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Interruption of inferior vena cava with azygos continuation is a rare venous anomaly. We report the case of a 17 old male with Wolf-Parkinson-White syndrome and a persistent vena azygos. Despite the complex anatomical situation, it was possible to safely ablate a lateral accessory pathway with radiofrequency energy using a femoral retrograde approach.

HISTORY AND OUTPATIENT INVESTIGATION: A 61-year-old woman presented with a six-month history of chest pain and shortness of breath on normal activity. The past medical history included hypertension treated with ACE inhibitors. While still an outpatient a diagnosis was made of cardiomyopathy with left atrial and ventricular dilatation, systolic and diastolic heart failure, moderate mitral valve regurgitation and newly documented atrial fibrillation.Right heart catheterization was carried out via the right femoral vein. The inferior vena cava was found to be on the left, none on the right. Venous inflow was via a dilated hemiazygos vein, a persistent left superior vena cava and a markedly dilated coronary sinus into the right atrium. The hepatic veins were also directly connected to the right atrium, as was shown by retrograde perfusion during a venogram. Coronary heart disease was excluded by angiography, but a right heart catheterization was not possible because of the atypical venous connections. Ultrasound examination revealed abdominal situs inversus and polysplenia. Magnetic resonance imaging of the thorax demonstrated bilateral bilobar lungs and bilateral hyparterial bronchi.Heterotaxia with anomalous systemic veins and visceral defects was revealed during a diagnostic work-up, which was indicated by the finding of a dilated cardiomyopathy with chronic atrial fibrillation, moderate mitral valve regurgitation and arterial hypertension. Arterial hypertension and heart failure were successfully treated by medication. Attempts at rhythm control were unsuccessful. Safety measures were established to prevent thromboembolic complications and endocarditis.Congenital anomalies of the systemic veins in adults are often discovered incidentally, because they are usually asymptomatic. They may cause diagnostic and therapeutic difficulties in cardiology, phlebology and surgery. These anomalies may increase the risk of thrombotic and thrombembolic events. Together with polysplenia and situs inversus they are phenotypical components of heterotaxia. They may have various clinical consequences and may occur spontaneously or may be familial.

Blunt chest trauma is a common injury in traffic accidents. Thoracic vessel trauma frequently affects intercostal arteries, the aorta and less often the subclavian artery. Azygos vein injury is uncommon and has previously been described in only 19 cases. The 20th case of blunt azygos vein injury due to high energy trauma as a consequence of a traffic accident is reported with a review of the literature. Preoperative diagnosis was performed by computed tomography. Azygos vein injury is rare but potentially lethal (8/20, 40.0%). Chest radiograph with right hemothorax is reported consistently except for two cases. Fractures of ribs and/or thoracic spine (T3-5) were found in nine patients, while neither were found in 11/20 cases. Pathognomonic signs have not been described in the literature. Early resuscitation and immediate thoracotomy with recognition and treatment of azygos vein rupture is necessary to avoid a fatal outcome.

A patient with a complete agenesis of the inferior vena cava is presented. In this rare anomaly the blood of the pelvic veins is drained through the dilated venae lumbales, vena azygos and vena hemiazygos into the superior vena cava. The malformation was detected within the scope diagnostics of deep vein thrombosis. The diagnosis was made by sonography, computed tomography and magnetic resonance angiography.

Experimental studies have shown that in traffic accidents with frontal impact the new airbag system can significantly reduce the incidence of severe injuries and fatal outcome. The question of whether the airbag itself induces specific patterns of injury needs further investigation. Two cases of traffic accidents with airbag protection are presented here. The first case report clearly shows the life-saving and injury-reducing effect of the airbag system in a traffic accident with frontal impact at 100 km/h. In the second case only minor injuries of the face were diagnosed initially. Hemodynamic instability occurred after 3 h of hospitalization due to rupture of the azygos vein. Analysis of the presented cases shows that, besides the well-known benefits, there are certain injury patterns that seem to be related to the use of airbags. These have not been described before. It is concluded that patients who were involved in traffic accidents with airbag deployment have to be hospitalized and followed up carefully over time, even though they are initially stable, as potentially fatal sequelae of deceleration trauma can occur later. In our opinion it is not possible to estimate the severity of airbag-associated injuries with conventional methods.

A tumor originating in a lobus v. azygos is very seldom. We report here on a patient with a poorly differentiated adenocarcinoma of the lobus v. azygos which exhibits a very aggressive growth. Depending on the tumor localization, the metastasis is typical and can be recognized by computertomography (CT). In spite of the large number of treatment strategies, the prognosis is poor.

Indirect vena azygos continuation syndrome and aneurysm are rare variations of the inferior vena cava (IVC). In this article we describe the ultrasound, angiographic and CT appearance of a 14-year-old girl with this congenital anormaly of the IVC.

The widths of the azygos vein were measured in 150 patients and correlated with the pressure in the right heart-atrium. We found a significant logarithmic correlation (r = 0.8) between the two parameters. Radiologic measurement of the width of V. azygos in chest radiographs or CT is useful to evaluate the function of the right heart.

The azygos continuation is a rare variation of the inferior vena cava (IVC), usually associated with cardiac anomalies. We report CT in two female patients with no cardiac disease. One had no further visceral abnormalities, while the other had polysplenia agenesis of the left lobe and a hypertrophic right lobe of the liver. This complex of anomalies has been demonstrated for the first time by imaging. Our cases show the variation of anomalies associated with azygos continuation. When planning therapeutic procedures (for example cava filtration) these anomalies are relevant. CT is sufficient for their demonstration and in most cases there is no need for confirmation by invasive methods.

Nausea and emesis after exercise were leading symptoms in a 28 year old patient with indirect vena azygos continuation syndrome. This anomaly was verified by sonography, abdominal CT and by venography. The CT examination revealed initially structures of malignant appearance low to the renal position by angiography. This appeared to be distended collaterals. Therapeutic intervention aims primarily to the prevention of complications such as thrombosis of the distal venous flow or venous insufficiency of the lower extremities. Prophylactically we suggest low dose heparin and compression stockings.

Atypical pattern of inferior cava (human embryo, sex: male, age: 6 month) is described. The left kidney is absent. The pelvis of the right kidney send two ureters to bladder. Pars hepatica of normal V. cava inferior is missed. Blood transport is formed by a vessel lateral of left suprarenal gland. This vessel is penetrating through pars lumbalis of diaphragm to thorax, goes in analogy to V. hemiazygos later to V. hemiazygos accessoria and flows into the right atrium.

The standard heart size, i.e., heart diameters and heart volume, of normal children aged 4-15 years were obtained. In all cases requiring exact heart-size determination, heart volume calculation is mandatory in children as well as in adults. Statistical work to date has provided the precise calculation of heart volume from plain films in the upright position. Additional plain films in the prone position are unnecessary because there is no evidence of an orthostatic influence on heart volume in children. The percentiles of normal heart volume related to body weight, representing the best correlation to the individual data, are given as well as percentiles related to age. Furthermore, ratios of normal vessel size to the height of the 8th thoracic vertebral body, measured on the same plain film, are given. In addition, the ratio of upper-to-lower lung vessel size is calculated. These ratios are useful criteria in estimating normal vessel size and also in cases with increased pulmonary venous pressure.

Deviation of a left subclavian vein catheter into the azygos vein occurred in a patient with cancer of the colon. On the p.a.-projection, the catheter seemed to be kinked in the vena cava. In the lateral view, the malposition in the azygos vein could be detected and was visualised by giving a bolus of contrast medium. By retracting the catheter under fluoroscopic control the proper position could be achieved. The importance of the lateral-view chest x-ray is discussed.

The value of computer tomography in the demonstration of venous collaterals in cases with occlusion or malformation of the superior and inferior vena cava has been demonstrated in five patients. The ascending lumbar veins and the vena azygos are of special significance in the formation of collaterals.

A vasal anomaly in the region of the Vena cava inferior is being described in the corpse of a 25-year-old man. 1. In the course of development the V. subcardinalis has not been joined to the Pars hepatica of the V. cava inferior, which originates from the V. hepatis revehens communis. In our case the Anastomosis intersubcardinalis remains and is subjected to a slight retroaortal displacement to the left. 2. Among the Vv. sacrocardinales the V. sacrocardinalis sinistra, which ought to involute after the sixth embryonal week, has been retained together with the Anastomosis intersacrocardinalis. 3. The Vv. supracardinales are connected with the intersubcardinal anastomosis and the intersupracardinal transversal anastomosis has been retained. 4. The Vv. caudales end in the Anastomosis sacrocardinalis at a point before the Sacrum and the Anastomosis intercaudalis has been retained, too. 5. The caudal section of the right lower cardinal vein in its prerenal part is retained with an anastomosis to the right subcardinal vein. 6. The portal blood of the liver is directly distributed to the atrium dextrum after it has passed through three Vv. hepaticae. The Lig. venosum is intrahepatic and is joined to the Vv. hepaticae. 7. The primitive bilateral-symmetric veinous system of the caudal half of the body continues to exist almost completely.

A strong tendency to symmetrical development of the organ systems manifests itself in the syndrome of Polysplenia. These symmetrical organs show the anatomy of leftsided structures. For this reason the syndrome is also referred to as the "syndrome of bilateral leftsidedness". It encompasses complex abnormalities of situs, typical cardiac and vascular deformities as well as extracardiac malformations. Polysplenia is the leading symptom. Diagnosis is rarely made intra vitam. Certain typical deformities can give hints to this diagnosis, which is finally proved by szintigraphic and arteriographic visualization of multiple spleens. A typical case is reported and subsequently discussed according to the picture of this syndrome in the literature.

The diagnostic spectrum for venography of the trunk is broad. During the traditional superior and inferior cavography, which should be used for clinical bone marrow functional blockage in connection with a confirmed tumor or for thrombosis, the combined retroperitoneal venography and cavography which we developed for clinical use as well as direct azygography provide valuable supplementary information which can be significant especially for preoperative questions. In the case of carcinoma of the esophagus or stomach, the question whether or not the tumor can be surgically removed or whether the tumor is already inoperable may be answered before surgery. In addition, direct azygography is suitable as a method to seach for lymph nodes metastases in carcinomas of the lung, stomach, kidney, adrenals and pancreas which cannot be ascertained via mediastinalscopy, and for systemic diseases. In addition to the prognostic evaluation of the tumor and the additional preoperative evaluation of neighboring tumors, various bone diseases of the lumbar vertebrae, e.g., inflammatory, tumerous and traumatic changes in the spine, may be localized on the retroperitoneal venogram and cavogram. They can also be used successfully to seach for metastases or in the case of a dislocation of an intervertebral disk. The execution of the various methods is relatively simple and they may be performed on a patient capable of surgery.

An aneurysm of the vena azygos should be taken into consideration when establishing the differential diagnosis of a tumor in the area of the right tracheobronchial angle or of an enlargement of the right upper mediastinum. Bilateral pelvic phlebography with demonstration of the retroperitoneal venous system and the azygos venous system is the only purposeful examination. Tentative diagnosis is made on the basis of the X-ray (radioscopy and general X-ray of the chest) and is supplemented by X-rays of the patient in a recumbent position (Valsalva- and Müller-test) and appropriate tomography. The most frequent cause of the azygos aneurysm in our patients was aplasia of the inferior vena cava. One patient presented an infrahepatic interruption of the inferior vena cava with azygos continuation. Phlebography of the inferior vena cava should always be performed in cases of azygos aneurysm. An abnormality of the inferior vena cava may be missing; in such cases the existence of a cardiac defect, abnormal emptying of pulmonary veins or hepatic cirrhosis should be taken into consideration. The enlargement of the azygotic arch may also occur during pregnancy. Thus an azygos aneurysm is frequently but not necessarily associated with enlargement of the azygotic arch. We saw one patient among our cases who presented aplasia of the inferior vena cava without any dilatation of the azygotic arch.

The incidence and development on the azygos vein lobe are reviewed briefly. Examination of 10 000 radiographs of normal people showed that it occurred in 0,7% of cases. The clinical significance of the azygos vein lobe is discussed. In particular it may important in evaluating post-operative radiographs of patients in intensive care.

The analysis of observation about the progress of 1136 malignant diseases of the epi- and mesopharynx and of the nasal cavity and sinuses from the ENT-Clinic of Jena showed in 16 to 18 per cent of the cases haematogenous metastases observed only in a third to a half in the lung. If the lung had been spared especially the axial skeleton and the liver had metastases. This finding was especially significant in cases of epipharyngeal carcinomas. The discussion about the causes of the frequent occurence of metastases in the axial skeleton led to the supposition, that an independent way of the spreading of haematogenous metastases via the vertebral venous system and the azygos veins could be possible.

For the radiologic diagnosis of secondaries of testicular tumors we use conventional plain films of chest and abdomen, IVP or infusion urography, tomography of the retroperitoneal space with or without contrast media and, according to the suspected site of metastases, further special radiologic techniques like lymphography, cavography, azygography, venography of the lumbar vein or, occasionally, aortography. The techniques are described, their value and limits discussed.

The technique and use of occlusion phlebography is described. The method is based on temporary occlusion of blood flow by means of a balloon catheter. Various balloon catheter systems were used and their technical properties were evaluated. The distal veins can be demonstrated by using double lumen catheters, distal and proximal veins by using a catheter with three lumina. Occlusion phlebography is a suitable method for demonstrating hepatic and renal veins; it improves the demonstration of the azygos vein, the suprarenal vein and of visceral pelvic veins, including the iliolumbar veins. It also permits demonstration of the inferior vena cava and parietal veins in the pelvis in separate stages. Occlusion phlebography is the method of choice for the direct demonstration of splenorenal shunts.

Dilatation of the azygos vein is usually due to increased pressure or flow, rarely is it diopathic. Another cause is so-called continuation of the azygos in cases of absence of the hepatic segment of the inferior vena cava. The method of choice for the investigation of azygos dilatation nowadays is computer tomography. Anomalies of the inferior vena cava can be recognized in this way unequivocally by a non-invasive method. Computer tomography frequently shows important additional abnormalities (eg. situs inversus, polysplenia), since it demonstrates all organs situated in the plane of section.

The absence or hypoplasia of the hepatic segment of the inferior vena cava with azygos continuation is a rare entity, sometimes associated with congenital heart disease, situs inversus or polysplenia syndrome. Ultrasonography as an easy, non-invasive procedure enables reliable diagnosis of this anomaly replacing inferior cavography. Ultrasonic scans performed in various directions allow a more subtle analysis of vessels and location of azygos continuation. We present an analysis of the sonographic feature in this anomaly, as studied in 2 patients. The diagnosis of this usually incidental finding (chest X-ray) can be of major clinical importance e.g. if special surgical procedures such as ligature of the azygos vein are considered.

A 23-year-old man with agenesis of the inferior vena cava (IVC) and azygos continuation had progressive, temporary, activity-dependent paraesthesias of the legs which developed after increasing sports activity as a soldier. The diagnosis was made from the chest X-ray (enlarged azygos shadow) and the computed tomogram (retro- and para-aortic space-occupying structures representing the enlarged collaterals draining the lower half of the body). There are at present no known therapeutic measures for this very rare anomaly. Management thus focuses on the prevention of complications, such as thromboses in the distal drainage channels.

Report on 2 patients, with a mediastinal enlargement at the right tracheobronchial angle revealing an ectasis of the orifice of vena-azygos. It could be shown that the enlargement of the vena azygos ist due to an increase of the flow-volume, caused by an abnormal embryonic drainage of the vena cava inferior into the vena azygos. The diagnostic possibilities for differentiation from vascular and nonvascular space-occupying processes in that region are discussed. An exact diagnosis is possible by angiography.