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Ann Thorac Surg 1997;63:1167-1169
© 1997 The Society of Thoracic Surgeons

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Case Report

Giant Azygos Vein Varix

Division of Cardiothoracic Surgery, University of Illinois at Chicago, Chicago, Illinois

Accepted for publication November 12, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Primary anomalies of the azygos vein generally result from intrathoracic tumor compression or inferior vena caval interruption with azygos vein continuation. Vascular malformations, although uncommon, can frequently mimic solid tumors and present as middle or posterior mediastinal masses. We present the case of an isolated giant azygos vein varix in an asymptomatic patient. Preoperative computed tomography and magnetic resonance imaging were not diagnostic in evaluating this patient's anatomy.

	Introduction

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A 68-year-old woman presented to her primary care physician for routine physical examination. No weight loss, hemoptysis, or cough were reported, along with no exposure to tuberculosis, asbestos, or other occupational carcinogens. Physical examination showed a mildly obese woman in no distress with clear lung fields on auscultation and a regular heart rhythm with no murmurs or gallops. Chest roentgenography yielded a new soft tissue shadow along the right heart border, which on lateral projection appeared to be located posterior to the trachea.

Magnetic resonance imaging of the chest demonstrated a smooth, homogeneous mass measuring 3 x 3 x 4 cm without evidence of compression of adjacent vascular structures or airway compromise (Fig 1). Bronchoscopic examination showed no endobronchial lesion. Computed tomography 3 months later revealed enlargement of the mass, without mediastinal adenopathy (Fig 2). Technetium-99m-methylene diphosphonate bone scan was negative for metastatic disease.

View larger version (108K): [in this window] [in a new window]   Fig 1. . Magnetic resonance image of the chest demonstrates a right hilar mass at the level of the azygos vein-superior vena cava confluence. The mass appears nonvascular and surrounded by lung parenchyma.

View larger version (142K): [in this window] [in a new window]   Fig 2. . Computed tomogram of the chest shows enlargement of the mass from 3 months prior without evidence of mediastinal adenopathy.

The postoperative course was uneventful, with the chest tube removed on the following day and the patient discharged on hospital day 4. Histologic evaluation of the specimen yielded flattened endothelial-like cells compatible with venous variceal dilation. Follow-up examination has been unremarkable at 1 year

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	Comment

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Differential diagnosis of a posterior mediastinal mass in an adult includes malignancy of the lung, lymphatic, nervous system, mesothelium; aneurysms or vascular malformations; and esophageal tumors or duplications. Azygos vein dilation is most frequently associated with inferior vena caval interruption, a congenital absence of the intrahepatic segment of the inferior vena cava wherein the azygos system dilates to accommodate visceral and lower extremity blood return to the right atrium. Chronic intraluminal pressure elevation can be secondary to increased forward blood flow or decreased efflux against an elevated right atrial pressure. Surgical azygos vein ligation or spontaneous occlusion in these situations produces disastrous results.

Less frequent causes of azygos vein dilation include cases of pulmonary sequestration with azygos drainage [1], venous pseudoaneurysm formation after chest trauma [2], or anatomic displacement from an azygos lobe [3]. Azygos vein enlargement secondary to isolated rupture or primary vascular neoplasia is extremely uncommon.

Primary varix of an isolated azygos vein segment is rare. In the literature are 2 previous case reports of asymptomatic masses located in the region of the right main bronchus that were found at thoracotomy to be azygos vein varices [4, 5]. One case of azygos vein varix associated with superior vena cava syndrome in the absence of malignancy has been described in the literature [6].

Computed tomography in this case was not helpful as contrast injection is timed to image arterial structures or large draining veins. Magnetic resonance, although it identified this anomaly as a soft tissue mass, was not able to clearly delineate the extension of the venous wall and thus make the diagnosis of a vascular structure. Other investigators have noted the shortcomings of magnetic resonance in evaluating this type of lesion [5], although direct bolus imaging has been used to quantitate azygos blood flow in cirrhotic patients [7]. Spiral and angiographic computed tomography have been successfully used to image an anomalous left brachiocephalic vein [8].

We do not support resection of intrathoracic malignant tumors with video-assisted thoracoscopic techniques. The video-assisted thoracoscopic approach was not used in this case given our high index of suspicion for malignancy. In retrospect, however, this azygos vein varix presented an ideal circumstance for application of the video-assisted thoracoscopic technique, which would certainly have been our choice if a diagnosis had been made preoperatively.

Primary vascular malformations should always be considered in the differential diagnosis of a mediastinal mass. The majority of adult non-malignancy-associated azygos vein dilation is secondary to syndromes of venous continuation. Pediatric patient populations with cardiac and visceral anomalies frequently have associated azygos vein abnormalities, with only rare cases of new or previously unrecognized pathology reported. Increasing use of spiral and angiographic computed tomography will increase preoperative diagnostic accuracy of these anomalies.

	Footnotes

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Address reprint requests to Dr Vigneswaran, Department of Cardiothoracic Surgery, University of Illinois Hospital, 840 S Wood St, M/C 958, Chicago, IL 60612.

	References

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1. Trigaux JP, Jamart J, Van Beers B, Goncette L, Pringot J. Pulmonary sequestration. Visualization of an enlarged azygos system by CT. Acta Radiol 1995;36:265–9.
2. Jain A, Blebea JS. Post-traumatic pseudoaneurysm of the azygous vein in a patient with azygous continuation. J Comput Assist Tomogr 1994;18:647–8.
3. Agrawal GG, Gandhi MS, Gandhi SD. Excessive anteriorisation of the superior vena cava associated with an azygos lobe. Surg Radiol Anat 1995;17:173–5.
4. Paramanathan A, Bapatla AS, Padmanabhan K, et al. An unusual cause of a right paratracheal mass. Chest 1994;106:1867–8.
5. Kurihara Y, Nakajima Y, Ishikawa T. Case report: saccular aneurysm of the azygous vein simulating a paratracheal tumor. Clin Radiol 1993;48:427–8.
6. Seebauer L, Prauer HW, Gmeinwieser J, et al. A mediastinal tumor simulated by a saccular aneurysm of the azygous vein. Thorac Cardiovasc Surg 1989;37:112–4.
7. Nabeshima M, Moriyasu F, Nishikawa K, et al. Azygos venous blood flow: measurement with direct bolus imaging. Radiology 1995;195:467–70.
8. Kim HJ, Kim HS, Lee G. Anomalous left brachiocephalic vein: spiral CT and angiographic findings. J Comput Assist Tomogr 1994;18:872–5.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ari O. Halldorsson Wickii T. Vigneswaran Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Podbielski, F. J. Articles by Vigneswaran, W. T. Search for Related Content PubMed Articles by Podbielski, F. J. Articles by Vigneswaran, W. T.