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Occlusion of Inferior Vena Cava—Features

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Occlusion of Inferior Vena Cava—Features Occlusion of Inferior Vena Cava—Features by RadionucMde Venography Wilfrido M. Sy, Ramon S. Lao, Anthony Nissen, and Toy S. Kim The Brooklyn Hospital at the Brooklyn-Cumberland Medical Center, Brooklyn, New York Six adults u-ith inferior vena cavai obstruction are ¡»resented.Three were the results of surgical intervention, tico icere secondary to large thrombi, and one leas due to pressure from a large renal-cell carcinoma and adjacent nodes. All underwent a modified approach of radionuclide venogra/ihy, using a moderately lartie volume of sodium perlechnetate. Features char acteristic of inferior vena cavai obstruction tcere demonstrated in five of the six patients, and these various features are described and discussed. JNucl Mecí19: 1007-1112, 1978 The observations made from radionuclide venog- weeks. Patients 4 and 6 had contemporaneous con raphy on six patients with obstruction of the inferior trast venography. Patient 4, in addition, had a con vena cava are the subject of this report. In a large trast venogram 1 yr earlier, which demonstrated series of 242 radionuclide venograms performed by thrombosis of the deep venous system of the right injection of a relatively large volume of [nn"'Tc] per- lower extremity. technetate, without benefit of applied tourniquets at the time of injection, three instances of inferior vena RESULTS AND DISCUSSION cavai obstruction were encountered (/). The find The inferior vena cava drains the portion of the ings in these three patients and in three others stud circulation below the diaphragm. Despite this major ied more recently form the basis of this report. function, complete occlusion of the cava is com In the normal radionuclide venogram of the lower patible with life because of the presence of several extremities and pelvis (/), the secondary and ter secondary systems that can assume its function when tiary channels of the venous circulation are not out required. Surgical ligation of the inferior cava is lined. When the inferior vena cava is obstructed, undertaken at times when there is risk of continued however, either by surgical ligation or pathologic embolization from thrombi in the vena cava and/or processes involving the vessel, some of these smaller its major tributary veins. Occlusion of the inferior tributaries will assume the function of the vena cava. cava by thrombus is usually the result of thrombus This is particularly true if the cavai obstruction is extension from one or both iliac veins, or others severe or complete. It is the intent of this paper to below them. illustrate, by means of appropriate scintigrams, the In the presence of severe or complete occlusion appearance of some of these "abnormal" tributaries of the inferior vena cava, the following collateral when obstruction of the inferior vena cava has oc systems may take over its function (2) Fig. 1 (3): curred. a) anastomoses between the ascending lumbar veins and the azygous-hemiazygous system; b) anastomo METHODS ses between the inferior deep epigastric and superior Four female and two male patients with inferior cavai obstruction had radionuclide venography per Received Dec. 28, 1977; revision accepted March 19, formed in accordance with the method described 1978. elsewhere (/). Table 1 is a résuméof some salient For reprints conlaci: Wilfrido M. Sy, Chairman, Depart ment of Nuclear Medicine. The Brooklyn Hospital at The clinical data on these patients. Patient 5 had a series Brooklyn-Cumberland Medical Center, 121 Dekalb Ave., of three studies performed at intervals of several Brooklyn, NY 11201. Volume 19, Number 9 1007 SY, LAO, NISSEN, AND KIM OBSTRUCTIONPatientTABLE 1. SUMMARY OF PATIENTS WITH INFERIOR VENA CAVAL No.1 sex32—8. dataAbdominal obstructionSurgicalof M umbrellaOvariancollaterals apparent on examination; 1-\- edema legs. IVC 23456Age 66F28—— 1975.Obese;carcinoma; repeated pulmonary embolism; IVC ligation, SurgicalSurgicalThrombiThrombiRenal-eel! F39— frank idiopathic hemoptysis; IVC ligation at another institution, 1974; myocardiopathy.Historyrestrictive F65— of pulmonary emboli; phlebitis & thromboembolism of lower extremities documented by contrast venography a year before; readmitted because of chest 1977.Breastpain & shortness of breath, F69— carcinoma with bone metastasis; paraplegic; abdominal-wall collaterals (later).Fever, MClinical weight loss; abdominal mass.Cause carcinoma epigastric veins; c) the thoraco-epigastric vein, inferior vena cava. The lack of other abnormal chan which connects the superficial inferior epigastric and nels usually associated with complete cavai occlusion the lateral thoracic veins; d) the vertebral plexus; might also suggest the partial nature of the existing and e) several anastomoses with the portal system. obstruction in this patient. The principal venous collaterals are the azygous- Patient 5 had a series of radionuclide venograms hemiazygous veins, since they connect the superior performed at intervals of several weeks (Fig. 4 A, and inferior venae cavae and anastomose with the B and C). These depicted the evolution of abdominal- common iliacs through the ascending lumbar veins wall collaterals, a progression that correlated with and other tributaries (3). In most instances it is clinical findings. In the initial study, the abnormali these bilateral collaterals that account for an impor ties included splayed paracaval activity, failure of tant, characteristic, and early feature of vena cavai the left common iliac vein to appear, and presence obstruction on radionuclidc venography. This fea of some pelvic collaterals (Fig. 4A). The progres- ture consists of splayed parallel paracaval radio- nuclide activity instead of the sharply angulated inverted-Y pattern normally outlined. The presence of split parallel paracaval activity was observed in all patients except Patient 6. Patients 2 and 3, who occesSOry had surgical ligations of the inferior venae cavae, —hemiazygôs demonstrated this feature (Fig. 2) and in effect were lateral the positive controls or standards for the abnormal thoracic studies. We note, on the other hand, that Patient 1, in whom surgical interruption ("umbrella" insertion) was also performed several years before, displayed only "ghost shadow" paracaval and iliac activity, thOracp .- but outlined rather large abdominal-wall and some epigastric pelvic collaterals (Fig. 2). While we suspected that the paralumbar plexus and the iliac veins might have occluded at the time of our radionuclide venogram, we did not feel justified to pursue this further with superficial ascending contrast venography. epigastric lumbar In Patient 4. although splayed parallel activity was inferior evident on the radionuclide venogram, the cause in deep epigastric this patient differs from that in the others. The ac tivity on the right was, in fact, due to a partially vertebral occluded inferior vena cava, while the uptake on plexus the left resulted from collaterals in the paralumbar plexus (Fig. 3 A and B). We note also that activity FIG. I. Collateral venous circulation when inferior vena cava in the left common iliac crossed over to join the is occluded just below renal veins (after Juergens 8. Payne) (3). 1008 THE JOURNAL OF NUCLEAR MEDICINE CLINICAL SCIENCES DIAGNOSTIC NUCLEAR MEDICINE FIG. 2. Helter-skelter pathways of ac tivity due to abdominal-wall collaterals (straight arrows). Paracaval and iliac "ghost shadow" activity (curved arrow). sion of the paralumbar and pelvic collaterals and veins, which connect the superficial epigastric to development of abdominal-wall anastomoses charac the lateral thoracic veins; the anastomosis between terized the findings on the second study (Fig. 4B). the inferior deep epigastric and superior epigastric At the time of the final study (Fig. 4C), the ab veins; and smaller para-umbilical tributaries. dominal-wall collaterals became readily identifiable In 24.5% of normal radionuclide venograms in on physical examination (Fig. 4D). Among the iden which both lower extremities were successfully stud tified venous pathways were the thoraco-epigastric ied (7), the great saphenous vein is outlined uni- FIG. 3. (A) Patient 4: incomplete inferior vena cavai occlusion (clear arrow) and enhancement of paralumbar plexus (solid arrow). (B) Contrast venography is confirmatory. Clear arrow points to paralumbar plexus, while solid arrow indicates site of occlusion at bi furcation. Volume 19, Number 9 1009 SY, LAO, NISSEN, AND KIM Ü FIG. 4. (A, B, C) Patient 5: evolution of abdominal-wall collaterals correlated with clinical progression of vessels on physical exami nation. Note splayed activity (solid arrow) and occluded left ¡Macvein (clear arrow in Fig. 4A). Arrows marked #1 (Figs. B & C) point to thoracoepigastric vein, and arrows marked #2 point to epigastric-inferior deep epigastric anastomoses. (D) Infrared photograph of abdominal-wall collaterals in Potient 5. laterally or bilaterally along with the deep venous The features of radionuclide venography observed system. When these paired saphenous veins are out in Patient 6 differ from those in the foregoing cases. lined simultaneously along with the deep system, Neither the characteristic splayed paracaval activity but with both pairs apparently exhibiting a sluggish nor the helter-skelter activity due to abdominal-wall ness, inferior cavai obstruction can probably be in collaterals was seen. Instead, a sharply truncated ferred (Fig. 5). This delayed flow pattern was inferior vena cava with a marked hang-up of activity observed in three patients (Nos.
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