Inferior Vena Cava Anomalies with Portal Vein System Continuation Presenting as Portal Hypertension with a Long-term Follow-up

Inferior vena cava (IVC) anomalies, such as the absence of an intra-hepatic IVC or IVC hypoplasia, are rare. Usually, these anomalies are asymptomatic and cause few clinical issues. We herien report a 53-year-old woman with IVC anomalies who demonstrated both azygos and portal vein system continuation. Over time, this resulted in gradually progressive portal hypertension due to abnormal hemodynamics. The increased inflow from the IVC to the portal vein system for an extended time may contribute to the development of portal hypertension without liver cirrhosis.

Aneurysms of the azygos vein

OBJECTIVE

Azygos vein aneurysms (AVAs) are uncommon and infrequently diagnosed. When confronted with a patient presenting with an AVA, physicians can rely on only a few case reports after an extensive literature search. To date, no guideline, no rule, and no review on the optimal treatment strategy for these patients exist.

METHODS

A PubMed and MEDLINE database search for papers and case reports describing AVA was performed. Cases from our own institutions were also reviewed.

RESULTS

The literature search identified 57 published case reports that were reviewed for inclusion. Of those published cases, etiologic factors can be classified into idiopathic, acquired, and traumatic causes. Most AVAs are limited to the azygos arch, a congenital anatomic weak point. Clinical symptoms generally remain nonspecific. Computed or magnetic resonance tomography scans are effective diagnostic tools, although the optimal therapeutic plan remains unclear. Complications include rupture, thromboembolism, mediastinal mass effects, and pulmonary artery hypertension.

CONCLUSIONS

Conservative treatment along with oral anticoagulation may be reasonable for some AVAs, but to date, there is no clear guideline or evidence-based threshold for surgical or interventional therapy. In review of the existing data and from our clinical and scientific knowledge, interventional or surgical treatment should strongly be considered in cases with clinical symptoms, pulmonary embolism or pulmonary arterial hypertension, thrombus formation within the AVA in patients with oral anticoagulation or for patients with a contraindication to oral anticoagulants, considerable increase in diameter or compression of adjacent structures, saccular AVA, or an underlying connective tissue disease. The most common procedure is surgical ligation of the AVA, although endovascular occlusion of the aneurysms is becoming more frequent.

Azygos Vein Z Scores in Healthy Fetuses and Fetuses With Venous Malformations Related to the Azygos Vein

OBJECTIVES

To establish fetal azygos vein and descending aorta sonographic Z score formulas based on femur length and gestational age and to determine the value of azygos vein diameter variation for potential use in the diagnosis of fetal venous malformations related to the azygos vein.

METHODS

A total of 452 healthy singleton fetuses and 25 fetuses with venous malformations related to the azygos vein underwent prenatal sonography in this retrospective study. Azygos vein and descending aorta diameters were measured offline after spatiotemporal image correlation volume acquisition. Normal azygos vein and descending aorta Z score formulas were constructed for these measurements based on femur length by performing standard regression analysis followed by weighted regression of absolute residual values. The azygos vein-to-descending aorta ratio was calculated. Three parameters were compared between venous malformations related to the azygos vein and healthy fetuses.

RESULTS

Azygos vein and descending aorta Z score formulas were constructed. Both showed a positive linear correlation with femur length (r = 0.79 and 0.90, respectively; P < .01) and gestational age (r = 0.79 and 0.91; P < .01). The azygos vein Z scores and azygos vein-to-descending aorta ratios of fetuses with malformations were significantly higher than those of healthy fetuses (P < .01). In the abnormal group, 96.0% of azygos vein Z scores (24 of 25) were greater than ±2, and 96.0% of azygos vein-to-descending aorta ratios (24 of 25) were greater than the 95% confidence interval.

CONCLUSIONS

The azygos vein Z score formulas we developed can provide a quantitative basis for prenatal screening of venous malformations related to the azygos vein. Azygos vein dilatation and an abnormal azygos vein-to-descending aorta ratio may contribute to increasing the recognition of venous malformations involving the azygos vein.

Long-term parenteral nutrition, via the azygos system, in an adolescent with cystic fibrosis

Venous access device is critically needed for long-term parenteral nutrition (PN), especially in children with chronic disease such as cystic fibrosis, short bowel syndrome, and permanent intestinal failure. When traditional sites are unavailable and venous access is very limited, alternative central routes are required. The access to the azygos system has been shown to be a safe, relatively easy solution in those special situations. We report the case of an adolescent who benefited from this central venous access for long-term PN and antibiotic treatment for >7 years with a limited number of complications.

Spontaneous portoazygos shunt in a patient with portal hypertension

We present a case of spontaneous portoazygos shunt in a patient with liver cirrhosis and portal hypertension. The shunt was incidentally detected by abdominal magnetic resonance imaging for routine evaluation of liver cirrhosis. Multiplanar reconstruction images demonstrated the portal vein communicating with the azygos vein that was dilated and tortuous along its course to the mediastinum. Although there has been a case of congenital portoazygos shunt reported in a neonate with multiple congenital anomalies, to the best of our knowledge, this is the first case of spontaneous portoazygos shunt developed in an adult with portal hypertension.

Percutaneous transluminal angioplasty for treatment of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis patients

BACKGROUND

Multiple sclerosis (MS) is a leading cause of neurological disability in young adults. The most widely accepted hypothesis regarding its pathogenesis is that it is an immune-mediated disease. It has been hypothesised more recently that chronic venous congestion may be an important factor in the pathogenesis of MS. This concept has been named 'chronic cerebrospinal venous insufficiency' (CCSVI) and is characterised by stenoses of either the internal jugular or azygos veins, or both. It is suggested that these stenoses restrict the normal blood flow from the brain, causing the deposition of iron in the brain and the eventual triggering of an auto-immune response. The proposed treatment for CCSVI is percutaneous transluminal angioplasty, also known as the 'liberation procedure', which is claimed to improve the blood flow in the brain thereby alleviating some of the symptoms of MS.

OBJECTIVES

To assess the effects of percutaneous transluminal angioplasty for the treatment of CCSVI in people with MS.

SEARCH METHODS

We searched the following databases up to June 2012: The Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register, CENTRAL in The Cochrane Library 2012, Issue 5, MEDLINE (from 1946), EMBASE (from 1974), and reference lists of articles. We also searched several online trials registries for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials assessing the effects of percutaneous transluminal angioplasty in adults with multiple sclerosis, that have been diagnosed to have CCSVI.

DATA COLLECTION AND ANALYSIS

Our searches retrieved 159 references, six of which were to ongoing trials. Based on assessment of the title or abstract, or both, we excluded all of the studies, with the exception of one which was evaluated following examination of the full text report. However, this study also did not meet our inclusion criteria and was subsequently excluded.

MAIN RESULTS

No randomised controlled trials met our inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no high level evidence to support or refute the efficacy or safety of percutaneous transluminal angioplasty for treatment of CCSVI in people with MS. Clinical practice should be guided by evidence supported by well-designed randomised controlled trials: closure of some of the gaps in the evidence may be feasible at the time of completion of the six ongoing clinical trials.

[Reconstruction of the superior vena cava by artificial graft bypass between right brachiocephalic vein and right atrial appendage preserving azygos vein circulation for mediastinal non-seminomatous germ cell tumor]

A 24-year-old man was admitted to our hospital for surgical resection of mediastinal non-seminomatous germ cell tumor after 4 courses of BEP therapy (cisplatin, bleomycin, etoposide). Although it became markedly smaller after chemotherapy, the tumor invaded the superior vena cava (SVC) and the left brachiocephalic vein (LBCV). Venogram demonstrated SVC obstruction above the azygos vein and missing LBCV. A blood return from the left upper limb was shown through thoracodorsal vein, intercostal vein, and accessory hemi-azygos continuation. Excision of residual tumor with SVC and LBCV was done through a median sternotomy. Vascular reconstruction was performed between the right brachiocephalic vein and the right atrial appendage with ringed polytetrafluoroethylene graft. SVC was sutured just above the azygos vein to preserve collateral circulation. LBCV reconstruction was abandoned because distal end of LBCV was entirely surrounded by postchemotherapy scar tissue. Venous occlusive symptoms were not seen in both intraoperative and postoperative period.

Diagnosis of inadvertent cannulation of the azygos vein during cardiopulmonary bypass

Cardiac surgery with cardiopulmonary bypass demands diligence and attention to detail to prevent neurologic injury. Arterial and venous cannulae are used to facilitate cardiopulmonary bypass. The assessment of adequate decompression of the venous circulation is an essential duty of the cardiac surgical team. Modalities for the assessment of adequate regional venous drainage are limited, however communication between the team and increased awareness of certain pathologic states can be useful. These modalities include cerebral oximetry and superior vena caval pressure monitoring, which were employed during a case with bicaval venous cannulation. Malposition of the superior vena cava cannula was detected after a series of events alerted the team that superior vena cava drainage may be compromised.

Azygos Vein Aneurysm—A Case for Elective Resection

Azygos vein aneurysm is a rare differential diagnosis for a posterior mediastinal mass lesion. It is often an incidental finding in a routine chest radiograph. Most azygos vein aneurysms are secondary to conditions causing elevated flow or pressure in the azygos system, like cardiac failure or cirrhosis of the liver. In this group of patients, once diagnosis is established, no treatment is required. Even in the idiopathic azygos vein aneurysms, where no primary cause can be identified, the recommendation so far has been to continue to observe rather than elective excision, since complications are unknown. We present the report of a 73 year old man who underwent excision of an azygos vein aneurysm, which contained a large, free floating thrombus. There has been another reported case of this complication as well [Gomez M-A, Delhommais A, Presicci PF, Besson M, Roger R, Alison D. Partial thrombosis of an idiopathic azygos aneurysm. Br J Radiol 2004;77:342-43].(1) In view of this we feel that it is safer to resect an idiopathic azygos vein aneurysm electively to prevent the possibility of pulmonary embolism.

[Azygos vein aneurysm occurring simultaneously with hemoptysis]

A 64-year-old man was admitted with hemoptysis. A chest X-ray showed a well-defined round nodule at the right tracheobronchial angle. Enhanced computed tomography revealed the superior vena cava to be completely occluded while the azygos vein was also observed to have formed an aneurysm. Bronchoscopy showed the submucosal bronchial vessels at the right second carina to be markedly dilated, and thus considered them to be the likely cause of hemoptysis. Based on the above findings, we considered the following events as the most likely to have taken place: The superior vena cava was completely occluded due to the long-term placement of a pacemaker. The blood flow of head and upper limbs could not sufficiently return to the heart, but instead flowed into the azygos vein via the collateral circulation. This resulted in both the formation of the azygos vein aneurysm and an elevated venous pressure of the bronchial vein. Due to this pressure elevation, the bronchial vein and small vessels had both ruptured, thereby inducing the onset of hemoptysis.

Permanent pacemaker lead implantation via azygous vein in a patient with silent superior vena cava syndrome

Occlusion of the superior vena cava is a rare but serious complication of transvenous endocardial pacing. We describe an unusual approach for permanent pacemaker implantation using the azygous vein in a patient with occlusion of the bilateral total subclavian and innominate veins after previous bilateral pectoral pacemaker implantation. Endocardial pacing using the azygous vein with minimal invasive thoracotomy may be a good option for patients with inaccessible subclavian route.

Percutaneous treatment of the superior vena cava syndrome via an excimer laser sheath in a patient with a single chamber atrial pacemaker

A 21-year-old woman presented with a pacemaker-associated superior vena cava (SVC) syndrome refractory to medical therapy. In the past, treatment of this condition has involved surgical exploration which is invasive. With the evolution of percutaneous techniques, treatment has included venoplasty and stenting over the pacemaker lead. There is limited experience with a more advanced percutaneous technique in which the lead is extracted by an excimer laser sheath. The extraction is immediately followed by venoplasty and stenting at the site of stenosis with subsequent implantation of a new permanent pacemaker at the previously occluded access site. The patient underwent this procedure which proved to be safe, minimally invasive, and an efficient method of treating SVC syndrome secondary to a single chamber atrial pacemaker.

Venobronchial Fistula: An Unusual Complication of Long-Term Central Venous Access

A venobronchial fistula developed between the azygous vein and the upper aspect of the right main bronchus 12 months after completion of the treatment of a stage IIIB non-small-cell lung cancer in a 54-year-old man. The fistula contained the tip of the catheter placed for chemotherapy perfusion. The reported case presented risk factors previously identified for such a complication. In addition, some clinical particularities were present, suggesting new potent risk factors and some preventive means for safe long-term central venous catheterization.

Strangulation of the reconstructive gastric tube by the azygos arch

Graft necrosis after esophageal reconstruction is a rare but disastrous complication associated with a high mortality rate. Azygos arch strangulation of the graft is an unusual cause of graft necrosis. We report two cases of postesophagectomy gastric tube reconstruction complicated by azygos arch strangulation and graft ischemia. In one patient, graft necrosis resulted and a reconstruction was performed later with a colon interposition. In the other patient, the azygos arch was divided and the graft was preserved. We recommend dividing the azygos arch routinely during transthoracic or thoracoscopic esophagectomy if the reconstruction graft is to be brought up through the posterior mediastinal route to help avoid this problem.

[Azygos vein aneurysm forming a mediastinal mass]

Aneurysm of the azygos vein is a rare cause of mediastinal mass that is normally detected radiologically in asymptomatic patients. In some cases a diagnosis is made by noninvasive methods, such as computed tomography and magnetic resonance. However, in the present case imaging revealed what appeared to be a solid mass. When the mass had been excised by thoracotomy, the histopathologic diagnosis was aneurysm of the azygos vein.

The second and third right posterior intercostal veins: an alternate route for central venous access with an implantable port in children

BACKGROUND/PURPOSE

Some children dependent on total parenteral nutrition for long periods have no more axillary, internal jugular, external jugular, saphenous, and femoral veins available for cannulation. In such patients, the central venous system can still be accessed via the azygos vein by placing an implantable port catheter through one of the right posterior intercostal veins. This is the first known description of such procedure.

METHODS

We report the use of the second and third right intercostal veins for placement of the catheter by right intrapleural thoracotomy in 2 pediatric patients with short gut syndrome.

RESULTS

Recovery from the thoracotomy was uncomplicated, and the patients could receive complete intravenous nutritive mixtures immediately after the insertion of the catheter. Both patients remain dependent on total parenteral nutrition and are awaiting an intestinal transplantation.

CONCLUSION

The knowledge of alternate routes to obtain central venous access for prolonged parenteral nutrition is critically important, and the azygos system can be used when more accessible veins are unavailable.

Azygos Tip Placement for Hemodialysis Catheters in Patients with Superior Vena Cava Occlusion

Chronic central venous access is necessary for numerous life-saving therapies. Repeated access is complicated by thrombosis and occlusion of the major veins, such as the superior vena cava (SVC), which then require novel vascular approaches if therapy is to be continued. We present two cases of catheterization of the azygos system in the presence of an SVC obstruction. We conclude that the azygos vein may be used for long-term vascular access when other conduits are unavailable and that imaging studies such as magnetic resonance venography, contrast-enhanced computed tomography or conventional venography can be employed prior to the procedure to aid with planning and prevent unforeseen complications.

Serum p53 antibodies in drainage blood from the azygos vein in patients with esophageal carcinoma

BACKGROUND

Serum p53 antibodies (p53-Ab) have been detected in some cancers. The possible correlation between serum p53-Ab levels in drainage blood from the azygos vein in patients with esophageal carcinoma and prognosis was investigated.

MATERIALS AND METHODS

Serum p53-Ab levels were examined in both the peripheral and azygos veins of 57 patients, and in the peripheral vein of 17 healthy volunteers. Serum p53-Ab levels were measured using an enzyme-linked immunosorbent assay.

RESULTS

The positive rate of serum p53-Ab in the peripheral vein of the patients was 31.6%, significantly higher than that of the normal volunteers. There were no significant correlations between the clinicopathological features and the serum p53-Ab in either the peripheral or azygos veins. Serum p53-Ab levels in either vein did not correlate with prognosis in the univariate survival analysis, although the levels in the two veins were significantly correlated.

CONCLUSION

Serum p53-Ab levels in the azygos vein did not reflect the tumor status or prognosis more directly or accurately than those in the peripheral vein, since levels in the two veins were similar. Therefore, measurement of serum p53-Ab in the azygos vein does not appear to be necessary.

A Novel Adjunctive Technique for Implantable Cardioverter Defibrillator Placement

High defibrillation thresholds (DFTs) occasionally are encountered during placement of implantable cardioverter defibrillators (ICDs). There are multiple strategies to lower DFTs in such patients, including reassessment of right ventricular lead position, alteration of the shock waveform, and implantation of subcutaneous arrays. This article describes a novel technique of implanting a high-voltage lead in the azygos vein. This procedure may serve as an adjunctive approach to reduce DFTs. The anatomic location of the azygos vein posterior to the heart provides a suitable shocking vector between the right ventricular electrode, a high-voltage lead placed in the azygos vein, and the ICD can.

Partial thrombosis of an idiopathic azygos vein aneurysm

Aneurysms of the azygos vein are often asymptomatic, detected on a chest radiograph simulating paratracheal mass. When the aneurysm is totally thrombosed, it is impossible to distinguish it from another cause of mediastinal mass. A case is presented in which partial thrombosis of the aneurysm and communication with the superior vena cava led to a diagnosis on angiography and CT.

Vascular tethering of the megaoesophagus by the azygos arch masquerading as a malignancy

We report the case of a 50-year-old male, a known case of achalasia cardia for 15 years, who after being successfully treated earlier by pneumatic dilatation, presented with recurrent dysphagia due to vascular tethering of the megaoesophagus by the azygos arch simulating a malignant oesophageal stricture. The patient underwent oesophagectomy because of our inability to rule out the possibility of a malignancy developing in the mid-portion of the long-standing megaoesophagus. We wish to highlight the existence of this new clinical entity and the diagnostic as well as therapeutic dilemmas posed by it.

Catheter ablation of left free wall accessory pathway in a patient with inferior vena cava interruption

Access to the right side of the heart for diagnostic and interventional procedures is usually obtained via the femoral vein and inferior vena cava. Anatomic variations or obstruction of the inferior vena cava can make this access difficult. In such cases, alternative routes to the right side of the heart such as the azygos vein and the superior vena cava can be used.

Transcatheter occlusion of a large aortoazygos fistula using the Amplatzer device

This report describes the percutaneous embolization of an unusual aortoazygos arteriovenous fistula in a 22-month-old child. The large fistula (8 mm) was successfully occluded using a 12- to 10-mm Amplatzer Duct Occluder device using the arterial approach. The device was incompletely deployed into the abnormal vessel to avoid tearing of the intima by the sharp distal disk.

Thoracic veins and the mechanisms of non-paroxysmal atrial fibrillation

OBJECTIVE

The purpose of this article is to review the importance of thoracic veins in the maintenance of sustained (non-paroxysmal) atrial fibrillation (AF).

METHODS

Thoracic veins, including the pulmonary veins (PVs), vein of Marshall (VOM) and the superior vena cava (SVC), have muscle sleeves that connect to the atria. It is well known that electrical activities can be recorded within these venous structures. In some incidences, these thoracic veins may serve as the trigger and/or the substrate for paroxysmal AF. The importance of thoracic veins in chronic (sustained) AF is less well appreciated. Therefore, we review the literature to determine if thoracic veins are important in the maintenance of sustained AF.

RESULTS

Our recent study demonstrated that repetitive rapid electrical activities are present in the PVs and in the VOM during pacing-induced sustained AF in dogs. Because of these repetitive rapid activities, these thoracic veins have shorter activation cycle lengths than that of the left atrium, which, in turn, has shorter cycle lengths than that of the right atrium. Others have demonstrated that PV isolation in humans can result in a cure of sustained human AF in >80% of patients undergoing concomitant surgery.

CONCLUSION

These findings suggest that repetitive rapid activities within the thoracic veins may be responsible for the maintenance of non-paroxysmal (sustained) AF.

Triplex operation for children with extrahepatic portal hypertension

BACKGROUND/PURPOSE

How to deal with the vexatious problem of esophageal and gastric varices secondary to extrahepatic portal hypertension has been discussed extensively among pediatric surgeons around the world. The aim of this study is to evaluate the effect of triplex operation (splenopneumopexy, portal azygous devascularization, and ligation of splenic artery) for children with portal hypertension in the author's hospital.

METHODS

From March 1993 to November 1998, 7 children with extrahepatic portal hypertension were admitted to the author's hospital to undergo triplex operation. The diagnoses of these patients were confirmed by gastroscopy, barium meal, and Doppler ultrasonography. The number of white blood cells and platelets and the hepatic function were checked before and after operation. And the free portal pressures (FPP) were checked before and after the ligation of the splenic artery. All patients underwent follow-up for 1 to 7 years (mean, 4.6 years). The episodes of upper gastrointestinal bleeding were recorded. The degree of varices of distal esophagus and proximal stomach were assessed by barium meal and gastroscopy. The diameters of the spleenic and portal vein were obtained by B ultrasonography. The portopulmonary shunt and portal blood flow were evaluated by color Doppler flow image (CDFI). The indices of hemorheology such as hematocrit, viscosity of whole blood and plasma, and the indexes of deformability and aggregability of red blood cells were obtained through viscometer (R-20 Seerle, Beijing, China).

RESULTS

There was no operative mortality in this group. Postoperatively, hemorrhage from the esophagus and gastric varices was completely controlled. Although the diameter of spleen reduced progressively, no patient's spleen recovered to normal during the follow-up period. The degree of varices was mitigated, and the FPP was decreased significantly to 34.48 +/- 5.71 cm H(2)O from the preoperative 42.62 +/- 6.72 cm H(2)O (P <.05). The rate of portal flow also was decreased. The direction of portal vein was bidirection (one part was away from the liver and the other was toward the liver). The numbers of white blood cells and platelets were increased. The viscosities of whole blood and hematocrit also were increased after operation.

CONCLUSION

The triplex operation is an effective procedure for the control of hemorrhage from varices in children with extrahepatic portal hypertension.

Endoscopic Doppler ultrasound for measurement of azygos blood flow. Validation against thermodilution and assessment of pharmacological effects of terlipressin in portal hypertension

BACKGROUND

Endoscopic ultrasound (EUS) is a new modality allowing real-time flow measurements by means of the Doppler technique. The aim of the study was to evaluate azygos blood flow measurements by endoscopic ultrasound.

METHODS

Measurements of azygos blood flow by EUS and by the thermodilution technique were compared in 20 patients with portal hypertension. The ability of EUS flowmetry to detect changes in the azygos and portal venous flow after an intravenous dose of 2 mg of terlipressin was evaluated in 13 of the patients in a double-blind, randomized, placebo-controlled, cross-over design.

RESULTS

The EUS Doppler and thermodilution measurements correlated significantly (R=0.81, P < 0.001). The azygos blood flow was found to be 14% higher by the EUS method than by thermodilution. The coefficient of variation of the EUS Doppler measurements of the azygos blood flow was 14.8%. After administration of terlipressin, the azygos blood flow, as measured by EUS Doppler, decreased significantly by 23% from 915 to 704 ml/min (P = 0.014) and the portal venous flow decreased by 28% from 1170 to 789 ml/min (P = 0.03). No effects of placebo were detected.

CONCLUSIONS

These results show that EUS measurement of the azygos blood flow correlate strongly to the measurements by the thermodilution technique, and EUS is moreover well tolerated by the patients. The method is applicable for monitoring pharmacological effects on the superior porto-systemic collateral circulation and portal venous flow in patients with portal hypertension.

Transcatheter coil occlusion of a thoracic arteriovenous fistula in an infant with congestive heart failure

An 8-week-old baby boy presented at our institution with a continuous murmur and congestive heart failure. Echocardiography showed normal cardiac anatomy. Catheterization revealed the presence of a large thoracic arteriovenous fistula between the descending thoracic aorta and the hemiazygous system, with eventual drainage into the azygous vein and the innominate vein. Coil occlusion was performed successfully with a Gianturco coil.

Transcatheter management of innominate vein thrombosis prior to bidirectional cavopulmonary anastomosis

Innominate vein thrombosis was diagnosed in an 8-months-old infant after stage I surgery for hypoplastic left heart syndrome. Cardiac catheterization identified venous collaterals bypassing the innominate vein via the azygous vein. Coil occlusion of the distal azygous vein allowed a subsequent cavopulmonary anastomosis directing collateral flow into the pulmonary bed. Cathet. Cardiovasc. Intervent. 49:61-63, 2000.

Surgical treatment of an endovascular metastatic melanoma of the superior vena cava

A 42-year-old woman, who had undergone excision of a melanoma of her right forearm 3 years before (Breslow's index 4.4 mm), was admitted to hospital for the evaluation of an superior vena cava syndrome. The thoracic CT scan and the phlebography showed obstruction of the superior vena cava by an endovascular tumor. Abdominal, pelvis and cranial CT scans did not reveal any other metastatic localization. Surgery with extracorporeal circulation was performed. The mass was resected and histopathologic examination confirmed the endovascular metastatic melanoma. There was no heart metastasis. The patient was then given a polychemotherapy. She was still alive after 18 months of follow-up after the initial metastasis. To our knowledge, no similar case has previously been reported and surgical treatment, as for isolated heart metastatic melanoma, may be considered for vascular metastasis, as in our case.

Computed tomography-guided central venous catheter placement in a patient with superior vena cava and inferior vena cava occlusion

An 18-year-old man with a gastrointestinal hypomotility syndrome required lifelong parenteral nutrition. Both the superior and inferior vena cava were occluded. Computed tomography guidance was used to place a long-term central venous catheter via a large tributary to the azygos vein.

Resection of a leiomyosarcoma of the azygos vein

We report the resection of a leiomyosarcoma of the azygos vein in an elderly woman. The rare nature of the tumor and the unusual site of origin are discussed.