Case report

Persistence and restoration of the patency of the left duct of Cuvier

A. García*, J. Rogondino, F. Londra and B. Afonso

Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina

Abstract he increased pressure in the portal circulation due to chronic liver disease favors the redistribution of the flow to the systemic circulation. Although rare, reperfusion of embryonic venous channels may be a possibility. Our aim is to report the persistence and patency of the ductus venosus, called the left duct of Cuvier, and to show its presentation in images. © 2015 Sociedad Argentina de Radiología. Published by Elsevier Spain, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Left Cuvier duct patency; Collateral circulation; Restoration of embryonic veins patency

Case Report identical diameter, with a tortuous path inside the liver seg- ments II and III (fig. 1). Then, it coursed towards the chest Sixty-seven year-old female patient with cryptogenic cirrhotic alongside the posterior wall of the left ventricle, outside the disease. Clinical findings included esophageal varices and he- pericardium (figs. 2 and 3). This finding corresponded to the patic encephalopathy resulting in repeated hospitalizations. left duct of Cuvier, which ascended to the left cardiac ve- Doppler examination of the liver did not reveal signs of por- nous sinus (without penetrating it) leading into the ipsilateral tal hypertension, and the flow direction in the portal vein jugular-subclavian venous confluence (fig. 4). and the hepatic artery was hepatopetal. The left portal vein showed collateral circulation towards the systemic circulation from its posterior branch. No ascites was observed and the echocardiogram showed no signs of cardiac overload. During hospitalization, the patient was placed on the waiting list for liver transplant. Therefore, for an early detection of he- patocellular carcinoma (HCC), the patient underwent a con- trast-enhanced magnetic resonance imaging (MRI) of the ab- domen, as well as an abdominal computed tomography (CT) in the arterial, portal and late phases to evaluate the hepatic gland, and a CT scan of the chest in the portal venous phase. We report this case to describe and learn about the imaging presentation of persistence of an embryologic venous system known as the “left duct of Cuvier” (LC). This system normally involutes. In our patient, the LC had its patency restored by cirrhosis (the patient’s baseline disease), playing the role of a portoca- Figure 1. 2D Reconstruction, axial maximum intensity pro- val anastomosis. The abdominal scan revealed a 35-mm HCC jection image shows patent anastomosis between the left in the hepatic segment VII. The scan also showed that the branch of the portal vein (red arrow) and the left duct of left branch of the portal vein joined a vascular structure of Cuvier (white arrow).

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a b

c d

Figure 2. Axial views of the upper abdomen. (a) The Cuvier duct (arrow) emerges from the left branch of the left portal vein. (b) The Cuvier duct courses towards the chest alongside the left hepatic lobe (arrow). (c) Visualization of the union between the left branch of the portal vein and the left duct of Cuvier (arrow). (d) The arrow shows the right branch of the portal vein.

The embryologic duct of Cuvier generally drains into the left Cuvier ducts: an embryologic review cardiac venous sinus. Embryologically, the right and left ducts of Cuvier anastomose and blood from the left side of the The term “Cuvier ducts” refers to the common (right and body is channeled to the right side, forming in the anterior left) primitive cardinal veins that during embryologic devel- region the left brachiocephalic vein and the left superior in- opment are used by the human circulatory system together tercostal vein (drains the 2nd and 3rd intercostal veins) (fig. 5). with umbilical and vitelline veins to drain the sinus venosus. At fifth week of gestation, three sets of large-sized veins can be distinguished (fig. 6): Discussion - Vitelline veins, which carry blood from the yolk sac to the sinus venosus. The heart and blood vessels develop from the mesoderm as - Umbilical veins, which originate in the chorionic villi and isolated masses and cords of mesenchymal cells in order to carry oxygenated blood to the embryo. rapidly deliver the necessary nutrients to the exponentially - Cardinal veins, which drain the body of the embryo. proliferating cells and dispose of waste products through the The anterior cardinal veins drain the cephalic portion of the connection with the maternal blood vessels in the placenta. embryo, while the posterior cardinal veins drain the remaining

96 Rev. Argent. Radiol. 2015;79(2): 95-99 A. García et al.

a b

c d

Figure 3. Axial views of the lower chest. Path of the duct of Cuvier, (a) entering the chest (arrow) and (b) passing behind the left ventricle (arrow), in (c) towards the left atrium where embryologically it should drain (arrow). However, it does not drain into it, but forms a vascular curl and continues ascending. (c and d) Emergence of an intercostal branch towards the chest wall (arrow). part of the body of the embryo. The anterior and posterior Porto-systemic anastomosis cardinal veins join and form the common cardinal veins, also called right and left ducts of Cuvier, which anastomose, allow- The portal system is not absolutely closed, but communicates ing the passage of blood from the left to the right1. The right with venous networks that are tributary to the vena cava. common cardinal vein and the proximal portion of the right - Esophageal anastomoses: anastomoses exist between the anterior cardinal vein form the superior vena cava2,3 (fig. 7). left gastric (coronary) vein and the inferior esophageal When the Cuvier ducts anastomose, blood from the left flows veins through the submucosal plexuses, which are often to the right, forming the left brachiocephalic vein and the left very thin. Increased pressure causes varicose dilatation of superior intercostal vein in the anterior region4-6. Persistence the esophageal veins. and/or restoration of the patency of this venous structure - Rectal anastomoses: superior rectal veins (portal tributar- causes direct communication between the portal venous sys- ies) anastomose with the middle and inferior rectal veins tem and the systemic veins, forming a porto-systemic anas- (branches of the internal iliac veins). tomosis7, 8. - Peritoneal anastomoses: these anastomoses have been called Retzius’ veins or system. This third group of anasto- moses exists along the sides of the intestinal walls, where

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mesenteric veins communicate with small-sized tributaries of the inferior vena cava, forming what is clinically known as “caput medusae”. - Fetal anastomosis: patency of umbilical, paraumbilical veins and ductus venosus connecting the left branch of the portal vein with the inferior vena cava. - Accessory portal veins: the liver does not only receive blood from the portal vein, but also from other veins known as ac- cessory portal veins. These small groups of vessels include: gastroepiploic veins, cystic veins, hilar veins or group of nutri- ent venules, diaphragmatic veins, suspensory ligament veins, and paraumbilical or round ligament veins.

Being aware of the possibility of patent embryological venous ducts that serve as portocaval anastomoses is essential for the evaluation and treatment of patients awaiting liver transplanta- tion, in order to prevent intraoperative complications that in- crease morbidity and mortality9-11.

Figure 4. 2D reconstruction of the chest and abdomen, coro- Addendum nal maximum intensity projection image showing the entire path of the Cuvier duct to the jugular-subclavian confluence (arrow). Although we performed a literature search, we have not found pictorial reports. a b

Figure 5. 2D Reconstruction of the chest and upper abdomen, (a) coronal maximum intensity projection and (v) volume rendering, showing the entire Cuvier duct entering the chest. The arrow points to the intercostal branch, which runs along the left lateral wall to the left subclavian vein.

Conflicts of interest The authors declare no conflicts of interest.

98 Rev. Argent. Radiol. 2015;79(2): 95-99 A. García et al.

Sinus venosus Superior Vena Cava

Left Cardinal Vein

Right Cardinal Vein

ductus venosus

Figure 6. Embryological development of cardinal veins.

Supracardinal vein

Common Cardinal Vein

subcardinal vein

Figure 7. Left cardinal vein regressing and right cardinal vein forming the Superior Vena Cava.

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