A case report of an interrupted inferior vena cava and azygos continuation: implications for preoperative screening in minimally invasive cardiac surgery

Abstract

Background Femoral cannulation is commonly used in minimally invasive cardiac surgery to establish extracorporeal circulation. We present a case with a finding that should be evaluated when screening candidates for minimally invasive cardiac surgery. Case presentation A 57-year-old male patient was scheduled for minimally invasive repair of the mitral and tricuspid valve and a MAZE-procedure. During surgery there was difficulty advancing the venous cannula inserted in the right femoral vein. On transesophageal echocardiography a guidewire advanced from the femoral vein was observed entering the right atrium from the superior vena cava. Despite inserting a second venous cannula in the jugular vein, venous drainage was insufficient for minimal invasive surgery. The approach was converted to a median sternotomy with bicaval cannulation. Re-examination of the preoperative computed tomography scan showed an interrupted inferior vena cava with azygos continuation. Discussion In patients with major venous malformations such as the interrupted inferior vena cava with azygos continuation a full sternotomy is the preferred approach. The venous system should be evaluated when screening candidates for minimally invasive mitral valve surgery with preoperative computed tomography. Additional cues to suspect interruption of the inferior vena cava are polysplenia and a broad superior mediastinal projection on the chest radiograph, mimicking a right paratracheal mass.

Case Report: Incidental finding of an atresia of the inferior vena cava—a challenge for cardiac surgery

“…Cetinkaya et al reported a case of a 61-year-old man with mitral and tricuspid valve replacement and an abnormal intraoperative IVC finding requiring conversion from a minimally invasive approach to a full sternotomy ( 5 ). Knol et al describe a similar case of a 57-year-old man with mitral and tricuspid insufficiency where a full sternotomy was also required after initially starting with a minimally invasive approach for valve reconstruction ( 6 ). In both cases, additional cannulation of the femoral vein was required for adequate venous drainage.…”

Extensive Deep Vein Thrombosis With Intraabdominal Extension Triggered by Oral Contraceptive Use in a Young Patient With Interrupted Inferior Vena Cava With Azygos Continuation: A Case Report

“…The azygous vein is derived from the supra-cardinal [ 9 , 10 ]. Agenesis or failed fusion of these segments can lead to interruption of the IVC [ 11 ].…”

Interrupted inferior vena cava syndrome discovered incidentally after minimally invasive mitral valve repair in a 31-year-old female patient: A case report

“…However, in some cases, the patient may have an interruption of the IVC, which can complicate the procedure. Preoperative imaging, such as CT, can be used to confirm safe femoral cannulation [ 2 ].…”

“…Multidetector row computed tomography (MDCT) and magnetic resonance imaging (MRI), are reliable non-invasive techniques for identifying IVC anomalies, accurately depicting the anatomy and variations of the IVC, and detecting any associated anomalies [ 3 ]. Additionally, physical examination and patient history, including polysplenia or a wide mediastinum, can also offer clues to IVC anomalies [ 2 ].…”

“…In MICS, a left or right mini-thoracotomy is used to achieve access to the heart [ 1 ]. Femoral cannulation is frequently performed during this procedure to establish extracorporeal circulation [ 2 ]. Presence of IVC interruption may lead to difficult or unsuccessful cannulation, so surgeons should be aware of such anomalies prior to surgery [ 3 ].…”