Gastric Varices Without Portal Hypertension: Role of Left Inferior Vena Cava?
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stimec-_Opmaak 1 23/10/12 16:38 Pagina 302 JBR–BTR, 2012, 95: 302-305. GASTRIC VARICES WITHOUT PORTAL HYPERTENSION: ROLE OF LEFT INFERIOR VENA CAVA? B.V. Stimec 1, L.A.B. Grønvold 2, D. Ignjatovic 2,3 , J.H.D. Fasel 1 A variant vascular anatomy was detected during regular analysis of multidetector computed tomography angio - graphy of the abdomen in a 70 year-old female patient, referred to the department of surgery for laparoscopic right colectomy for colon cancer. The anomalous vessel was located left to the aorta, and was consistent with a persistent left inferior vena cava. It was connected by two retroaortic rootlets to the dorsal surface of the regular right inferior vena cava and had four notable tributaries – an anastomosis with the iliolumbar trunk, ovarian vein, renal vein and the inferior phrenic vein. In the upper abdomen, the left inferior vena cava took a tortuous course, passing at first between the spleen and the diaphragm, then curving below the inferior splenic border and terminating in an irregu - lar network in the posterior region of gastric fundus and cardia, close to the splenic hilum, without supradiaphrag - matic continuation. Despite this extraordinary termination, there were no signs of portal hypertension or data on previous occurrence of this condition. Key-words: Stomach, varices – Magnetic resonance (MR), vascular studies – Venae cavae, MR. Variations of the inferior vena cava (IVC) and its tributaries were once regarded as numerous in form and rare in incidence. These varia - tions, however, have been more fre - quently reported with the advent of multislice helical CT imaging modal - ities. A persistent left inferior vena cava is found in 0.2%-0.5% and a double IVC in 0.2-3% of the general population in autopsy series (1-5). The case of the gastric varices we report hereinafter deserves attention for its atypical appearance, lack of pertinent clinical etiology and the direct anatomical framework of the persistent inferior left vena cava. Case presentation The investigation was conducted Fig. 1. — Synoptical coronal CT of the abdomen, level of the in accordance with Ethical Principles portal vein confluence (asterisk). for Medical Research Involving Human Subjects (6). A 70-year-old woman was referred to the department of sur - left-sided ovarian adenocarcinoma pression of the left ureter by the gery for colon cancer, located in the for which she underwent a bilateral pelvic tumor and consequent ascending colon, just proximal to the salpingo -oophorectomy, supra - hydronephrosis. hepatic flexure. The laparoscopic vaginal hysterectomy and recto - There were no biochemical, radio - right colectomy was performed, but sigmoid resection two years earlier, logical or anamnestic findings sug - the patient developed signs of anas - followed by a re-operation for gesting clinically significant portal tomotic leakage and underwent re- anastomotic leakage, and a sigmoid - hypertension, such as low platelet operation with a resulting ileostomy. ostomy. No retroperitoneal lym - count, splenomegaly, portal vein Final histopathology showed an ade - phadenectomy was performed. She diameter above the upper limit, nocarcinoma (stage Dukes C) with had been treated by adjuvant schistosomiasis, excessive alcohol metastases to local lymph nodes. chemotherapy and had undergone intake, melena, hematemesis, etc. The patient had had a previous introduction of a left JJ (pig-tail) Therefore, the upper endoscopy was history of progressive and infiltrating stent, due to the long-standing com - not indicated. The pre- and postoperative helical CT was performed with a 64-detector CT scanner (Toshiba, TS_Aquillion64). From: 1. Faculty of Medicine, Department of Cellular Physiology and Metabolism, Portal-venous phase images were Anatomy Sector, University of Geneva, Geneva, Switzerland, 2. Vestfold Hospital Trust, obtained after contrast media Department of Surgery, Tonsberg, Norway, 3. Department of Digestive Surgery, administration (320 mg/ml, 80 ml), Akershus University Hospital, University of Oslo, Lørenskog, Norway. Address for correspondence: Dr B.V. Stimec, M.D., Ph.D., Faculty of Medicine, using a power injector at a rate of Department of Cellular Physiology and Metabolism, Anatomy Sector, University of 2.5 ml/s. The CT parameters were as Geneva, Rue Michel-Servet 1, 1211 Geneva, Switzerland. follows: pitch was 0.828, tube volt - E-mail: [email protected] age 120 kV, maximum tube current stimec-_Opmaak 1 23/10/12 16:38 Pagina 303 GASTRIC VARICES WITHOUT PORTAL HYPERTENSION — STIMEC et al 303 A Fig. 3. — Grayscale outline of the LIVC. Captions: ILV – com - mon trunk for iliolumbar / left ascending lumbar vein; LRV – left renal vein, LOV – left ovarian vein; LIPV – left inferior phrenic vein. Other captions as in Figure 2. testinal cancer, with enlarged paraaortic lymph nodes. During this B period the patient was also diag - nosed with an aggressive leukemia Fig. 2. — A. 3D volume rendering. CT – celiac trunk, LIVC – left and died shortly thereafter due to inferior vena cava (ur – upper root, lr – lower root), SMA – supe - rior mesenteric artery, SMV – superior mesenteric vein, SV – sepsis. splenic vein, PV – portal vein, RIVC – right inferior vena cava. The CT disclosed a 10 mm by B. Detail from Fig. 2 A: arborization of the upper part of LIVC 10 mm gallstone in the gallbladder, with tortuous gastric varices. otherwise the liver and the bile ducts were considered normal. The bipolar diameter of the spleen was 11.7 cm, and the calibers of the splenic vein, 250 mAs, 3 mm reconstructed sec - superior mesenteric vein and the tion thickness, 3 mm reconstruction interval. Analysis was performed by means of 2D multiplanar reconstruc - tion with maximum intensity projec - Table I. — Morphometry of the persistent LIVC. tion and 3D volume rendering tech - nique using the Osirix algorithm. Skeletotopy Caliber (cm) Length (cm) In the later clinical follow-up, Upper root L2 / L3 0.884 4.330 diagnostic imaging revealed a tumor Lower root L3 (lower half) 0.646 5.771 in the distal ileum, highly suspicious Trunk L3 – T12 / L1 1.039 10.144 of a local recurrence of her gastroin - stimec-_Opmaak 1 23/10/12 16:38 Pagina 304 304 JBR–BTR, 2012, 95 (5) portal vein were 0.872 cm, 0.840 cm Discussion cardinal vein systems are relatively and 0.976 cm, respectively (Fig. 1). isolated (5, 7-9). On the other hand, Both the pre- and postoperative The embryogenesis of the IVC is a the duplication of the vena cava may CTs revealed a vessel located left to composite process, with some also be associated with a retrocaval the aorta, consistent with a persist - stages still uncertain or under ureter, which descends between the ent left inferior vena cava (LIVC). Two debate. It is based on sequential for - venae cavae and the aorta (4). In our venous rootlets emerged from the mation, regression, anastomosing case, no congenital anomalies of the dorsal surface of the regular right and fusion of multiple paired axial urinary system were observed. IVC, passed to the left retro-aortical - venous channels: postcardinal, sub - Further, taking into account the cau - ly, and merged into the trunk of LIVC cardinal, supracardinal, azygos and docranial direction of the blood flow (Fig. 2). subcentral. The double IVC derives for the ovarian vein and the iliolum - There were four notable tributar - from the persistence of both the bar vein, it would be unlikely that the ies/branches to the LIVC (Fig. 3 and right and left supracardinal veins. initial gynecological operation has 4, Table I): Although the left IVC is considered to elicited the development of a collat - be strictly subrenal (3-5, 7, 8), there eral venous channel. – common trunk for iliolumbar / left are extremely rare reports of its The ratio between the two IVC cal - ascending lumbar vein; supra renal hemiazygos continua - ibers has not been often addressed – stump of the left ovarian vein; tion (9). In the case reported by Lao in the literature, only with regard to – left renal vein; and et al. (10), the left vena cava crossed the determination of duplication – left inferior phrenic vein the midline to the right and emptied type (2) or the regression of the right The first branch (common trunk into the azygos vein. IVC (5). Our case shows the persist - for iliolumbar / left ascending lumbar Embryologic changes affecting ent LIVC to have a caliber approxi - vein) emerged from the lower root the veins are considered to also mately one-third of its counterpart. and not from the LIVC trunk itself. In induce variations in lymphatic The most enigmatic part of our the upper abdomen, the LIVC took a drainage (1). LIVC case was its cranial portion. tortuous course, passing at first With regard to the two IVC conflu - Unlike the reports in which the per - between the spleen and the ence and/or anastomoses, the LIVC sistent LIVC continues the hemiazy - diaphragm, then curving below the crosses the aorta anteriorly (5, 7, 8), gos course and opens into the coro - inferior splenic border and terminat - or posteriorly (4), at the level of the nary sinus (5), in our case the per - ing in an irregular network in the left renal vein. A highly positioned sistent vessel did not traverse the posterior region of gastric fundus, preaortic crossing may lead to inter - diaphragm. Instead, it dispersed in a close to the splenic hilum (Fig. 2B). mittent celiac trunk compression network in the region of gastric fun - In relation to the gastric wall, this syndrome (3). Our case had two dus, resembling the MDCT picture of network was found to lie extramural - retroaortic roots connecting the right gastric varices (11). It has been noted ly (Fig. 4). According to the Sarin and left IVC at the levels of second that, unlike the cardiac veins and classification, these gastric varices and third lumbar vertebra, respec - varices which are continuous with would correspond to group IGV-1.