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Ann Thorac Surg 2007;84:661-663
© 2007 The Society of Thoracic Surgeons

Case Reports

Dual Inferior Vena Cava: Two Inferior Vena Cava Filters

Zubair A. Hashmi, MD*, Gregory G. Smaroff, MD

Western Reserve Care System/NEOUCOM, Northside Medical Center, Youngstown, Ohio

Accepted for publication March 23, 2007.

* Address correspondence to Dr Hashmi, Western Reserve Care System/NEOUCOM, Northside Medical Center, 500 Gypsy Ln, Suite 200, Youngstown, OH 44505 (Email: z_hashmi{at}yahoo.com).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
The formation of the venous drainage system of the human body is a complex process involving structures forming and regressing in a predefined order. Interruption of any one of these steps results in the formation of a congenital anomaly. Knowledge of these anomalies can prevent us from potential serious and sometimes fatal complications. Variations from the normal anatomy of the inferior vena cava (IVC) occur in 3% of the population. The complex embryology of the IVC stems from three pairs of fetal veins: (1) posterior cardinal veins, (2) subcardinal veins, and (3) supracardinal veins. The cardinal veins constitute the main venous drainage system of the embryo. Although venous anomalies are rare, their knowledge is crucial in diagnosis and treatment. These variations should not be mistaken for pathologic finding, but should be viewed as normal findings of abnormal embryogenesis. We present a case here identifying a dual IVC, subsequently leading us to place two IVC filters.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
The formation of the venous drainage system of the human body is a complex process involving structures forming and regressing in a predefined order. Interruption of any one of these steps results in the formation of a congenital anomaly. Knowledge of these anomalies can prevent us from potentially serious and sometimes fatal complications.

Errors in the embryogenesis of the inferior vena cava (IVC) can result in several anomalies. Congenital variations of the IVC originate during weeks 4 to 8 of embryogenesis of three paired veins: (1) posterior cardinal veins, (2) subcardinal veins, and (3) supracardinal veins [1]. Variations of the IVC can occur in 3% of the population [2, 3], with dual IVC being the most common [4]. Other variations include, but are not limited to, transposition of the IVC, circumaortic renal vein, retroaortic renal vein, and absence of the hepatic portion of the IVC.

These variations are often incidental surgical and radiologic findings. Computed tomography, magnetic resonance imaging, and ultrasound are all good methods of defining the anatomy; however a cava gram best delineates the course of the IVC [5, 6]. Radiologic mapping is necessary before attempting any invasive procedure requiring the IVC. Patency, size, and types of collateral venous pathways of the IVC must be assessed for proper therapeutic planning [6]. We present a case identifying a dual IVC, subsequently leading us to place two IVC filters.

The patient is a 70-year-old man who presented with increased cough and shortness of breath of 3 days duration. Symptoms were exacerbated with movements and activity. The patient had persistent hematuria for several days prior to admission. One month prior to this admission, the patient had a right foot pinning due to a traumatic injury.

Admission vitals were stable, with the patient on 3 L oxygen through nasal cannula breathing for 18 to 20 minutes. Radiologic workup of the patient revealed massive bilateral pulmonary embolisms on computed tomographic scan of the chest and right lower extremity deep venous thrombosis on ultrasound. In view of the hematuria, we proceeded to take the patient to the operating room for insertion of an IVC filter.

We initiated our insertion of the filter through the left common femoral vein; using a large gauge needle the vein was aspirated and the guidewire was placed. A guidewire was confirmed to be in the inferior vena cava by fluoroscopy. Then the catheter was placed using the Seldinger technique. Using fluoroscopy, the third vertebral body was identified. The patient had a normal creatinine (<1.0) level, so a venogram was done to identify the renal veins. We perform a venacavagram at the time of filter placement for patients with normal creatinine levels. With marginal creatinine levels we use half strength dye for the venacavagram.

At this time, after shooting the venogram, the inferior vena cava appeared to be approximately 1 to 1.5 cm in diameter. This seemed to be very small compared with the vertebral body. The venogram did show that the IVC was on the left side of the vertebral body, and then by vertebral body of T12 made a 90° turn to the right, and the dye then went superiorly toward the heart. There did seem to be some backflow of the dye coming down from the turning point. This contrast formed the letter "h," thus leading us to believe that there was another venous drainage coming into the inferior vena cava. Therefore we decided to leave the catheter in place and shoot another venogram from the right groin.

This venogram showed another IVC to the right of the vertebral body, with both inferior vena cavas joined approximately at the T12 level. Because we had one catheter in each IVC, we proceeded to place two IVC filters at the vertebral body L3 (Fig 1).


Figure 1
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  		Fig 1. Sagittal view of dual inferior vena cava with two filters.

 
Postoperatively the patient was sent for computed tomographic scan of the abdomen and pelvis to better delineate the IVC anatomy. Axial-sagittal-coronal cuts were performed. It seems that our patient indeed has two inferior vena cavas that confluence at level T12. Just proximally at T10 to T11, both renal veins joined the common IVC. Distally each IVC had its own internal and external iliac veins. Interestingly, after reviewing the computed tomographic scan we observed that both internal iliac veins joined and separated again in their respective directions (Fig 2). The large vasculature structure seen traveling in the middle of the "h" confluence, between the filters, on the sagittal image can be traced on the computed tomographic scan as being the abdominal aorta.


Figure 2
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  		Fig 2. Schematic drawing of the patient’s inferior vena cava (IVC) anatomy. (1 = common IVC; 2 = renal vein; 3 = IVC; 4 = internal iliac vein; 5 = external iliac vein.)

 
The rest of the hospital course was uneventful for the patient. He was seen by both the urology and pulmonary services. The patient was discharged soon thereafter with a follow-up appointment for both services.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
The IVC is formed by the joining of the common iliac veins at the level of L5 vertebral body. It lies to the right of the aorta and midline, coursing up through the diaphragmatic hiatus at the T8 vertebral body and ending with the Eustachian valve of the right atrium. The average diameter of the infrarenal IVC is approximately 23 mm [7]. The IVC is a valve-less, elastic structure responding to volume and intraabdominal pressure.

There are variations in the normal anatomy of the IVC in 3% of the population. The complex embryology of the IVC stems from three pairs of fetal veins: (1) posterior cardinal veins, (2) subcardinal veins, and (3) supracardinal veins. The cardinal veins constitute the main venous drainage system of the embryo.

Posterior cardinal veins normally completely regress. Persistence results in a retro-caval ureter. The only adult derivative is the root of the azygos vein and confluence of the common iliac veins [8]. Subcardinal veins form the intrahepatic IVC that contribute to the renal veins and suprarenal segment of the IVC. Supracardinal veins give rise to the infrarenal IVC and the azygos and hemi-azygos veins. Caudal to the kidneys, the left supracardinal vein degenerates and the right supracardinal vein becomes the IVC. Dual IVC results from failure of regression of the left supracardinal vein, whereas a left-sided IVC is due to regression of the right supracardinal vein [3, 4, 7].

The presence of recurrent pulmonary embolus after IVC filter placement should raise the suspicion of venous anomaly. Identifying both IVCs in our patient allowed us to place two IVC filters, thus significantly decreasing the morbidity of subsequent pulmonary embolisms from his lower extremity deep venous thrombosis [9, 10]. The dual IVC was only an incidental finding that became apparent during the filter placement. If we had identified this anomaly prior to our procedure, a single suprarenal filter would not have been inserted in the common IVC. The complication of renal vein thrombosis with a single suprarenal filter far outweighs the risk of placing two IVC filters.

Although venous anomalies are rare, knowledge of them is crucial in diagnosis and treatment. Errors may result in misinterpretation of anomalous venous drainage as a mass or lymphadenopathy; such may be the case in testicular tumors. Recognition before an operation prevents significant bleeding and helps maintain vascular anastamosis, especially during organ transplantation or radical nephrectomy [1, 8]. In conclusion these variations should not be mistaken for pathologic finding, but should be viewed as normal findings of abnormal embryogenesis.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Tore HG, Tatar I, Celik HH, Oto A, Aldur MM, Denk CC. Two cases of inferior vena cava duplication Folia Morphol 2005;64:55-58.
  2. Taniguchi H, Miyauchi Y, Kobayashi Y, Seino Y, Takano T. Pulmonary embolism from thrombosis in a duplicated inferior vena cava developing after an electrophysiologic procedure J Interv Card Electrophys 2001;5:75-79.[Medline]
  3. Tatar I, Tore HG, Celik HH, Karcaaltincaba M. Magnetic resonance venography of double inferior vena cava Saudi Med J 2005;26:101-103.[Medline]
  4. Artico M, Lorenzini D, Mancini P, Gobbi P, Carloia S, David V. Radiological evidence of anatomical variation of the inferior vena cava Surg Radiol Anat 2004;26:153-156.[Medline]
  5. Rohrer M, Cutler B. Placement of two Greenfield filters in a duplicated vena cava Surgery 1988;104:572-574.[Medline]
  6. Saito H, Sano N, Kaneda I, et al. Multisegmental anomaly of the inferior vena cava with thrombosis of the left inferior vena cava Cardiovasc Intervent Rad 1995;18:410-413.
  7. Kaufman JA, Lee MJ. Vascular and interventional radiology—the requisites. Philadelphia, PA: Mosby; 2004. pp. 350-355.
  8. Nagashima T, Lee J, Andoh K, et al. Right double inferior vena cava J Comput Assist Tomogr 2006;30:642-645.[Medline]
  9. Anne N, Pallapothu R, Holmes R, Johnson, MD. Inferior vena cava duplication and deep venous thrombosis Ann Vasc Surg 2005;19:740-743.[Medline]
  10. Sartori MT, Zampieri P, Andres AL, Prandoni P, Motta R, Miotto D. Double vena cava filter insertion in congenital duplicated inferior vena cava Haematologica 2006;91:42-43.



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