Oesophagectomy in a patient with azygos vein continuation of the inferior vena cava: report of a case
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Abstract:
The azygos system of veins varies greatly in its mode of origin, but the variation in which the azygos vein is a continuation of the inferior vena cava (IVC) is rare. During an oesophagectomy, the azygos vein typically is transected as a requirement of the surgery. In this case, the enlarged azygos and its arch were a continuation of the IVC. During our procedure, we first established a bypass between the right femoral vein and the jugular vein in case of injury to the azygos vein, and we then performed a McKeown oesophagectomy without transecting the azygos vein. Our experience suggests that an oesophagectomy in cases with an azygos vein continuation of the IVC is feasible. An adequate medical examination and careful reading of the imaging is crucial for the safety of these surgical procedures. An appropriate surgical approach should be selected according to the location of the tumour, the size of the tumour and its anatomical features. The establishment of a veno-venous bypass and protection of the azygos arch in patients whose azygos vein is a continuation of IVC is necessary.Keywords:
Azygos vein
Azygos vein
Vena cava
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Azygos vein
Venous access
Port (circuit theory)
Internal jugular vein
Central venous catheter
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Azygos vein
Brachiocephalic vein
Right gastric vein
Left Pulmonary Vein
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The effects of superior vena cava obstruction vary according to the degree and location of the obstruction and the suddenness of its development. To determine the tolerance of animals to this condition, to measure the effect on venous pressure and to trace the paths of collateral circulation, experimental obstruction of the superior vena cava was produced in dogs. The vein was exposed through an intercostal incision and completely occluded by dividing between ligatures. The usual aseptic technique was followed and the operations were performed under intratracheal ether anesthesia administered with positive pressure. Obstructions were of 2 types, (1) above the junction of the azygos vein, and (2) including the azygos vein. Two attempts were also made to obstruct the superior vena cava below the junction of the azygos vein but both dogs died within a few minutes. Obstruction above the level of the azygos vein was produced in 7 dogs. One died within 24 hours and 3 died within 12 to 14 days as a result of a propagating thrombus or an empyema. Three recovered. Of the latter, one was sacrificed for study after 30 days. Another was later subjected to azygos vein obstruction and the third is alive after more than 5 months. One dog survived the immediate effects of a 2-stage obstruction of the superior vena cava and azygos vein but died at the end of 21 days from an infected bilateral pleural effusion. The most striking general results of superior vena cava obstruction were cyanosis of the tongue and oral mucosa and injection of the conjunctivae. Somnolence, listlessness and slow deep respirations were also noted. The dogs with obstruction just above the right atrium, dying within a few minutes, had extreme cyanosis of the upper part of the body.
Azygos vein
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Blood samples from the superior vena cava (SVC) are usually considered an acceptable representation of mixed systemic venous return in identifying and quantifying left-to-right atrial shunts. However, if during sampling from the SVC unrecognized entrance of the catheter into the azygos vein takes place, diagnostic errors may result. Blood samples from the azygos vein were collected from 60 children with congenital heart disease and the oxygen saturations ranged from 20% to 92%. These saturations were compared to those of samples taken from the superior vena cava above the entrance of the azygos vein. No substantial difference (saturation within ±4%) was found in 24 patients, while 28 patients had a significantly higher saturation in the azygos vein (from +5% to +21%) and eight patients had a lower saturation (from –5% to –16%). A significant left-to-right shunt may be overlooked or erroneously thought to be present when sampling of blood takes place unknowingly from the azygos vein. Examples are presented. Approaching from the groin it was possible to catheterize the azygos vein in two thirds of the cases when a deliberate attempt was made to do so.
Azygos vein
Oxygen Saturation
Venous blood
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Obstruction of the blood flow from the superior vena cava (SVC) to the right atrium causes the SVC syndrome. The azygos system is the most important way to overcome SVC obstruction. Azygos vein enlargement can be seen secondary to the SVC syndrome. Although a few cases showing 18 F-FDG uptake along the SVC in SVC syndrome were reported before, 18 F-FDG PET/CT findings of azygos vein enlargement have not been documented yet. Herein, we presented an intriguing case of azygos vein enlargement secondary to SVC syndrome on 18 F-FDG PET/CT.
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The superior vena caval syndrome has been recognized since 1757, at which time William Hunter described a case secondary to aortic aneurysm. Individual case reports have appeared since, and in the past thirty years, larger series have been reported. Despite this two-hundred-year history, uniformity of opinion as to the best method of therapy of the syndrome is still lacking. The anatomy of the superior vena cava adequately explains the clinical picture which results from obstruction or compression of this vessel. It drains venous blood from the head and neck and the thoracic wall. Of considerable importance is the fact that the lower half of the superior vena cava is enclosed within the fibrous layer of the pericardium. Its main tributary is the azygos vein which arises at the level of the renal veins and ascends the posterior mediastinum to join the superior vena cava at the level of the second costal cartilage. Obstruction to the superior vena cava may occur at three sites: (a) above the entrance of the azygos vein, with the azygos vein and proximal superior vena cava patent; (b) at the junction of the azygos vein with the superior vena cava; (c) proximal to the entrance of the azygos vein into the superior vena cava. The superior vena cava is particularly vulnerable to obstruction because it is a thin-walled, low-pressure vessel locked in a tight compartment and surrounded by nodes, bronchi, and aorta. A slowly developing obstruction such as that seen with benign lesions is tolerated well; a rapidly developing obstruction, as with malignant lesions, is tolerated poorly. The symptoms of the superior vena caval syndrome are due to venous hypertension in the areas normally drained by the vessel or its tributaries. They will vary in severity depending on the degree, location, and rapidity of the obstruction, as well as on the development of a collateral circulation. The elevated venous pressure causes edema to develop in the organs and tissues drained by the superior vena cava. A major principle of therapy, therefore, is to reduce the edema and thereby relieve most of the symptoms as rapidly as possible. This is especially so in those patients with the “wet-brain” syndrome, characterized by drowsiness, stupor, unconsciousness, and seizures. It is well established that cellular edema is one of the early tissue reactions to radiotherapy. This usually can be avoided if radiation therapy is begun with small doses which are gradually increased with the patient's response. It may take many days before an effective amount of therapy can be delivered to the tumor or to the lymph nodes causing the caval obstruction. Other measures, such as intensive diuresis with mercurials, a low-salt diet, and maintenance of the patient in a head-elevated position for as much of the time as is possible, may help to reduce the disturbing edema, but will do nothing to relieve the cause of the obstruction.
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Effects of acute occlusion of superior vena cava were studied in dogs. Occlusion of superior vena cave was made by catheter with inflatable baloon inserted into superior vena cava via jugular vein. Following results were obtained. 1) Azygos vein played the most important role as collateral circulation when superior vena cava was occluded. 2) A steady state of circulatory hemodynamics was reached about 30 minutes after acute occlusion of superior vena cava at the point distal to azygos vein and then gradually retnrned to normal state in accordance with complete development of collateral circulation. 3) Marked changes in circulatory hemodynamics developed when superior vena cava and azygos vein were concomitantly occluded. Dogs, whose azygos vein had been divided one week ago, died whthin 70 to 90 minutes on acute occlusion of superior vena cava.
On the contrary, dogs, whose azygos vein had been divided two weeks ago, survived two hours' occlusion of superior vena cava. However, cardiac output did not return to preocclusion level even 20 minutes after release of occlusion. 4) The cause of death in the case of acute occlusion of superior vena cava including azygos vein was supposed to be central nature due to functional loss of central nervous system.
Azygos vein
Collateral circulation
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Objective To observe enhancement of CT imagining of systemic-to-pulmonary venous shunts in patients with superior vena cava syndromes(SVCS).Also to analyze the notable and reoccurring characteristics of systemic-to-pulmonary venous shunts.Methods Divide 33 SVCS patients into three groups according to the position of blocking: position of blocking above the azygos vein,position of blocking below the azygos vein,position of blocking above and below the azygos vein.Also divide 33 SVCS patients into two groups according to pleural thickening or not.Results There are 7 patients in the group of blocking above the arch of azygos vein,9 patients in the group of blocking below the arch of azygos vein,and 17 patients in the group of blocking above and below the arch of azygos vein.There are 10 patients in the group of pleural thickening and 23 patients in the group of pleural not thickening.Conclusion Systemic-to-pulmonary venous shunts in superior vena cava obstruction commonly shows in two forms of on computer tomography.Shunts occurrence are closely related to position of blocking in superior vena cave and pleural thickening or not,it frequently occurs in the group of blocking above and below the arch of azygos vein in the group of pleural thickening.
Azygos vein
Pleural thickening
Blocking (statistics)
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A 43-year-old woman was referred to our hospital for an abnormal shadow on chest X-ray. Computed tomography revealed a tumor with calcification of 9.8 cm in size at the anterior mediastinum. The infiltration into the left brachiocephalic vein and superior vena cava by tumor was suspected. Surgery was performed under a diagnosis of mature teratoma. The tumor was found to adhere firmly to superior vena cava (SVC), left brachiocephalic vein, right phrenic nerve, and the arch of the azygos vein. To ensure the blood flow, an artificial blood vessel was placed between left brachiocephalic vein and right atrium. Then SVC was clamped and the tumor was resected with the part of SVC.
Azygos vein
Brachiocephalic artery
Brachiocephalic vein
Phrenic nerve
Mediastinal tumor
Jugular vein
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