Abdominal CT findings when the superior vena cava, brachiocephalic vein, or subclavian vein is obstructed

OBJECTIVE: We evaluated findings on contrast-enhanced abdominal CT scans that suggest obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein. SUBJECTS AND METHODS: We conducted a retrospective review of 22 patients with superior vena caval, brachiocephalic vein, or subclavian vein obstruction and analyzed the upper abdominal images on a chest CT scan or an abdominal CT scan. We assessed collateral vessels in the upper abdomen to answer the following question: Did enhancement approach undiluted IV contrast or were there other findings? In the second part of our study, we conducted a prospective review of abdominal CT scans of 200 patients without known mediastinal disease or known upper extremity venous occlusion to determine the frequency of abnormal enhancement of these vessels in a healthy population. RESULTS: The groups of collateral vessels revealed on abdominal CT scans were azygos or hemiazygos veins, internal mammary veins, lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus veins, and small mediastinal collateral veins. In the retrospective series, one patient had focal enhancement of the liver and early inferior vena caval enhancement due to collateral vessels. In the prospective series, abdominal CT scans of two patients (1%) revealed dense undiluted enhancement of one or more groups of collateral vessels: One patient had an ipsilateral pacemaker, and the other patient had an anterior neck phlegmon to the upper mediastinum. Both conditions may have been factors in the revealing of the collateral vessels. Two other patients (1%) in the prospective series had mild to moderate vessel enhancement that was less than that from undiluted contrast material. In one of these patients, the enhancement was related to abdominal wall hyperemia after surgery. In the other patient, enhancement may have been the result of ipsilateral axillary nodes. CONCLUSION: On upper abdominal CT scans, dense undiluted contrast material in the collateral vessel groups that we studied suggests possible obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein.     

Ct of congenital anomalies of the inferior vena cava

The authors report six congenital abnormalities of the inferior vena cava detected on computed tomography (CT). The CT findings of one of these, the left inferior vena cava, have not been previously reported. The embryology of the inferior vena cava and the possible congenital abnormalities that can occur are discussed. Congenital abnormalities of the inferior vena cava are rare but potentially important to the radiologist, the surgeon, and the patient. They are easily identified on CT and should be considered when interpreting any CT of the abdomen or chest.     

Leiomyosarcoma of the superior vena cava. A first case with resection

Leiomysarcomas, rare malignant tumors of the veins, are located predominantly in the inferior vena cava. We report our experience with a leiomyosarcoma in the superior vena cava of a 44-year-old white man. The lesion had been locally excised and then recurred 2 1/2 years later. The recurrent tumor was widely excised and the superior vena cava was repaired with a saphenous vein patch graft. The area of the recurrence was treated with cobalt 60 therapy. Four years later, 6 1/2 years after initial treatment, the patient is alive and well without evidence of recurrence.     

Leiomyosarcoma of the inferior vena cava

BACKGROUND: The inferior vena cava is an uncommon location for leiomyosarcoma, a malignant tumor which develops from the smooth muscle tissue of the media. CASE REPORT: A 76-year-old woman was hospitalized for swelling of the lower limbs. Ultrasonography, computed tomography of the abdomen and magnetic resonance imaging showed tumoral invasion of the inferior vena cava extending to the atrium. Histology examination of a tumoral fragment obtained by transjugular catheterism affirmed the diagnosis of leiomyosarcoma. DISCUSSION: Prognosis of leiomyosarcoma of the inferior vena cava is very poor. No medical or surgical treatment has given satisfactory results. Two factors would explain the poor prognosis: the tumoral localization and the low degree of tumoral differentiation. Clinical presentation and imaging findings suggest the diagnosis which must be confirmed by pathology examination of a tumoral biopsy specimen.     

Inferior vena cava stenosis and pancreatic ascites complicating chronic calcific pancreatitis: a case report

A 19-year-old Thai male, who was a regular drinker, presented with massive ascites, back pain and leg edema for four months. On examination there was obvious clinical evidence of an inferior vena cava obstruction. Inferior vena cavography showed narrowing of the hepatic portion of IVC with collateral circulation. Surgical dilatation of the inferior vena cava was performed. The ascites were diagnosed four months later as pancreatic ascites with a very high ascitic amylase level. Computerised axial tomography and endoscopic retrograde pancreatography showed evidence of chronic calcific pancreatitis and pseudocyst. After further medical treatment, ascites and inferior vena cava stenosis subsided which was confirmed by repeated vena cavography, computerised axial tomography and magnetic resonance imaging. The cause of inferior vena cava stenosis and clinical obstruction in this case most likely resulted from phlebitis secondary to pancreatitis. The etiology of chronic calcific pancreatitis in this case might be alcoholic abuse and/or nutritional tropical pancreatitis. Inferior vena cava stenosis and associated pancreatic ascites complicating chronic calcific pancreatitis has not been previously reported in Thailand.     

Fat collection related to the intrahepatic inferior vena cava on CT

OBJECTIVE: The purpose of our study is to describe the CT findings of fat collections related to the intrahepatic inferior vena cava and to review the literature about this benign incidental finding. CONCLUSION: Focal collections of fat related to the inferior vena cava are benign incidental findings located exclusively at the level of the liver. The fat collections are always adjacent to the medial wall of the inferior vena cava; appear to be extraluminal in origin and may, in fact, be entirely extraluminal; and are uncommon findings that are usually of no clinical significance.     

Demonstration of inferior vena cava patency by retrograde azygous venography

Gaining access for vena cavography may be difficult in patients with multiple venous occlusions. We report the use of selective azygous venography to demonstrate potency of the proximal inferior vena cava (IVC) when no alternative route was available and noninvasive techniques were not applicable. The proximal superior vena cava and the distal IVC were occluded.     

Temporal changes in PO2 of R3230AC tumors in Fischer-344 rats

It has been hypothesized that abdominal trauma may be one of the factors involved in membranous obstruction of the inferior vena cava. We present two cases of membranous obstruction of the inferior vena cava associated with trauma. One asymptomatic case, associated with an occult myeloproliferative disorder, developed within 3 years of a violent abdominal trauma. The other case, associated with familial plasminogen deficiency, was discovered at surgery 3 days after a road accident with obvious abdominal trauma, since superimposed extensive thrombosis of the inferior vena cava caused acute Budd-Chiari syndrome. We conclude that underlying prothrombotic conditions are probably necessary for the development of membranous obstruction of the inferior vena cava and that minor trauma may contribute to the development of thrombosis through indirect mechanisms.     

Transiliac catheterization of the inferior vena cava for long-term venous access in children

In infants and children requiring prolonged, multiple central venous (CV) catheterizations, the superior (SVC) and inferior vena cava may become thrombosed or stenotic, making CV access a difficult problem. Use of the iliac vein may be an acceptable alternative. We report a patient with thrombosis of the SVC in whom the external iliac vein was accessed through a retroperitoneal approach for placement of an implantable port. This technique is easy to perform, and there are no special materials or patient positioning required.     

Morphogenesis of the vena cava inferior roots in human embryogenesis

The roots of the vena cava inferior are formed during the 2nd month of human embryogenesis in the course of transformation of posterior caudal veins and their tributaries, including anastomoses with umbilical veins, which is associated with the growth of pelvic kidney and lower extremities. The roots and initial part of vena cava inferior originate from secondary cardinal veins, primarily from sacrocardinal anastomosis and sacrocardinal veins proximal regions.     

Anesthetic management for renal tumor extending to the inferior vena cava

A 58 year-old woman underwent radical nephrectomy, thrombectomy and ileo-cecal resection for renal tumor with thrombus involving the inferior vena cava and ascending colon cancer. In a patient having tumor thrombus extending to the vena cava, recognition of the position of the thrombus is important for surgical and anesthetic management in pre- and intra-operative periods. Transesophageal echocardiography (TEE) enabled us to visualize the real-time movement and deformity of thrombus by surgical manipulation and compression during operation. TEE seemed also very useful not only in understanding the hemodynamics during operation but also in detecting the residual tumor and the blood flow in liver and the inferior vena cava after operation.     

Left-sided laparoscopic para-aortic lymphadenectomy: anatomy of the ventral tributaries of the infrarenal vena cava

OBJECTIVE: We evaluated the anatomy of the infrarenal portion of the human inferior vena cava and their ventral tributaries by video laparoscopy. STUDY DESIGN: A total of 112 patients underwent laparoscopic para-aortic lymphadenectomy for gynecologic malignancies. All procedures were videotaped. The number and anatomic distribution of the infrarenal tributaries of the anterior part of the inferior vena cava was evaluated retrospectively from videotapes. The inferior vena cava was divided into 3 levels: the area of the bifurcation of the vena cava (level 1), the area between the bifurcation and the inferior mesenteric artery (level 2), and the area between the inferior mesenteric artery and the right ovarian vein (level 3). RESULTS: Tributaries were found in level 1 in 65 (58%) patients, in level 2 in 22 (19.6%) patients, and in level 3 in 1 (0.9%) patient; in 24 (21.5%) patients no tributaries were found. A total of 237 tributaries was counted: 82.3% (195 of 237) were located at level 1, 17.3% (41 of 237) at level 2, and 0.4% (1 of 237) at level 3. Patients with tributaries had a mean of 3 tributaries in level 1, a mean of 1.7 tributaries in level 2, and 1 patient had 1 tributary in level 3. CONCLUSIONS: The ventral tributaries of the inferior vena cava show a specific distribution pattern. The knowledge of these anatomic landmarks can be important for laparoscopic surgeons to avoid accidental injury.     

VDD pacing in persistent left superior vena cava

Although persistent left superior vena cava (PLSVC) is the most common major venous anomaly of the heart, associated absence of the right superior vena cava with normal visceral situs is exceedingly rare. Such a patient presented with complete heart block requiring permanent pacing. This was achieved successful using a single lead VDD system via the PLSVC with atrial sensing in the coronary sinus.     

Rupture of a dissecting aneurysm into the superior vena cava in Marfan's syndrome

Aneurysmal dilatation of the aorta with subsequent dissection or rupture occurs frequently in patients with Marfan's syndrome. These complications are among the major causes of death. We report the case of a 51-year-old man with annulo-aortic ectasia in Marfan's syndrome. Acute aortic dissection and rupture into the superior vena cava occurred 8 years after aortic valve replacement. The preoperative diagnosis was made by right heart catheterization and computed tomography. A markedly increased left-to-right shunt occurred with rapid enlargement of the fistula due to the fragility of the aortic wall characteristic of Marfan's syndrome. Postmortem examination demonstrated severe medial necrosis with rupture of the aortic wall into the superior vena cava which was adherent to the suture line of the aortotomy from the previous surgery. Type A aortic dissection with severe congestive heart failure strongly suggested rupture into the pulmonary circulation.     

Replacement of the retrohepatic vena cava in segmental liver transplantation

Reduced grafts represent an important technical development in paediatric liver transplantation. The use of a left lateral segment graft has required preservation of the native inferior vena cava to "piggy-back" the graft onto it. We report four children who underwent left lateral segment transplantation with caval replacement using the donor iliac vein because the native retrohepatic inferior vena cava was small, friable or difficult to preserve. There were no caval or hepatic vein complications post-transplant and the donor iliac vein proved to be a satisfactory interpositional graft. The technique offers the advantages of a wider retrohepatic cava avoiding venous outflow or caval obstruction, provides good tissue to suture and is well suited for the triangulation technique of the left hepatic vein.     

Intracaval ultrasonography in the diagnosis of tumour involvement of the vena cava

A retrospective study of 34 consecutive patients with possible tumour involvement of the vena cava was performed to assess the usefulness of intracaval ultrasonography. Twenty-five of the 34 patients were operated and resection carried out in 23, including seven with combined resection of the vena cava. The sonographic criterion for vena cava invasion was obliteration of the echogenic ring of the vena cava wall or intracaval tumour mass. The sensitivity, specificity and overall accuracy of intracaval endovascular ultrasonography in the diagnosis of tumour involvement of the vena cava were 100, 96 and 97 per cent respectively. The respective values were 91, 61 and 71 per cent for computed tomography and 82, 67 and 72 per cent for cavography. Ultrasonography is a useful technique that can precisely evaluate the vena cava for possible tumour invasion, especially when the presence or extent of tumour involvement is not definitely established by conventional imaging techniques.     

Primary malignant lymphoma of superior vena cava

A 78-year-old woman suffered from superior vena cava (SVC) syndrome. Computed tomography and angiography revealed a mass within the SVC. The SVC was resected via median sternotomy, followed by reconstruction using an artificial graft. The resected specimen showed a polypoid tumor within the SVC that had invaded the wall of the SVC. Histologic diagnosis was diffuse large-cell non-Hodgkin's lymphoma. Most surrounding lymph nodes showed reactive swelling, but one showed a partial microscopic metastasis. These pathologic findings indicated that the tumor was an SVC-originating malignant lymphoma. The patient is now alive and tumor-free 65 months after the operation.     

Successful treatment by percutaneous balloon angioplasty of Budd-Chiari syndrome caused by membranous obstruction of inferior vena cava: 8-year follow-up study

OBJECTIVES: This study sought to report the long-term result (up to 8 years) of percutaneous transluminal balloon angioplasty (PTBA) for Budd-Chiari syndrome (BCS) caused by membranous obstruction of the inferior vena cava (MOVC). BACKGROUND: We previously reported on this nonoperative form of therapy in a smaller series of patients and found the short-term results to be excellent. METHODS: We studied the long-term results of PTBA in the treatment of BCS caused by MOVC in 42 patients who underwent PTBA with the Inoue balloon catheter between June 1988 and February 1996. There were 28 men and 14 women with a mean age of 35.6 years (range 16 to 56). MOVC was incomplete in 27 patients and complete in 15. PTBA was successful in 38 patients (91%). The longest follow-up period was 8 years. RESULTS: All 38 patients who successfully underwent PTBA showed marked symptomatic improvement. Immediately after PTBA, the diameter of the inferior vena cava at the MOVC increased from 1.7 +/- 2 to 19.9 +/- 3.5 mm (p < 0.0001), the caval pressure below the MOVC decreased from 23.6 +/- 8.5 to 12.0 +/- 6.5 mm Hg (p < 0.0001), and the enlarged liver size decreased from 6.5 +/- 1.5 to 2.0 +/- 1.5 cm below the right costal margin at the midclavicular line (p < 0.0001). Over a follow-up period of up to 8 years (7 to 8 years in 4 patients, 5 to 7 years in 12, 3 to 5 years in 11, 2 to 3 years in 6 and < 2 years in 9), MOVC returned in only 1 patient. This patient, our first, required a second PTBA 3 years later and a third 4.25 years after the second PTBA, in combination with stent placement for recurrence of stenosis. CONCLUSIONS: PTBA with the Inoue balloon catheter is an effective, safe and long-lasting alternative to surgical treatment of patients with BCS due to MOVC.     

A case of superior vena cava syndrome caused by Klebsiella pneumoniae

A 27 yr old man presented with productive cough, fever and manifestations of superior vena cava syndrome. He was an alcoholic but had been in good health until 3 days prior to admission. The physical examination, the chest radiograph and the results of the sputum culture were compatible with Klebsiella pneumoniae pneumonia of the right upper lobe. The superior vena cava scintigram using technetium-99m showed near total occlusion of the superior vena cava, while sputum cytology, chest computed tomography, and bronchoscopy were all negative for malignant aetiology. Antibiotic therapy brought about slow resolution of the pneumonia and also of the superior vena caval obstruction. The follow-up scintigram showed normalized venous flow of the superior vena cava. To our knowledge, this is the first case of superior vena cava syndrome developed in probable association with Klebsiella pneumoniae pneumonia.     

Translumbar inferior vena cava access for Hickman line insertion

The procedure of translumbar inferior vena cava access and Hickman line insertion is described in a patient with acute myeloid leukaemia and thrombosis of the right internal jugular and right innominate vein. This is a useful technique for the interventionist offering a central venous access service.