the underlying cause of IVCS and to guide clinical decisions. Interventional therapy has changed the therapeutic approach in symptomatic patients. This article provides an overview over IVCS and focuses on interventional therapeutic methods and results.

Peripartum clinical manifestations of a mesentericorenocaval shunt in a Burmese cat

Case summary

A 3-year-old entire female Burmese cat was presented for investigation of intermittent lethargy during gestation followed by persistent hypersalivation and ataxia postpartum. The cat had queened three litters in total, with clinical signs worsening during the most recent lactation period. Mild anaemia (26%), hypoglycaemia (2.4 mmol/l; reference interval [RI] 3.9–8.3 mmol/l) and increased postprandial serum bile acids (74 µmol/l; RI <25 µmol/l) were identified on initial bloodwork. Multiphase contrast-enhanced CT identified a mesentericorenocaval portosystemic shunt; this was attenuated surgically with an ameroid constrictor. Clinical signs resolved after surgery. Follow-up 3 months postoperatively revealed normal pre- and postprandial serum bile acids (2 µmol/l and 3 µmol/l, respectively) with repeat CT identifying evidence of shunt attenuation. The cat continued to be healthy and free of clinical signs 12 months postoperatively.

Relevance and novel information

Mesentericorenocaval portosystemic shunt morphology has not been previously reported in the cat and should be considered as a differential diagnosis for cats presenting with peripartum onset of malaise, ptyalism or ataxia.

Inferior vena cava filter – comprehensive overview of current indications, techniques, complications and retrieval rates

Summary: Inferior vena cava (IVC) filter has been used to manage patients with pulmonary embolism and deep venous thrombosis. Its ease of use and the expansion of relative indications have led to a dramatic increase in IVC filter placement. However, IVC filters have been associated with a platitude of complications. Therefore, there exists a need to examine the current indications and identify the patient population at risk. In this paper, we comprehensively reviewed the current indications and techniques of IVC filter placement. Further, we examined the various complications associated with either permanent or retrievable IVC filters. Lastly, we examined the current data on filter retrieval.

Inferior Vena Cava Atresia: Characterisation of Risk Factors, Treatment, and Outcomes

PURPOSE

To characterise (1) the risk factors associated with inferior vena cava (IVC) atresia, (2) the radiographic and clinical presentations of deep vein thrombosis (DVT) in patients with IVC atresia, and (3) the treatment and outcome of DVT in patients with IVC atresia.

METHODS

The electronic medical record was systematically reviewed for thrombotic risk factors in patients who presented with lower-extremity DVT (n = 409) at a single centre between 1996 and 2017. Patients with IVC atresia were identified based on imaging and chart review. Differences in demographics and thrombotic risk factors between patients with and without IVC atresia were statistically assessed. Extent and chronicity of DVT on imaging, clinical presentation, treatment, and outcomes were evaluated for all patients with IVC atresia.

RESULTS

4.2% of DVT patients (17/409) were found to have IVC atresia; mean age at diagnosis was 25.5 ± 9.4 years. The rate of heritable thrombophilia was significantly higher in patients with IVC atresia compared to patients without IVC atresia (52.9% vs. 17.9%, p < 0.0001). There were bilateral DVT in 70.6% of IVC atresia patients; DVT was chronic in 41.2% and acute on chronic in 58.8%. Pre-intervention Villalta scores were 13.9 ± 9.8 in the left limb and 8.5 ± 7.0 in the right limb. DVT in IVC atresia patients was typically treated with catheter-directed thrombolysis followed by stent placement, achieving complete or partial symptom resolution in 78.6% of cases.

CONCLUSION

Thrombotic risk factors such as heritable thrombophilia are associated with IVC atresia. IVC atresia patients can experience high burdens of lower-extremity thrombotic disease at a young age which benefit from endovascular treatment.

LEVEL OF EVIDENCE

Level 4.

Slc:Hartley guinea pigs frequently possess duplication of the caudal vena cava

The formation of the caudal vena cava is a complex process involving development, regression, and anastomosis. In mammals, the normal caudal vena cava runs to the right side of the abdominal aorta, while duplication of the caudal vena cava has been identified as a congenital abnormality in both companion animals and humans. The present study demonstrates that Slc:Hartley guinea pigs frequently possess asymptomatic duplicated caudal vena cava. The prevalence was 30% and 24% for males and females, respectively, with no sex-related differences. In accordance with Saad et al. (2012)’s criteria, duplicated caudal vena cava were classified into two distinct variations. The dominant variation was a complete duplication without iliac anastomosis where the left caudal vena cava continued from the left common iliac vein and joined the left renal vein; the left renal vein ran to the right to join the right caudal vena cava. The alternative variation was an incomplete duplication where the left caudal vena cava joined the right infrarenal caudal vena cava at a more cranial point than in normal cases; the renal segment was unchanged. Iliac anastomosis was not found in any cases. Duplicated caudal vena cava neither affected the body weight nor the kidney weight. In conclusion, Slc:Hartley guinea pigs frequently possess asymptomatic duplicated caudal vena cava in the absence of iliac anastomosis and appear to be a novel and useful animal model for duplicated caudal vena cava in animals and humans.

Right varicocele secondary to left-sided inferior vena cava with a retro-aortic left renal vein and azygos continuation

Varicocele represents the main cause of male infertility. Right-sided varicocele is rare and can be due to renal malignancy or a venous abnormality. The most common anomaly of the inferior vena cava (IVC) is interruption of IVC with azygos continuation, which is recognized as an uncommon congenital anomaly. The prevalence of the interruption of IVC is less than 0.3% in the healthy population. We describe the case of a 26-year-old man who had right varicocele because of a right-sided IVC with a retro-aortic left renal vein and azygos continuation. The right and left IVCs received the right and left common iliac veins, respectively, and the left renal vein crossed posteriorly to the aorta and joined the right IVC. The right IVC continued cephalad as the azygos vein within the retrocrural space. Isolated right-sided varicoceles are uncommon, but practitioners should be aware of such a condition. In case of a venous anomaly, clinicians should aware of the association with other important clinical presentations.

Case report. Multiple Mediastinal Arteriovenous Fistulas in a Patient with Myocardial Ischemia Symptoms and Tachy-Brady Arrhythmias

Arteriovenous fistulas are abnormal vascular communications between the arterial and venous system and may lead to the development of arteriovenous shunts. These malformations are extremely rare, and their diagnosis can be difficult due to the lack of symptoms or the absence of hemodynamic consequences. In many cases, arteriovenous fistulas are discovered by chance. In this brief report, we present the case of a 31-year-old male with symptoms suggestive of angina pectoris, tachycardia-bradycardia syndrome and multiple episodes of syncope. Multi-slice computed tomography revealed the presence of multiple mediastinal fistulas connecting the aorta, superior vena cava, pulmonary veins and azygos system.