Duplicate inferior vena cava in liver transplantation: A note of caution when left renal vein ligation is needed

Abstract

In the case of a hemodynamically significant splenorenal shunt (SRS; spontaneous [5%-12%] (1) or surgical), ligation of the left renal vein (LRV) at its root into the inferior vena cava (IVC) is indicated during liver transplantation (LT) in the following 2 situations:1. To improve the flow through portoportal anastomosis and prevent portal blood steal through the splenorenal siphon. (2,3) 2. To perform renoportal anastomosis in case of stage IV portal vein thrombosis. (4)(5)(6) In this setting, the presence of a duplicate IVC should be diagnosed up front because inadvertent ligation of the duplicate left IVC misdiagnosed with the LRV might result in extensive thrombosis of the left IVC, iliac, and leg deep veins.We report here, for the first time, a case of a cadaveric LT in a recipient with large SRS where a duplicate left IVC was ligated inadvertently. Case ReportA 55-year-old man with hepatocellular carcinoma and alcoholic cirrhosis was referred to our department for LT. This patient had severe portal hypertension and recurrent episodes of hepatic encephalopathy. Preoperative computed tomography (CT) showed a large patent SRS (Fig. 1A). Upon Doppler ultrasonography (DUS), the portal vein was patent with hepatofugal monophasic flow diverted to the SRS. The LT procedure's plan included preservation of the native IVC and ligation of the LRV to optimize the portal vein flow during LT and to prevent any blood steal through the SRS siphon. (3) At the time of surgery, the LRV was approached by following the infrahepatic IVC downward. The vein identified as the LRV at its root into the IVC was taped. No mobilization of the right colon or Kocher maneuver was required. Following portal reperfusion (cold ischemia time 5 5 hours), the portal flow upon DUS showed drastically improved portal flow upon clamping of the taped vein. This was subsequently ligated. Arterial and biliary reconstructions were then performed as usual. At postoperative day 1, a massive left leg edema was found. DUS revealed thrombosis extending from the left iliac vein to the left femoral vein. CT diagnosed the duplicate IVC (Fig. 1B) and extensive thrombosis of the left IVC from its ligation on the left border of the right IVC to the left femoral vein (Fig. 2). Retrospective analysis of the pretransplant CT demonstrated that the anatomical variation was already visible: the left-sided inferior vena cava (L-IVC) ran parallel to the left side of the abdominal aorta to receive the LRV and then crossed the aorta anteriorly to join the contralateral right-sided inferior vena cava (R-IVC) and to drain into a common suprarenal IVC (Fig. 1B). Curative anticoagulation was initiated. At 9 months, the patient is alive with normal DUS and no sequelae. The left iliac vein and IVC are partially repermeabilized.Abbreviations: CT, computed tomography; DUS, Doppler ultrasonography; IVC, inferior vena cava; L-IVC, left-sided inferior vena cava; LRV, left renal vein; LT, liver transplantation; R-IVC, right-sided inferior vena cava; SRS, splenorenal shunt. Address re...

Images – Duplicated inferior vena cava

“…2,3 As an example, one case report showed that a misdiagnosis of the left IVC as the left renal vein and subsequent inadvertent ligation of the left IVC led to deep vein thrombosis in the iliac and deep leg veins. 4 Preoperative identification is especially important for renal surgery, done by laparoscopic approaches, where a limited field of view can pose challenges for the identification of vascular anomalies. 2 IVC duplication is most often discovered incidentally upon radiologic investigation.…”

Anomalias Congênitas De Veia Cava Inferior E Suas Implicações Para Transplante De Fígado: Uma Revisão Integrativa Da Literatura

“…Pode haver também outras variações, como VCI direita dupla ou VCI esquerda dupla, além de VCI dupla com continuação do hemiázigo da veia cava esquerda. 1,2,4,5 Essa condição, geralmente assintomática, pode gerar complicações na colocação do filtro de veia cava, e podendo também ser confundida com um linfonodo, tendo por isso, implicações clínicas. Além disso, pode estar associada a várias outras malformações, vasculares e não vasculares, havendo, também, um risco aumentado de eventos tromboembólicos.…”

“…Nesse processo, podem ocorrer malformações anatômicas raras, usualmente assintomáticas, sendo um achado incidental em exames de imagem, principalmente através de Tomografia Computadorizada (TC), podendo ser erroneamente diagnosticadas como massas, levando a um tratamento incorreto. [1][2][3][4][5][6][7]…”