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Ann Thorac Surg 1996;61:1253-1255
© 1996 The Society of Thoracic Surgeons

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Case Report

Azygos Vein Aneurysm: Contribution of Transesophageal Echography

Departments of Pneumology, Gastroenterology, and Thoracic and Cardiovascular Surgery, Centre Hospitalier Régional and Universitaire de Rennes, Rennes, France

Accepted for publication October 20, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We report a case of idiopathic aneurysm of the azygos vein associated with lung cancer. This abnormality is exceptional because we could find only 8 previous published cases. Computed tomographic scan and especially transesophageal echography were of major importance in identifying the vascular nature of the radiographic abnormality and thus excluding extension of lung cancer.

	Introduction

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Aneurysms of the azygos vein are a rare cause of mediastinal widening. They usually result from venous dilatation due to abnormal vascular drainage encountered in patients with portal hypertension or venous malformations. Idiopathic aneurysms are much more exceptional, and the diagnosis is usually made by operation. We observed a case of azygos vein aneurysm associated with lung cancer. The computed tomographic and transesophageal echographic findings strongly suggested formation of liquid before operation.

A 70-year-old man who was taking oral anticoagulants (acenocoumarol) was hospitalized for investigation of a hematoma involving the pectoralis major. Five years earlier, he had undergone coronary revascularization of the left anterior descending coronary artery with an internal mammary artery bypass graft and of the right coronary artery and the circumflex artery with venous bypass grafts. The postoperative period had been uneventful, and follow-up standard chest radiographs were considered normal.

The pectoral hematoma had developed after minimal exercise in a period of antivitamin K overdose (prothrombin rate was 12%). Abnormal chest radiographs prompted transfer to our unit for further investigations.

At admission, the patient was in good general health with no sign of functional respiratory impairment. Except for the coronary bypass operation, his past medical history was uneventful. Physical examination was normal except for the pectoral hematoma, which was healing. There was no sign of portal hypertension, abnormal collateral circulation, or edema. Chest radiograph revealed a dense, well-limited 3-cm opacity in the right upper lobe and widening of the upper mediastinum. On computed tomographic scan (Fig 1), the opacity in the right upper lobe was seen as a parenchymal 3 x 3-cm homogeneous tissular mass. The mediastinal opacity extended vertically over 7 cm. It was clearly distinct from the esophagus and closely associated with the azygos arch. Its density was 45 Hounsfield units, and slight enhancement occurred after injection of contrast medium. Fiberoptic bronchoscopy showed only widening of the right upper lobe division, with no malignant cells revealed by biopsies or aspiration. Due to the proximity to the esophagus, transesophageal echography (EUM20; Olympus) was performed and confirmed the anechogenic nature of the mediastinal abnormality. It was clearly distinct from the esophageal wall, seen as the classic fine-layers pattern, and appeared to compress the azygos arch (Fig 2). The examination also demonstrated that the mediastinal abnormality and azygos vein were contiguous just below the arch (Fig 3). Because of the suspicion of lung cancer in the right upper lobe, a thoracotomy was planned.

View larger version (125K): [in this window] [in a new window]   Fig 1. . Computed tomographic scan showing mediastinal formation, behind main bronchi, distinct from esophagus, slightly enhanced by contrast injection.

View larger version (122K): [in this window] [in a new window]   Fig 2. . Echoendoscopic view of anechogenic mass (M), distinct from the esophageal wall, in close contact with the azygos arch (arrowhead), under the aorta (A). (T = transducer.)

View larger version (93K): [in this window] [in a new window]   Fig 3. . Echoendoscopic view of anechogenic mass (M) connected with the azygos vein (arrow). (A = aorta; T = transducer.)

	Comment

Top Footnotes Abstract Introduction Comment References

 
Aneurysms of the azygos vein are rare causes of mediastinal widening. In a review published in 1979, Siddorn and Worsornu [1] could find only 16 cases in the British medical literature.

Most cases occur in patients with vascular diseases: portal hypertension, heart failure, malformations of the inferior vena cava including partial or total agenesia, or obstruction of the inferior vena cava by a tumor or other cause (lymph node). In such cases, dilatation is directly related to major increase in blood flow because the azygos and hemiazygos veins form a collateral system. Diagnosis is often achieved by means of computed tomographic scan and vascular explorations [2].

Idiopathic aneurysms are by far the rarest; we found only 8 previous published cases [1, 3, 4]. Most have been observed fortuitously. In 1 case, there were signs of superior vena cava compression [3], but like all the other cases, the precise diagnosis was only achieved after thoracotomy. Vascular explorations suggested an aneurysmal pathology of the superior vena cava, as in the case reported by Seebauer and associates [4], who suggested an aneurysm based on computed tomography and magnetic resonance imaging but were unable to identify the precise structure involved. In one case of aneurysm of the hemiazygos, the diagnosis could be made by means of computed tomographic scan alone [5]. Our case was associated with lung cancer, but no relation between these two disorders could be established, even after thoracotomy.

The spontaneous course of these aneurysms is unknown because surgical repair was performed in all reported cases. It must be emphasized, however, that in all but 1 case there was no clinical expression.

Our report points to the ability of venous aneurysms to simulate mediastinal tumors and the usefulness of transesophageal echography for exploring the mediastinum [6, 7]. We used transesophageal echography to establish the vascular nature of the mediastinal abnormality and to suggest the diagnosis of azygos aneurysm.

	Footnotes

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Address reprint requests to Dr Delaval, Service de Pneumologie, Centre Hospitalier Régional et Universitaire de Rennes, 35033 Rennes Cedex, France.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Siddorn JA, Worsornu L. Dilatation of the azygos vein simulating a mediastinal tumour. Thorax 1979;34:117–9.[Abstract/Free Full Text]
2. Dudiak CM, Olson MC, Posniak HV. CT evaluation of congenital and acquired abnormalities of the azygos system. Radiographics 1991;11:233–46.[Abstract]
3. Barraine R, Gasquet C, Cabrol C, Tournoux B, Bordage JP, Bonneau A. Les anévrysmes de la veine azygos. Arch Mal Coeur 1981;6:755–9.
4. Seebauer L, Prauer HW, Gmeinwieser J, Sebening F. A mediastinal tumor simulated by a sacculated aneurysm of the azygos vein. Thorac Cardiovasc Surg 1989;37:112–4.[Medline]
5. Hayward I, Forrest JV, Sagel SS. Hemiazygos vein aneurysm: CT documentation. J Comput Assist Tomogr 1989;13:1072–4.[Medline]
6. Ayala K, Chandrasekaran K, Karalis DG, Parris TM, Ross JJ. Diagnosis of superior vena caval obstruction by transesophageal echocardiography. Chest 1992;101:874–6.[Abstract/Free Full Text]
7. Kondo D, Imaizuni M, Abe T, Naruke T, Suemasu K. Endoscopic ultrasound examination for mediastinal lymph node metastases of lung cancer. Chest 1990;98:586–93.[Abstract/Free Full Text]

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