Downloaded from www.ajronline.org by 117.245.40.235 on 11/10/15 from IP address 117.245.40.235. Copyright ARRS. For personal use only; all rights reserved

545

Case Report

Left Retrocaval Cava Joseph

A. Pierro,1 Mehdi

Ureter Associated Soleirnanpour,

and Jeffrey

ment of the IVC with a prevalence of 0.1% [5]. Our case is unique in that two rare anomalies occurred simultaneously with normal situs. Although retrocaval ureter almost invariably involves the right side, a bilateral retrocaval ureter has been reported once in an acardiac fetus [6], and a case of left retrocaval ureter has been described in a patient with situs inversus totalis [7]. The embryogenesis of the IVC is a complex process of development, anastomosis, and regression of three paired venous systems: the posterior cardinal, the subcardinal, and the supracardinal systems. Aberrant completion of this corn-

Case Report A 34-year-old

man presented

of urinalysis

showed

pneumonia

showed

a normal

delayed

excretion

ureter

and medial

Postinfusion proximal

were in the right with scans

ureter

right

with recurrent normal lower

lobe.

system.

severe

hydronephrosis

of the middle

showed

with

respect

the

abdominal

limits.

collecting

deviation

CT left

within

An

left with

ureteral

there

proximal

was hydro-

(Fig. 1 A).

course

of the

transposition

of

the IVC located to the left of the aorta, suggesting ureter(Figs. 1 B and 1 C). CTfindings were confirmed by

using

the

Seldinger

approach

to the

a left retrocaval with venography left femoral vein. This ap-

dinal system.

proach will more likely opacify both IVCs if duplication is present and the left IVC if transposition exists (Fig. 1 D) [1 , 2].

cardinal

system

ureter results

from persistence

elements of the subcardinal system of the IVC, rather than the normal

that lies dorsal

to the ureter

of

as the supra-

[5, 6]. The

embryologic integrity of the hepatic (prerenal) and renal segment derived from the subcardinal system is maintained [3]. The left-sided IVC would then receive the left renal vein before

Discussion

crossing

The prevalence of transposition or left-sided IVC as cited in several studies is 0.2%-0.5% [3-5]. Retrocaval ureter is a rare, congenital anomaly resulting from abnormal develop-

I

A retrocaval

the ventral venous infrarenal segment

only

Received

variants: left renal

vein, and circumaortic left renal vein [2-4]. Development of the left-sided IVC and retrocaval ureter as described in this case requires two simultaneous caval anomalies. In this case, formation of the left IVC required regression of the supracardinal system, which normally forms the infrarenal segment of the IVC, and persistence of the left subcar-

urogram

side,

segment

medial

anomalous

plex embryogenesis may result in four anatomic duplicated IVC, transposition or left IVC, retroaortic

pain. Re-

radiographs

excretory

On the

posterior

to the

Chest

Vena

L. Bory

Numerous authors have discussed the developmental anomalies of the inferior vena cava (IVC) [1 -3]. Although rare, appreciation of venous anomalies is important to prevent misinterpretation of a pathologic process such as paraaortic lymphadenopathy and to raise the suspicion of associated vascular abnormalities. We report what we believe is the first case of simultaneous anomalies resulting in left retrocaval ureter associated with left IVC without total situs inversus.

suIts

with Left Inferior

March

All authors:

1 , 1 990; accepted

Department

after revision

of Radiology,

continuing

anterior cephalad

September

in the normal

prerenal

[2, 3]. This is the usual route for venous

portion

of the IVC

return with left-sided

April 3, 1990.

St. Elizabeth

Hospltal

Medical

Center,

1 044 Belmont

Ave.,

J. A. Pierro. AJR 155:545-546,

to the aorta at the level of the renal vein,

1990 0361-803x/90/1553-0545

0 American

Roentgen

Ray Society

Youngstown,

OH 44501 -1 790. Address

reprint

requests

to

PIERRO

Downloaded from www.ajronline.org by 117.245.40.235 on 11/10/15 from IP address 117.245.40.235. Copyright ARRS. For personal use only; all rights reserved

546

ET AL.

AJR:155,

September

1990

Fig. 1.-A, Excretory urogram shows severe left hydronephrosls, hydroureter, and medial doviation of ureter with S or fishhook deformity at point of obstruction (arrow). B and C, Enhanced CT scans of abdomen progressing interiorly obtained after excretory urography (arrowhead, Inferior vena cava [IVC]; arrow, left ureter). Ureter courses medially and posterior to transposed IVC. 0, Left femoral venogram shows opaclflcatlon of left IVC, crossing at level of renal veins (U level) and continuing superiorly on right side as normal prerenal segment of IVC.

C

D

Other anomalous routes into the thorax via azygous or hemiazygous continuation have been well described [3]. The importance of diagnosing left IVC and retrocaval ureter has been well documented. Radiologic and surgical awareness will prevent problems when planning aortic aneurysm repair, left sympathectomy, renal transplantation, donor evaluation, nephrectomy, and adrenalectomy. It will also aid in evaluating retroperitoneal masses or adenopathy and avoiding accidental laceration or ligation of the anomalous IVC, which may lead to death [4]. In summary, a case of left-sided IVC and retrocaval ureter IVC.

is reported.

Radiologic

evaluation

including

excretory

urog-

raphy, CT, and venography. However, other techniques such as MR imaging and sonography are documented also [2].

REFERENCES 1 . Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the inferior vena cava: review of embryogenesis and presentation of a simplified classification. Br J Radio! 1974;47:206-213 2. Giordano JM, Trout HH. Anomalies of the inferior vena cava. J Vasc Surg 1986;3:924-928 3. Mayo J, Gray A, St. Louis E, Grosman H, McLoughlin M, Wise D. Review: anomalies of the inferior vena cava. AJR 1983;140:339-345 4. Brener BJ, Daring AC, Frederick PL, Linton AR. Major venous anomalies complicating abdominal aortic surgery. Arch Surg 1974;1 08:159-165 5. Clements JC, Mcleod DG, Greene WA, Stutzman RE. A case report: duplicated vena cava with right retrocaval ureter and ureteral tumor. J Uro! 1978;1 19(2):284-285 6. Gladstone RJ. An acardiac foetus. J Anat 1905;40:71 -81 7. Brcoks RE. Left retrocaval ureter associated with situs inversus. J Urol

1962;88(4):484-487