Interrupted Inferior Vena Cava and Duplicated Superior Vena Cavae Identified During Catheter Ablation

Figures

• 

  Figure 1. Contrast-Enhanced Coronal CT Image in Soft Tissue Window Through the IVC and Abdominal Aorta Depicting the Interrupted IVC (Red Arrows) CT = computed tomography; IVC = inferior vena cava.

• 

  Figure 2. CT and Radiologic Depiction of Thoracic and Abdominal Venous Anomalies (A) Contrast-enhanced coronal CT image in soft tissue window through the azygos and aortic arches and (B) Posteroanterior chest radiograph demonstrating a dilated azygos vein measuring 16 mm in diameter. (C) Contrast-enhanced axial chest CT image in soft tissue window through the aortic arch after right upper extremity contrast injection demonstrating duplicated SVCs, including a right SVC (yellow arrow) and persistent left SVC (blue arrow), with a dilated azygos vein (green arrow) adjacent to the aortic arch (red arrow). (D) Contrast-enhanced 90-mm thickness coronal CT maximum intensity projection image in bone window after left upper extremity contrast injection demonstrating drainage of the persistent left SVC into a markedly enlarged coronary sinus. (E) Contrast-enhanced 20-mm thickness axial CT maximum intensity projection image in soft tissue window through the inferior cavoatrial junction (red arrows) depicting hepatic veins draining directly into the right atrium. Dilated azygos (blue arrow) is positioned right of the aorta at the level of the hiatus. CT = computed tomography; SVC = superior vena cava.

• 

  Figure 3. Normal vs Abnormal Thoracic and Abdominal Venous Anatomy (A) Normal thoracic and abdominal venous anatomy, including the hepatic (green), renal (purple), infrarenal (orange), and iliac (yellow) venous segments. (B) Abnormal venous anatomy demonstrating absence of the hepatic segment of the IVC, with preserved renal (purple), infrarenal (orange), and iliac (yellow) segments. Additional findings include azygos continuation from an interrupted IVC (red), duplicated SVCs with a persistent left SVC draining into a markedly enlarged coronary sinus (blue), and anomalous hepatic venous drainage, with the right hepatic vein draining directly into the right atrium and the left hepatic vein draining into the coronary sinus (brown). IVC = inferior vena cava; SVC = superior vena cava; RA = right atrium; RV = right ventricle; v. = vein.

• 

  Figure 4. Embryologic Development of the Abdominal Venous System (A) Early embryonic venous architecture composed of bilateral anterior and posterior cardinal veins, vitelline veins, and umbilical veins. (B) Intermediate stage demonstrating emergence of the subcardinal system, with formation of the hepatic segment of the IVC from the vitelline vein. (C) Abnormal development illustrating 2 venous anomalies: failure of hepatic segment formation resulting in an interrupted IVC with subsequent azygos continuation (red dashed lines), and persistence of the left anterior cardinal vein forming a left persistent superior vena cava draining into the coronary sinus (green circle). IVC = inferior vena cava; v. = vein.

• 

  Figure 5. Normal Embryologic Development of the Thoracic Venous System vs Left Persistent SVC Development (A) Normal embryologic development of the thoracic venous system. The left anterior cardinal vein regresses, leaving behind the oblique vein of the left atrium (purple), which drains into the coronary sinus. The SVC forms from the right anterior and common cardinal veins. (B) Left persistent SVC due to failure of regression of the left anterior cardinal vein. The resulting left SVC (purple) drains into an enlarged coronary sinus. The right SVC remains present, forming a duplicated SVC configuration. IVC = inferior vena cava; SVC = superior vena cava; v. = vein.

• 

  Visual Summary. Summary of Diagnostic Evaluation, Management, and Anatomic Delineation in a Patient Presenting With Palpitations and Near Syncope Initial work-up suggested supraventricular ectopy refractory to medical therapy, prompting attempted catheter ablation. The procedure was aborted given inability to achieve conventional femoral venous access. Subsequent computed tomography angiography revealed an interrupted intrahepatic IVC (red arrows) with azygos continuation and duplicated SVCs, including a persistent left SVC draining into an enlarged coronary sinus. ECG = electrocardiogram; IVC = inferior vena cava; MRI = magnetic resonance imaging; RA = right atrium; RV = right ventricle; SVC = superior vena cava; v. = vein.