Updates Surg (2015) 67:325–327 DOI 10.1007/s13304-015-0301-8
LETTER TO THE EDITOR
Inferior vena cava duplication Massimo Chiarugi1 • Lorenzo Fregoli1 • Pietro Iacconi1
Received: 5 May 2015 / Accepted: 19 May 2015 / Published online: 29 May 2015 Ó Italian Society of Surgery (SIC) 2015
Dear Editor, Duplication is an uncommon anomaly of the inferior vena cava and it may occur in up to 3 % of general population. Although it remains asymptomatic, inferior vena cava duplication may play a role as a confounding factor in imaging diagnostic tests and also may represent a hazard for bleeding during retroperitoneal surgery. A 72-year-old woman was referred to the department for a pelvic mass involving the wall of the intraperitoneal rectum. Two years before she had undergone open surgery consisting of hysterectomy and bilateral annessectomy for ovarian cancer. Surgery was followed by chemotherapy courses. In the follow-up, a CT scan of the abdomen revealed, in adjunct to the pelvic lesion, a rounded enhanced structure 11 mm in diameter located near the left side of the infrarenal aorta that was reported as an enlarged lymph node (Fig. 1). Clinical features strongly suggested a pelvic recurrence from ovarian cancer involving the rectum with aortic lymph-nodes metastasis and surgery was planned. At laparotomy, the diagnosis of pelvic recurrence of ovarian cancer extended into the rectal wall was confirmed. After mobilization of the descending colon and the sigmoid, it was discovered that the left common iliac vein did not merge with the right common iliac vein to form the inferior
& Massimo Chiarugi [email protected] Lorenzo Fregoli [email protected] Pietro Iacconi [email protected] 1
Department of Surgical, Medical, Molecular Pathology, and Critical Care, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124 Pisa, Italy
vena cava (IVC) (Fig. 2). The left common iliac vein proceeded cephalad representing a left IVC, to flow into the left renal vein (RV). During its course, the left IVC drained the left gonadic vein. The venous trunk formed by the left IVC and the left RV passed anteriorly to the aorta, and drained into the right IVC to form a single suprarenal IVC (Fig. 3). No enlarged node was found around the aorta. The IVC anomaly did not prevent performing the planned procedure of anterior resection of the rectum that was safely accomplished. Surprisingly, the IVC anomaly had not been mentioned in the report of the hystero-annessectomy operation. The IVC is formed between weeks 6 and 10 of gestation. It has been estimated that duplication occurs in 0.2–3.0 % of the general population [1]. The infrarenal portion of the IVC is formed from two embryonic veins, the supracardinal veins. The right supracardinal vein persists and develops as IVC while the left supracardinal vein regresses. Persistence of both supracardinal veins results in duplication of IVC [2]. Failure to form an adequate anastomosis between the embryonic supracardinal veins has been suggested as an alternative theory to explain the IVC anomaly [3]. Typically, the IVC presents bilaterally and the left renal vein ends into the left IVC, which crosses anterior to the aorta to join the right IVC. Depending on the size of the duplicated IVC and the preaortic trunk, a morphologic classification of this anomaly has been proposed [4]. Type I duplication refers to bilateral and symmetrical IVC having the same caliber of the preaortic trunk; in type II, both the right and left IVC are symmetric but their caliber is smaller compared to the caliber of the preaortic trunk, and in type III duplication the caliber of the left IVC is smaller in comparison to the caliber of the right IVC and the preaortic trunk. In the presented case, the caliber measured by CT scan was 11 mm for the left IVC and 19 mm for the right
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Updates Surg (2015) 67:325–327
Fig. 1 CT scan of the abdomen showing a roundish contrastenhanced mass nearby the left side of the infra-renal aorta (arrow) Fig. 3 The inferior mesenteric artery has been ligated and divided. The left inferior vena cava flows together with the left renal vein into a venous preaortic trunk after having drained the left gonadic vein. LIVC inferior vena cava, LRV renal vein, LGV gonadic vein, PAT preaortic trunk, IRA infra-renal aorta
Fig. 2 The IVC duplication as seen at laparotomy from the patient’s right side. The inferior mesenteric artery has been dissected free. The figure shows the absence of the union between to left and right common iliac veins with no vein passing beneath the right common iliac artery. IMA inferior mesenteric artery, LIVC left inferior vena cava, RIVC right inferior vena cava, RCIV right common iliac vein, RCIA right common iliac artery
IVC, suggesting a type III duplication. Type III duplication is believed to be the expression of an only partial regression of the left supracardinal vein. IVC duplication is usually asymptomatic and is mostly diagnosed during retroperitoneal surgery. However, in some circumstances, IVC duplication has a clinical impact. For example, patients with deep vein thrombosis may have recurrent thromboembolism despite the presence of an IVC filter. In other instances, the left IVC may be misdiagnosed as lymphoadenopathy of the left retroperitoneum raising indication to surgical excision or biopsy and this was our case. Also in transplant surgery, the duplication of IVC may have a clinical relevance. When a donor nephrectomy is performed, the left-sided kidney is traditionally preferred
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because of the longer renal vein. A left IVC shortens the length of the renal vein in the graft that may require an IVC cuff. Other conditions in which IVC duplication may affect surgical decision include aortic aneurysm surgery and reno-ureteral surgery. In theory an unknown IVC duplication might increase the risk of bleeding during abdominal surgery. In addition, should the aberrant vein be ligated, the venous outflow from the lower limb might be severely affected. The literature search is, however, surprisingly poor of reports addressing complications related to the anatomical variations of the IVC [5]. Nevertheless, surgeons involved in retroperitoneal procedures should be acquainted of the potent anomalies of the vena cava to minimize morbidity. Conflict of interest
None.
Statement of human rights All procedures performed in the study were in accordance with the ethical standards of the University of Pisa and Azienda Ospedaliera Pisana and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Statement on the welfare of animals This article does not contain any studies with animals performed by any of the authors.’’ ‘‘This article does not contain any studies with human participants or animals performed by any of the authors.’’ Informed consent Informed consent was obtained from all individual participants included in the study.
References 1. Philips E (1969) Embryology, normal anatomy and anomalies. In: Ferris EJ, Hippona FA, Kahn PC, Philips E, Shapiro JH (eds)
Updates Surg (2015) 67:325–327 Venography of the inferior vena cava and its branches. Williams and Wilkins, Baltimore, pp 1–32 2. Bass JE, Redwine MD, Kramer LA, Huynh PT, Harris JH (2000) Spectrum of congenital anomalies complicating retroperitoneal surgery. Radiographics 20:639–652 3. Shaw MBK, Cutress M, Papavassiliou V, White S, Sayers R (2003) Duplicated inferior vena cava and crossed renal ectopia with abdominal aortic aneurysm: preoperative anatomic studies facilitate surgery. Clin Anat 16:355–357
327 4. Natsis K, Apostolidis S, Noussios G, Papathanasiou E, Kyriazidou A, Vyzas V (2010) Duplication of the inferior vena cava: anatomy, embryology and classification proposal. Anat Sci Int 85:56–60 5. Christakis PG, Cimsit B, Kulkarni S (2012) Complication arising from a duplicated inferiro vena cava following laparoscopic living donor nephrectomy: a case report. Transplant Proc 44:1450–1452
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LETTER TO THE EDITOR
Inferior vena cava duplication Massimo Chiarugi1 • Lorenzo Fregoli1 • Pietro Iacconi1
Received: 5 May 2015 / Accepted: 19 May 2015 / Published online: 29 May 2015 Ó Italian Society of Surgery (SIC) 2015
Dear Editor, Duplication is an uncommon anomaly of the inferior vena cava and it may occur in up to 3 % of general population. Although it remains asymptomatic, inferior vena cava duplication may play a role as a confounding factor in imaging diagnostic tests and also may represent a hazard for bleeding during retroperitoneal surgery. A 72-year-old woman was referred to the department for a pelvic mass involving the wall of the intraperitoneal rectum. Two years before she had undergone open surgery consisting of hysterectomy and bilateral annessectomy for ovarian cancer. Surgery was followed by chemotherapy courses. In the follow-up, a CT scan of the abdomen revealed, in adjunct to the pelvic lesion, a rounded enhanced structure 11 mm in diameter located near the left side of the infrarenal aorta that was reported as an enlarged lymph node (Fig. 1). Clinical features strongly suggested a pelvic recurrence from ovarian cancer involving the rectum with aortic lymph-nodes metastasis and surgery was planned. At laparotomy, the diagnosis of pelvic recurrence of ovarian cancer extended into the rectal wall was confirmed. After mobilization of the descending colon and the sigmoid, it was discovered that the left common iliac vein did not merge with the right common iliac vein to form the inferior
& Massimo Chiarugi [email protected] Lorenzo Fregoli [email protected] Pietro Iacconi [email protected] 1
Department of Surgical, Medical, Molecular Pathology, and Critical Care, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124 Pisa, Italy
vena cava (IVC) (Fig. 2). The left common iliac vein proceeded cephalad representing a left IVC, to flow into the left renal vein (RV). During its course, the left IVC drained the left gonadic vein. The venous trunk formed by the left IVC and the left RV passed anteriorly to the aorta, and drained into the right IVC to form a single suprarenal IVC (Fig. 3). No enlarged node was found around the aorta. The IVC anomaly did not prevent performing the planned procedure of anterior resection of the rectum that was safely accomplished. Surprisingly, the IVC anomaly had not been mentioned in the report of the hystero-annessectomy operation. The IVC is formed between weeks 6 and 10 of gestation. It has been estimated that duplication occurs in 0.2–3.0 % of the general population [1]. The infrarenal portion of the IVC is formed from two embryonic veins, the supracardinal veins. The right supracardinal vein persists and develops as IVC while the left supracardinal vein regresses. Persistence of both supracardinal veins results in duplication of IVC [2]. Failure to form an adequate anastomosis between the embryonic supracardinal veins has been suggested as an alternative theory to explain the IVC anomaly [3]. Typically, the IVC presents bilaterally and the left renal vein ends into the left IVC, which crosses anterior to the aorta to join the right IVC. Depending on the size of the duplicated IVC and the preaortic trunk, a morphologic classification of this anomaly has been proposed [4]. Type I duplication refers to bilateral and symmetrical IVC having the same caliber of the preaortic trunk; in type II, both the right and left IVC are symmetric but their caliber is smaller compared to the caliber of the preaortic trunk, and in type III duplication the caliber of the left IVC is smaller in comparison to the caliber of the right IVC and the preaortic trunk. In the presented case, the caliber measured by CT scan was 11 mm for the left IVC and 19 mm for the right
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Updates Surg (2015) 67:325–327
Fig. 1 CT scan of the abdomen showing a roundish contrastenhanced mass nearby the left side of the infra-renal aorta (arrow) Fig. 3 The inferior mesenteric artery has been ligated and divided. The left inferior vena cava flows together with the left renal vein into a venous preaortic trunk after having drained the left gonadic vein. LIVC inferior vena cava, LRV renal vein, LGV gonadic vein, PAT preaortic trunk, IRA infra-renal aorta
Fig. 2 The IVC duplication as seen at laparotomy from the patient’s right side. The inferior mesenteric artery has been dissected free. The figure shows the absence of the union between to left and right common iliac veins with no vein passing beneath the right common iliac artery. IMA inferior mesenteric artery, LIVC left inferior vena cava, RIVC right inferior vena cava, RCIV right common iliac vein, RCIA right common iliac artery
IVC, suggesting a type III duplication. Type III duplication is believed to be the expression of an only partial regression of the left supracardinal vein. IVC duplication is usually asymptomatic and is mostly diagnosed during retroperitoneal surgery. However, in some circumstances, IVC duplication has a clinical impact. For example, patients with deep vein thrombosis may have recurrent thromboembolism despite the presence of an IVC filter. In other instances, the left IVC may be misdiagnosed as lymphoadenopathy of the left retroperitoneum raising indication to surgical excision or biopsy and this was our case. Also in transplant surgery, the duplication of IVC may have a clinical relevance. When a donor nephrectomy is performed, the left-sided kidney is traditionally preferred
123
because of the longer renal vein. A left IVC shortens the length of the renal vein in the graft that may require an IVC cuff. Other conditions in which IVC duplication may affect surgical decision include aortic aneurysm surgery and reno-ureteral surgery. In theory an unknown IVC duplication might increase the risk of bleeding during abdominal surgery. In addition, should the aberrant vein be ligated, the venous outflow from the lower limb might be severely affected. The literature search is, however, surprisingly poor of reports addressing complications related to the anatomical variations of the IVC [5]. Nevertheless, surgeons involved in retroperitoneal procedures should be acquainted of the potent anomalies of the vena cava to minimize morbidity. Conflict of interest
None.
Statement of human rights All procedures performed in the study were in accordance with the ethical standards of the University of Pisa and Azienda Ospedaliera Pisana and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Statement on the welfare of animals This article does not contain any studies with animals performed by any of the authors.’’ ‘‘This article does not contain any studies with human participants or animals performed by any of the authors.’’ Informed consent Informed consent was obtained from all individual participants included in the study.
References 1. Philips E (1969) Embryology, normal anatomy and anomalies. In: Ferris EJ, Hippona FA, Kahn PC, Philips E, Shapiro JH (eds)
Updates Surg (2015) 67:325–327 Venography of the inferior vena cava and its branches. Williams and Wilkins, Baltimore, pp 1–32 2. Bass JE, Redwine MD, Kramer LA, Huynh PT, Harris JH (2000) Spectrum of congenital anomalies complicating retroperitoneal surgery. Radiographics 20:639–652 3. Shaw MBK, Cutress M, Papavassiliou V, White S, Sayers R (2003) Duplicated inferior vena cava and crossed renal ectopia with abdominal aortic aneurysm: preoperative anatomic studies facilitate surgery. Clin Anat 16:355–357
327 4. Natsis K, Apostolidis S, Noussios G, Papathanasiou E, Kyriazidou A, Vyzas V (2010) Duplication of the inferior vena cava: anatomy, embryology and classification proposal. Anat Sci Int 85:56–60 5. Christakis PG, Cimsit B, Kulkarni S (2012) Complication arising from a duplicated inferiro vena cava following laparoscopic living donor nephrectomy: a case report. Transplant Proc 44:1450–1452
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