CASE 11846 Published on 04.06.2014

Transposition of IVC (Left-sided IVC)

Section

Abdominal imaging

Case Type

Anatomy and Functional Imaging

Authors

Harshavardhan B, Himabindu T, Anandapadmanabhan J, Gurubharath Ilangovan, Arul Yagappa, Subramanian V

Shri Sathya Sai Medical College and Research Institute,
Thiruporur - Guduvanchery Main Road,
Ammapettai village,
Sembakkam Post - 603108.
Chengalpattu Taluk,
Kanchipuram District.

Patient

45 years, male

Categories

Area of Interest Abdomen, Anatomy, Veins / Vena cava ; Imaging Technique CT

Procedure Contrast agent-intravenous ; Special Focus Embolism / Thrombosis, Congenital, Inflammation ;

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Clinical History

A 45-year-old man was admitted in the ER for recurrent right iliac fossa pain. He was referred for evaluation because of right iliac fossa tenderness and mass. He had been treated medically for similar complaints three months before.

Imaging Findings

Plain and contrast-enhanced CT abdomen revealed heterogeneous collection with heterogeneous enhancement medial and inferior to the caecum which showed the regression of the phlegmon on follow-up examination.
As noted incidentally, the inferior vena cava (IVC) formed behind the left common iliac artery at the L5 vertebral level and coursed proximal to the left of the aorta until it reached the left renal vein and then crossed anterior to the abdominal aorta and posterior to the superior mesenteric artery to assume the normal right side. At the point of crossing, it received the left renal vein. The right renal vein drained into the IVC on the right side.

Discussion

Pertaining to the complex embryological development of the venous system, inferior vena cava (IVC) variants could be anticipated. There are post-renal, renal and pre renal variations. The post-renal variants are persistent right posterior cardinal vein (retrocaval or circumcaval ureter), persistent left supracardinal vein (transposition of IVC or left-sided IVC), persistent both supracardinal veins (duplication of IVC). The renal level variant is circumaortic venous collar and pre-renal variant of IVC is azygos continuation of IVC.
A left-sided IVC usually ends at left renal vein and crosses anteriorly to join normal pre-hepatic segment of IVC. Sometimes it crosses more posterior to aorta. Distally the IVC bifurcates into common iliac veins. [1, 2, 3]
Persistence of left supracardinal vein and regression of right supracardinal vein results in a left-sided IVC. The prevalence of it is 0.2%–0.5% (3, 4). Typically, the left IVC joins the left renal vein, which crosses anteriorly to the aorta uniting with the right renal vein to form a normal right-sided prerenal IVC. The major clinical significance of this anomaly is the potential for misdiagnosis as left-sided paraaortic adenopathy [3, 5]. In addition, spontaneous rupture of an abdominal aortic aneurysm into a left IVC resulting in aorto-caval fistula has been reported [3, 6].
Diagnosis of left-sided IVC is important for planning of vascular procedures like portosystemic shunts, abdominal aortic aneurysm repair, ligation of IVC in thromboembolic disease, placement of IVC filter, nephrectomy and renal transplantation.

Differential Diagnosis List

Transposition of IVC (left-sided IVC)

Duplication of IVC

Left-sided para-aortic adenopathy

Anomalous left gonadal vein

Final Diagnosis

Transposition of IVC (left-sided IVC)

References

[1] Vogel HJ, Falke TH, Wondergem JH, Beerman H, Eulderink F. (1990) Multilocular renal cyst associated with transposition of the inferior vena cava and malrotation of the bowel. Eur J Radiol Mar-Apr;10(2):140-2. (PMID: 2338097)

[2] Royal SA, Callen PW. (1979) CT evaluation of anomalies of the inferior vena cava and left renal vein. AJR Am J Roentgenol May;132(5):759-63 (PMID: 107741)

[3] Bass JE, Redwine MD, Kramer LA, Huynh PT, Harris JH Jr. (2000) Spectrum of congenital anomalies of the inferior vena cava: cross-sectional imaging findings. Radiographics May-Jun;20(3):639-52. (PMID: 10835118)

[4] EJ, Hipona FA, Kahn PC, Phillips E, Shapiro JH, (1969) mbryology, normal anatomy, and anomalies. Venography of the inferior vena cava and its branches. Baltimore, Md: Williams & Wilkins, 1-32

[5] Siegfried MS, Rochester D, Bernstein JR, Milner JW (1983) Diagnosis of inferior vena cava anomalies by computerized tomography. Comput Radiol 7:119-123 (PMID: 6851499)

[6] Davachi AA (1965) Acute spontaneous rupture of an arteriosclerotic aneurysm into an isolated left sided inferior vena cava. Am J Cardiol 15:416 (PMID: 14263043)

Case information

URL:	https://eurorad.org/case/11846
DOI:	10.1594/EURORAD/CASE.11846
ISSN:	1563-4086

Figure 1

Contrast-enhanced CT Abdomen - Axial sections in venous phase

Axial sections of venous phase

Axial sections of venous phase - Inferior vena cava located between aorta and superior mesenteric artery (crossing the midline).

Axial sections of venous phase

Axial sections of venous phase - Inferior vena cava located in the left side of aorta.

Figure 2

Contrast Enhanced CT Abdomen - Sagittal reconstruction

Sagittal reconstruction along the aorta shows the cross section of IVC lying anterior to the abdominal aorta and posterior to the superior mesenteric artery.

Figure 3

Contrast Enhanced CT Abdomen - Coronal reconstruction

Coronal recontruction image shows the left-sided position of the IVC inferiorly which crosses the abdominal aorta anteriorly to assume the normal right side.

Figure 4

Sagittal reconstruction series of CT Abdomen - Contrast Enhanced

Sagittal series (right to left) - Inferior vena cava forms on the left side at L5 vertebral level and crosses the midline between the aorta and superior mesenteric artery to continue on the right side.