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Chronic liver disease is still a major problem because disease progression will ultimately lead to liver cirrhosis. Portal hypertension is the hallmark in advanced liver disease management. By establishing portal vein access, endoscopic ultrasound (EUS) has been utilized in various clinical applications. In comparison to standard upper gastrointestinal endoscopy, EUS-Doppler has been shown to be a better modality for detecting esophageal and gastric varices along with peri-esophageal collateral veins, para-esophageal collateral veins, and perforating veins, and may be used to objectively predict the recurrence of bleeding. EUS-guided portal vein catheterization has also been proposed to overcome the limitations of trans-jugular approaches. The combination of EUS-elastography and azygos vein evaluation can also enhance the diagnostic accuracy of each modality. Another well-known implementation of EUS-guided procedures is in the management of ascites; particularly in paracentesis and ascitic fluid analysis. In addition, the most common clinical application of EUS in the treatment of portal hypertension is through vascular therapy or creation of intrahepatic portosystemic shunts. Major drawbacks of EUS mainly revolve around technical difficulties, the high cost of the procedure, as well as the requirement of more studies in humans to evaluate EUS-guided advanced therapeutic modalities in portal hypertension.

A 14-year-old boy with hypertrophic cardiomyopathy (HCM) diagnosed at the age of 1 year and with massive left ventricular hypertrophy suffered an episode of ventricular fibrillation during mild effort. He underwent a dual-chamber implantable cardioverter defibrillator (ICD) implantation. The defibrillation threshold testing (DFT) was ineffective. Subcutaneous multi-coli arrays tunneled into the left postero-lateral position and connected to the superior vena cava (SVC) port of the dual-chamber ICD were added to increase the myocardial mass involved in the defibrillation shock pathway. A new DFT was unsuccessful. The patient was transferred to our hospital for myectomy. An epicardial defibrillation patch was placed on the left ventricular lateral wall, but again, DFT testing was ineffective using the right ventricular (RV) coil to lateral patch as shock pathway. Another epicardial defibrillation patch was then placed on the inferior wall. In this case, DFT testing was effective with a defibrillation pathway between the two patches and the can. In November 2015, a high shock impedance alarm was recorded through remote monitoring, thus compromising the safety of the ICD shock pathway. The patient underwent the implant of a new trans-venous defibrillation coil lead in the azygos vein. After few months, the patient developed symptomatic severe aortic regurgitation and underwent an aortic valve replacement. During the operation, DFT testing was performed and was successful. Our case illustrates that azygous vein ICD lead implantation is efficacious in HCM with massive hypertrophy and high DFT, and prompts further studies to systematically investigate its efficacy in this particular subgroup of the HCM population.

Introduction. A combination of two rare congenital lung diseases - congenital cystic-adenomatous malformation of the lower lobe of the left lung and intralobar sequestration of the lung- is an extremely rare pathology in medical practice.Material and methods. The article describes a case of successful treatment of an 8-year-old child with cystic-adenomatous transformation of the lower lobe of the left lung in combination with intralobar sequestration. A child with chronic pneumonia was prescribed CT of his chest organs with intravenous contrast enhancement. A combination of cystic adenomatous malformation with intralobar sequestration of the lung was revealed at this examination. The sequestration zone was supplied with blood via the artery from the thoracic aorta, and the wide vein went towards the opposite hemithorax and flowed into the azygos vein. The patient had a planned surgery: left-sided lateral thoracotomy, lower lobectomy with ligation of additional vessels.Results. The early postoperative period was uneventful. Next year, there were no exacerbations of pneumonia. The child considers himself healthy. The histological report No. 31568 - 31577 confirmed type II cystic adenomatous malformation with sequestration of the lung.Conclusion. Modern diagnostic tools allow to put a correct diagnosis at the preoperative stage. In the described case, possible intraoperative complications were avoided because surgeons knew specific blood supply in the diseased area before surgery.

Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with typical MRI findings among which engorgement of the venous sinuses, pachymeningeal enhancement, and effacement of the suprasellar cistern have the highest diagnostic sensitivity. SIH is in almost all cases caused by spinal CSF leaks. Spinal MRI scans showing so-called spinal longitudinal extradural fluid (SLEC) are suggestive of ventral dural tears (type 1 leak) which are located with prone dynamic (digital subtraction) myelography. As around half of the ventral dural tears are located in the upper thoracic spine, additional prone dynamic CT myelography is often needed. Leaking nerve root sleeves typically associated with meningeal diverticulae (type 2 leaks) and CSF-venous fistulas (type 3 leaks) are proven via lateral decubitus dynamic digital subtraction or CT myelography: type 2 leaks are SLEC-positive if the tear is proximal and SLEC-negative if it is distal, and type 3 leaks are always SLEC-negative. Although 30–70% of SIH patients show marked improvement following epidural blood patches applied via various techniques definite cure mostly requires surgical closure of ventral dural tears and surgical ligations of leaking nerve root sleeves associated with meningeal diverticulae or CSF-venous fistulas. For the latter, transvenous embolization with liquid embolic agents via the azygos vein system is a novel and valuable therapeutic alternative.

Background Management of thoracic vascular injury predominantly focuses on the aorta and its tributaries while reports of venous injury are less frequent. Although rare, traumatic azygous vein injuries are associated with high mortality. Prompt treatment is required and has traditionally been open surgery. We present a case of an endovascular repair of an azygous vein injury. Case presentation A female patient presented to our trauma center following ejection after a motor vehicle collision (MVC). CT imaging workup revealed mediastinal and periaortic hematoma with active contrast extravasation adjacent to the azygos vein. She was referred to interventional radiology for vascular evaluation and potential endovascular intervention. The patient met criteria for class III hypovolemic shock upon arrival in the endovascular suite. Aortography demonstrated no arterial injury. Venography revealed a pseudoaneurysm on the superior aspect of the azygos arch and contrast extravasation from the inferior margin of the azygous arch. A stent-graft was deployed and post-deployment venogram showed no extravasation and successful exclusion of the injuries. The patient did not have further signs of bleeding. She left the interventional suite with improved vital signs, yet her condition remained guarded. Follow-up CT chest confirmed continued patency of the stent-graft at 8 days and 2 years post-procedure. Conclusion Historically, azygos vein injuries are a rare occurrence and managed with open surgery. Swift management is necessary to prevent the increased morbidity and mortality associated with azygous vein injury, particularly in polytrauma patients such as the one presented here. We believe endovascular stent-graft treatment offers an innovative alternative to the current standard of operative management of azygos vein injury.

Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department.This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis.The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively.CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.

Catheter ablation of cardiac arrhythmias is usually performed through the femoral venous approach. Systemic venous return anomalies such as interruption of the inferior vena cava may represent a challenge during electrophysiological procedures. A 55-year-old patient with previous surgical correction of abnormal pulmonary venous return was admitted for poorly tolerated atrial flutter recurrences. He also had an interrupted inferior vena cava continuing as azygos vein and left superior vena cava draining via coronary sinus into the right atrium. Cavotricuspid isthmus radiofrequency ablation was successfully performed through the persistent left superior vena cava using a three-dimensional (3D) electroanatomical mapping system. Despite systemic venous abnormalities may potentially have important implications during electrophysiological procedures, arrhythmias can be successfully ablated with the aid of 3D electroanatomical mapping systems.

Background Video-assisted thoracoscopic surgery (VATS) is being used to treat esophageal submucosal tumors (SMTs) all over the world. However, this technique is difficult when the tumor is large and located on the left side wall of the esophagus, within the upper mediastinum. This is because, with VATS, the surgical forceps have a limited range of motion. Robot-assisted thoracoscopic surgery (RATS) using the da Vinci surgical system may be extremely useful for enucleation of esophageal SMTs within the narrow upper mediastinum. Case presentation A female in her thirties experiencing epigastric pain visited our hospital and was diagnosed with a large esophageal leiomyoma within the upper mediastinum. From its size (10 cm), it was judged to have malignant potential. We performed SMT enucleation using RATS with a da Vinci surgical system Xi. This was our second case using this system. The patient was placed in the left lateral position. Four da Vinci trocars (8 mm) were inserted into the 10th, 7th, 5th and 3rd intercostal spaces (ICS), and an assist port was added in the 5th ICS. We opened the superior mediastinal pleura cranially and caudally from the arch of the azygos vein and expanded the superior mediastinum after dividing the azygos vein. We made an incision in the muscular layer of the esophagus and, using a monopolar hook and monopolar scissors, enucleated the esophageal tumor in a protective manner so as not to damage its capsule or mucosa while applying appropriate robot-specific counter traction. We then sewed up the muscularis using 4–0 Vicryl, inserting the endoscope into the thoracic esophagus to substitute for a bougie. In addition, the pleura was sutured using barbed suture. The surgical procedure was straightforward and smooth. The patient was discharged on postoperative day 4 with no surgical complications. The tumor was definitively diagnosed pathologically from paraffin sections as a benign esophageal leiomyoma. Conclusions RATS enables more delicate and precise esophageal SMT enucleation without surgical complications, though various challenges remain to be overcome.

Background Azygos vein aneurysms are extremely rare, and their pathogenesis is not clear. The overwhelming majority of patients have no obvious clinical symptoms and are found to have the disease by physical examination or by chance. There are few reports on the diagnosis of and treatment strategy for this disease. Moreover, the choice of therapeutic schedule and the treatment window are controversial. Case summary We report a case of azygos vein arch aneurysm in a 53-year-old woman. The patient had symptoms of back pain, chest tightness, and choking. Enhanced chest computed tomography showed a soft-tissue mass in the right posterior mediastinum, which was connected to the superior vena cava. The enhancement degree in the venous phase was the same as that of the superior vena cava. The patient received video-assisted thoracoscopic surgery. After the operation, her back pain disappeared, and her dysphagia and chest tightness were also significantly relieved. The postoperative pathology confirmed hemangioma. The patient was discharged on the seventh day after surgery without any comp-lications. Conclusion Some patients with hemangioma of the azygos vein arch may experience dysphagia and chest tightness caused by the tumor compressing the esophagus and trachea. Enhanced computed tomography scanning is vital for the diagnosis of azygos vein aneurysms. In addition, despite the difficulty and risk of surgery, thoracoscopic surgery for azygos vein aneurysms is completely feasible.

We present a case of a port malposition into the azygos vein resulting in both a broncho-esophageal and veno-bronchial fistula. While complications of central venous catheter malposition into the azygos vein are well documented in literature, these unique complications have not yet been described. This case underscores how utilizing state of the art technology like intra-cavity electrocardiography rather that reliance on fluoroscopy can help eliminate catheter malposition and its potential catastrophic consequences.

Background: Peripherally inserted central catheter (PICC) has been widely used. The catheter-related complications might occur and the reports of secondary malposition into azygos veins were rare. Methods: This retrospective review summarized the experience in diagnosis and management of secondary malposition of PICC into azygos veins in 25 cases. Results: When the catheter dysfunction occurred in the PICC on the left limb, it was necessary to consider whether there would be malposition into azygos veins after other reasons were excluded. The malposition could be diagnosed by chest lateral radiograph or chest computed tomography. The secondary malposition into azygos veins was resolved by repositioning or withdrawing the PICC. After re-inserting the catheter, it should be closely monitored whether the malposition occurred again. Intracavitary electrocardiogram positioning technology was used to confirm the catheter tip position before using corrosive drug. After the catheters withdrawn from the azygos veins, close attention should be paid to the property and concentration of the infusion drug strictly and the complications such as blockage and re-malposition. No serious complications such as infection, thrombosis and extravasation occurred in this group of patients after treatment. Conclusions: The results of our study suggested that the right limb is recommended for PICC catheterization in order to avoid secondary malposition into azygos veins and the malposition into azygos veins should be dealt with in time.

Introduction: Exercise pulmonary hypertension (exPH) has been defined as total pulmonary resistance (TPR) >3 mm Hg/L/min and mean pulmonary artery pressure (mPAP) >30 mm Hg, albeit with a considerable risk of false positives in elderly patients with lower cardiac output during exercise. Methods:We retrospectively analysed patients with unclear dyspnea receiving right heart catheterisation at rest and exercise (n=244) between January 2015 and January 2020. Lung function testing, blood gas analysis, and echocardiography were performed. We elaborated a combinatorial score to advance the current definition of exPH in an elderly population (mean age 67.0 years±11.9). A stepwise regression model was calculated to non-invasively predict exPH. Results: Analysis of variables across the achieved peak power allowed the creation of a model for defining exPH, where three out of four criteria needed to be fulfilled: Peak power ≤100 Watt, pulmonary capillary wedge pressure ≥18 mm Hg, pulmonary vascular resistance >3 Wood Units, and mPAP ≥35 mm Hg. The new scoring model resulted in a lower number of exPH diagnoses than the current suggestion (63.1% vs. 78.3%). We present a combinatorial model with vital capacity (VCmax) and valvular dysfunction to predict exPH (sensitivity 93.2%; specificity 44.2%, area under the curve 0.73) based on our suggested criteria. The odds of the presence of exPH were 2.1 for a 1 l loss in VCmax and 3.6 for having valvular dysfunction. Conclusion: We advance a revised definition of exPH in elderly patients in order to overcome current limitations. We establish a new non-invasive approach to predict exPH by assessing VCmax and valvular dysfunction for early risk stratification in elderly patients.

Background: Heterotaxy syndrome is associated with a plethora of cardiovascular and other multi-system anomalies with a high childhood mortality. A dilated azygos vein as part of the polysplenia variant of heterotaxy syndrome may cause oesophageal stenosis owing to a prolonged compression. We describe our technique of extramediastinal oesophago-oesophagostomy in the prone position for this rare congenital syndromic malformation with an excellent outcome. Patients and Methods: A 17-year-old boy with heterotaxy syndrome presented with intermittent dysphagia and postprandial emesis with failure to thrive. Despite the presence of diverse anatomic abnormalities, it was only his symptom of dysphagia due to oesophageal stricture that merited surgical intervention. He underwent an azygos-preserving extramediastinal oesophago-oesophagostomy in the prone position without segmental resection with the establishment of continuity using a modified Collard-type anastomosis. Results: The patient had an uneventful convalescence, with imaging after 1 year showing no re-stenosis. After a follow-up of 3 years, the patient is free of symptoms and has gained weight. Conclusion: Oesophageal stenosis may result from prolonged compression by anomalous vasculature. An isolated correctable anatomic derangement, young age with good functional reserve, other associated anomalies not causing any symptoms, the physiological advantages of executing the surgery in a prone position and availability of expertise in minimally invasive surgery ensured excellent outcomes. The hitherto unreported technique may open up avenues for further research regarding the behaviour of the oesophageal muscular tube with transection and re-anastomosis for rare benign abnormalities.

Introduction Kidney and liver cysts in autosomal dominant polycystic kidney disease (ADPKD) can compress the inferior vena cava (IVC), but IVC compression prevalence and its risk factors are unknown. Methods Patients who have ADPKD (n = 216) with abdominal magnetic resonance imaging (MRI) studies and age-/sex-matched controls (n = 216) were evaluated for IVC compression as well as azygous vein diameter (a marker of collateral blood flow) and IVC aspect ratio (left-to-right dimension divided by anterior-to-posterior dimension with a value of 1 corresponding to a circular (high pressure) IVC caudal to compression. Results Severe IVC compression (≥70%) was observed in 33 (15%) ADPKD subjects and mild compression (≥50% to 40 years old, with Mayo Clinic class 1D/E, and in females with ht-LV > 2000 ml/m., Graphical abstract

BACKGROUND Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP. Our primary aim was to assess the effect of PNB on postoperative ISP, following video-assisted thoracic surgery (VATS). METHODS This prospective, randomized, patient-blinded, single-institution trial was registered at the University Hospital Medical Information Network (UMIN000030464). Enrolled patients had been scheduled for VATS under general anesthesia with epidural analgesia. Patients were randomly allocated to receive infiltration of the ipsilateral phrenic nerve at the azygos vein level with either 10 mL of 0.375% ropivacaine (PNB group) or 0.9% saline (control group) before chest closure. Postoperative ISP was assessed using a numerical rating scale (NRS, 0-10) at rest at 2, 4, 8, 16, and 24 hours. The incidence of ISP was defined as the proportion of patients who reported an NRS score of ≥1 at least once within 24 hours after surgery. In the primary analysis, the proportion of patients with ISP was compared between PNB and control groups using the χ2 test. NRS values of ISP and postoperative incision pain within 24 hours were investigated, as was the frequency of postoperative analgesic use. Incision pain was assessed using an NRS at the time of ISP assessment. Finally, the incidence of postoperative nausea and vomiting and shoulder movement disorders were also evaluated. RESULTS Eighty-five patients were included, and their data were analyzed. These patients were randomly assigned to either PNB group (n = 42) or control group (n = 43). There were no clinically relevant differences in demographic and surgical profiles between the groups. There was no significant difference in the incidence of ISP (the control group 20/43 [46.5%] versus the PNB group 14/42 [33.3%]; P = .215). The severity of ISP was lower in the PNB group than in the control group (linear mixed-effects model, the main effect of treatment [groups]: P < .001). There were no significant differences between groups in terms of postoperative incision pain. The frequency of postoperative analgesic use was significantly higher in the control group (Wilcoxon rank sum test, P < .001). Postoperative nausea and vomiting did not significantly differ between the 2 groups. There were no changes in the range of shoulder joint movement. CONCLUSIONS Azygos vein level PNB did not significantly affect the incidence of ISP after VATS.

An azygos vein varix was incidentally discovered in a 26-year-old man. Owing to the potential risk of pulmonary emboli, we implanted a covered stent in the superior vena cava, effectively excluding the varix. Eighth months later, the varix was thrombosed and involuted. (Level of Difficulty: Advanced.), Graphical abstract

A 28-year-old woman with polysplenia was referred to our hospital for atrial lead failure. She had undergone an intracardiac repair (ICR) for incomplete atrioventricular septal defect and the implantation of epicardial pacing leads due to complete atrioventricular block at the age of 1 year. When she was 13 years old, an endocardial dual-chamber pacemaker was implanted via the right subclavian vein because of epicardial lead failure. The contrast-enhanced computed tomography scan revealed an inferior vena cava defect with an azygos vein connection to the superior vena cava, occlusion of the right brachiocephalic vein, a defect of the left brachiocephalic vein, and a persistent left superior vena cava ligated at the ICR. Therefore, lead exchange was indicated. During the operation, the temporary pacing lead and the guidewire for emergent deployment of the Bridge Occlusion Balloon® were advanced through the azygos vein and placed at the right ventricle and the hepatic vein, respectively. Both 11-Fr and 13-Fr mechanical rotational dilator sheaths were needed for the lead extraction owing to dense calcification and tight adhesions. The atrial lead was successfully extracted without any complications despite extremely restricted venous access. A new atrial lead was inserted through the space created by the 13-Fr sheath.

Background With the popularization of thoracoscopic surgery, more and more macrovascular malformations have been reported. Understanding some vascular malformations with relatively fixed anatomical site and their range of drainage could avoid severe complications during the surgery. Persistent left superior vena cava (PLSVC) is a common thoracic vascular malformation, and is always combined with other cardiovascular dysplasia. As for the patient with upper left lung cancer in this case, he had PLSVC and left azygos vein, and non-metastatic enlargement of the lymph nodes at the same time, which had influenced the decisions on surgery and treatment. We made a summary of experience regarding this. Case presentation A 46-years-old male patient, his CT found a space-occupying lesion in the superior lobe of the left lung. The chest CT showed that the patient had PLSVC and left azygos vein, and multiple enlarged lymph nodes in the mediastinum. The patient received thoracoscopic upper left lung lobectomy and lymph node dissection. It was discovered that the left azygos vein had a concealed form, which influenced the lymph node dissection. The post-surgery pathology showed that there was squamous cell carcinoma in the upper left lung (pT2bN0M0 p Phase IIA) and no cancer metastasis with the lymph nodes. The patient had a good post-surgery recovery. Conclusions PLSVC is not rare, and is always combined with other vascular malformations. If discovering PLSVC before surgery, we suggest completing chest enhanced CT and vascular reconstruction, to find out other cardiovascular malformations that may exist. Left azygos vein is a rare vascular malformation, but it has a relatively fixed anatomical site, and always co-exists with PLSVC, therefore, understanding anatomy of left azygos vein is good for preventing accidental damage. Especially when performing surgery above the left pulmonary artery trunk, attention shall be paid to preventing damage to the left azygos vein. In addition, as for the patient with the diagnosis of lung cancer before surgery, it is not reliable to judge whether there is metastasis or not merely according to the size of the lymph nodes, instead, PET-CT or needle biopsy is recommended.

For critically ill patients, central venous catheterization may not always be placed in a correct tip position, even when guided by ultrasound. A case of inadvertent catheterization into azygos vein is described.

Inferior vena cava (IVC) anomalies, such as the absence of an intra-hepatic IVC or IVC hypoplasia, are rare. Usually, these anomalies are asymptomatic and cause few clinical issues. We herien report a 53-year-old woman with IVC anomalies who demonstrated both azygos and portal vein system continuation. Over time, this resulted in gradually progressive portal hypertension due to abnormal hemodynamics. The increased inflow from the IVC to the portal vein system for an extended time may contribute to the development of portal hypertension without liver cirrhosis.

Some patients with intestinal failure, who are dependent on total parenteral nutrition for long periods, suffer from a lack of suitable conventional venous access points, including axillary, external jugular, internal jugular, subclavian, saphenous, and the brachio-cephalic and femoral veins, due to their occlusion. Furthermore, extensive central venous stenosis and/or thrombosis of the superior and inferior vena cava may preclude further catheterization, so uncommon routes must be used, which can be challenging. In such patients, the azygos vein via the intercostal vein is a viable candidate. Thoracotomy-assisted, thoracoscopy-assisted, and cut-down procedures are currently suggested such access. We found that ultrasound-guided percutaneous puncture method was a safe and minimally invasive approach and successfully placed two central venous lines in preparation for small bowel transplantation via two different intercostal veins (ninth and tenth). Although the lung was actually located just below the target veins, an ultrasound provided augmented and clear vision, which contributed to the safe performance of the procedure without the need for invasive surgical intervention, such as thoracotomy, thoracoscopy, or rib resection using the cut-down technique. Furthermore, constant positive-pressure ventilation during vein puncture under general anesthesia also helps avoid venous collapse. Despite carrying a slight risk of light injury to the lung, artery, and nerve along with the vein compared to other procedures, we believe that ultrasound-guided puncture under general anesthesia is feasible as a minimally invasive method.

BACKGROUND Vena cava anomalies are rare congenital defects due to incorrect development during fetal life, ranging from minor asymptomatic anatomic variations to complex life-threatening abnormalities. Echocardiography plays a fundamental role in the diagnosis, with advanced imaging techniques allowing detailed anatomic delineation. Invasive cardiology techniques are a promising therapeutic approach, but surgery is probably the best option when diffuse compromise of the systemic veins is present. CASE REPORT An 8-month-old infant presenting episodes of labial cyanosis and a failure to thrive was diagnosed with severe superior vena cava (SVC) stenosis at the right atrium ostium, with decompression via azygos vein and mild inferior vena cava (IVC) stenosis. The patient was referred for surgery, with IVC enlargement and removal of a fibromuscular tissue band on the anterior aspect of the SVC ostium. At a 6-month follow-up, the patient is asymptomatic, with excellent surgical outcome. To the authors' knowledge, only two cases of congenital SVC stenosis have been previously described.

This study aims to report the Budd-Chiari syndrome clinical research status and progress that has occurred in over nearly 30 years in China, and emphasize the value of imaging in facilitating the diagnosis of Budd-Chiari syndrome based on more than 2500 cases. Findings on ultrasonography, computed tomography, magnetic resonance imaging, and digital subtraction angiography images are used to propose new Budd-Chiari syndrome types and subtypes. The new subtype classification presented here has important value for guiding interventional treatment. This study also proposes a new concept of anatomical and functional obstruction of hepatic vein that stresses the compensatory value of accessory hepatic vein and azygos vein and describes the risk of manipulation of the communication branch of inferior vena cava obstruction in interventional therapy.

Digestive system complications are among the most important causes of postoperative poor quality of life after open and conventional laparoscopic splenectomy and azygoportal disconnection (CLSD). We firstly developed a modified vagus nerve-preserving laparoscopic splenectomy and azygoportal disconnection (MVLSD). In this study, we aimed to evaluate whether MVLSD is feasible and safe and to determine whether MVLSD can effectively eliminate postoperative digestive system complications, in comparison with CLSD. In this randomized controlled single-center study, 60 patients with cirrhosis were randomly assigned to undergo either CLSD (n = 30) or MVLSD (n = 30) between April and December 2018. The primary outcome was delayed gastric emptying (DGE). Endoscopic physicians were blinded to group assignments. One patient who received MVLSD withdrew from the study. There were no significant differences in intraoperative blood loss, incidence of blood transfusion, time to off-bed activity, time to first flatus, and postoperative hospital stay between the two groups. Compared with CLSD, operation time and incidences of DGE, diarrhea, epigastric fullness, and overall postoperative complications were all significantly reduced in the MVLSD group (all P

Purpose: The aim of this study was to investigate the clinical effectiveness of azygos vein preservation when using a thoracoscope in the operation for type III esophageal atresia for children. Mat...

Anterior surgical approaches to the thoracic spine are common procedures for the treatment of many diseases of the thoracic spine. Purpose of this anatomic study is to investigate the course of the segmental vessels of the thoracic spine for the anterior and lateral transthoracic approach from the right side. 26 formalin-fixed human cadavers (20 femaless/6 male) with an average age of 84.9 ± 8.3 (range 67–97) were included. The segmental arteries and veins of the right thoracic cavity coursing between the third and twelfth thoracic vertebral body have been investigated. To define the localization of the vessels in accordance with the associated vertebral bodies, the distance between the endplates and vessels was measured in the ventral, middle and dorsal parts. The results of the study reveal that not only one, but also two segmental arteries and veins may course over the right hemi-vertebral body, especially in the upper and middle thoracic spine. Furthermore, in the middle and lower thoracic spine (T7–T12) the vessels course over the middle and lower third of the craniocaudal extent of the vertebral body. On the contrary, in the upper thoracic spine (T3–T6), the vessels may course over the entire extent of the vertebral body. Due to these common anatomic variations and variability of the course of the segmental vessels, spinal surgeons should remain careful in the identification of the segmental vessels in order to minimize risk of vascular injury in case of right-sided anterior and lateral approach to the thoracic spine.

Background Esophageal squamous cell carcinoma with tumor thrombus in the arch of the azygos vein has not been reported to date. Neoadjuvant chemotherapy can decrease the stage in patients with advanced preoperative tumor staging, regaining surgical opportunities and significantly prolonging progression-free survival and overall survival. Herein, we present a case of esophageal squamous cell carcinoma accompanied by tumor thrombus in the arch of the azygos vein, and the patient underwent radical surgery after neoadjuvant chemotherapy. Case presentation A 63-year-old male with esophageal squamous cell carcinoma was found to have tumor thrombus formation in the arch of the azygos vein. Four courses of neoadjuvant chemotherapy with the TP regimen (paclitaxel plus nedaplatin) were given. Reexamination revealed a significant reduction in tumor and tumor thrombus volume. Therefore, McKeown radical resection for esophageal cancer and removal of the tumor thrombus in the arch of the azygos vein were performed. Postoperative pathology suggested complete remission of the esophageal tumor and the presence of small focal cancer tissues in the arch of the azygos vein. Conclusion We report a case of esophageal squamous cell carcinoma with tumor thrombus formation in the azygos vein. We conducted radical resection after 4 rounds of neoadjuvant chemotherapy, and the pathological results revealed complete remission of the tumor. We report our experience addressing this rare case, and we hope to find the underlying mechanism of tumor thrombus formation and whether it has any effects on prognosis in our future study.

A 43-year-old asymptomatic patient was diagnosed with an azygos vein aneurysm on contrast-enhanced computed tomography; at the 5-year follow-up, contrast-enhanced computed tomography revealed development of an azygos vein aneurysm. However, preoperative contrast-enhanced computed tomography at our hospital showed thrombus development along with shrinkage of the azygos vein aneurysm. To prevent thrombus dissemination, we decided to perform surgery. The aneurysm was excised via video-assisted thoracoscopic surgery, and the patient recovered uneventfully. Thoracoscopic surgery is effective in managing azygos vein aneurysms and preventing embolisms in thrombotic aneurysms. This procedure was chosen to avoid excessive compression of aneurysms and to prevent pulmonary embolism. This report presents a case of surgical management of an idiopathic azygos vein aneurysm with thrombosis.Clinical registration number 2020-S-20.

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the benefits and harms of preservation of the azygos vein versus ligation of the azygos vein during primary surgical repair of congenital esophageal atresia.

Background Retroaortic course and azygos continuation of aberrant left brachiocephalic vein is a rare venous anomaly, which is usually associated with congenital heart disease and pulmonary artery anomalies. Venous stasis is a cause of pulmonary arterial thromboembolism, which can result from venous anomalies. Case presentation We describe the case of a 91-year-old female admitted to our hospital with shortness of breath diagnosed with pulmonary embolism and infarctions by a CT pulmonary angiogram. CT also showed aberrant left brachiocephalic vein with vascular webs at its retroaortic course and azygos continuation, suggesting chronic venous thrombosis, which was considered to be the suspected source of emboli. Conclusion To our knowledge, this is the first report presenting this vascular anomaly manifesting with chronic venous thrombosis and pulmonary embolism. Although rare, awareness and identification of this entity is important, especially in the absence of obvious embolic sources or in patients with recurrent embolus/consolidation. LEARNING POINTS Awareness of congenital anomalous drainage anatomy is important even if there has been a relatively benign clinical course. Alterations in morphology due to age and degenerative change may result in altered flow predisposing to chronic embolic phenomena. Recurrent consolidation may not necessarily be due to infection in the elderly, a recurrent embolic phenomenon may also be a cause, in this case without a common cause such as deep vein thrombosis.

Benign tumors of the esophagus are rare. Among them, leiomyomas are common. Surgical enucleation is indicated in cases, which have symptoms or large tumors. The enucleation through video assisted thoracoscopic surgery has been developed as a preferred approach for the majority of lesions in recent years. However, the complete thoracoscopic enucleation for an esophagus leiomyoma at the level of the azygos vein without cutting the vein and nor using artificial pneumothorax by CO2 insufflations is a challenge for thoracic surgeons. This case report was a 64-year-old female who presented dysphagia and chest pain. Chest computed tomography and esophageal endoscopy displayed an esophageal mass. We used complete thoracoscopic enucleation to treat this condition. The tumor was at the level of the azygos vein. Therefore, it was difficult to remove the tumor without cutting the azygos vein without utilizing the artificial pneumothorax. However, we enucleated it completely with no complications. The complete thoracoscopic enucleation of the esophageal leiomyoma at the level of the azygos vein without cutting the vein without using the artificial pneumothorax should be applied. A methylene blue swallowing study is an alternative method to a barrium swallowing study while the chest tube is still placed in the pleural space.

Atrial septal defect combined with interrupted inferior vena cava (IVC), which is a rare condition, makes it impossible to apply totally endoscopic surgery (TES). The most difficulty is how to drain blood from the posthepatic segment of the IVC. In this study, we report a case of a 44-year-old female patient who was diagnosed with secundum atrial septal defect combined with interrupted IVC with azygos-hemiazygos continuation. This patient underwent successful repair by TES with transthoracic cannulation for the posthepatic segment of the IVC.

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication after vaccination of Oxford-AstraZeneca coronavirus disease 2019 (COVID-19) vaccine (AZD1222) or Janssen COVID-19 vaccine. It makes a rare complication of thrombosis at common and/or uncommon organs with thrombocytopenia after COVID-19 vaccination four to 28 days later and most patients were younger than 60 years of age. We reported the case of a 75-year-old female with end-stage renal disease who received regular hemodialysis. She received Oxford-AstraZeneca COVID-19 vaccination eight days ago and then she suffered from intermittent chest tightness and epigastric pain with tarry stool passage for two days. Severe thrombocytopenia with elevated D-dimer value was noted and computed tomography of the chest showed azygos vein thrombosis. Elevated cardiac enzyme with ST-T change in 12-lead electrocardiogram was also noted. For positive anti-platelet factor 4 antibodies, VITT with myocardial infarction and azygos vein thrombosis was diagnosed.

Patients with genetic disorders are potentially more susceptible to present vascular abnormalities compared to the general population. For these patients, unusual difficulties could appear during a CVC placement procedure that could lead to major complications if venous abnormalities are undiagnosed. Ultrasound and fluoroscopy guidance should be used routinely for all patients in order to avoid complications and catheter misplacement.

Minimally invasive esophagectomy (MIE) for oesophageal cancer has gained wide popularity in recent years due to its improved morbidity and mortality outcomes. We describe our modified technique of MIE in prone position with preservation of the arch of azygos vein. In our experience with 14 patients, the mean operative duration was 378 min (standard deviation [SD] 378 ± 59 min) and the mean blood loss was 390 ml (SD 390 ± 142 ml). The mean lymph node count was 28 (range 17-54). The Visick score was I in 12 (85.7%) patients and II in 2 (14.3%) patients at follow-up. The preservation of azygos vein arch is a technically feasible procedure and may be associated with a better quality of life outcome.

Chylothorax is defined as the accumulation of chyle in the pleural space, mainly by damaging to the thoracic duct. 99mTc-Dextran is a relatively new tracer for lymphoscintigraphy. A 40-year-old woman had recurrent chylothoraxes after thymoma resection and ligation of the thoracic duct owing to intraoperative suspected thoracic duct injury. She underwent lymphoscintigraphies using 99mTc-sulfur colloid and 99mTc-dextran, respectively, to identify the possible leakage site of the thoracic duct. The images showed increased 99mTc-dextran but unimpressive 99mTc-sulfur colloid activity at the leakage site. Based on the results, this patient received surgery anastomosing the thoracic duct and the azygos vein.

Carcinoma of unknown primary rarely occurs in the middle mediastinum. Here, we present three cases of carcinoma of unknown primary in the middle mediastinum, which were treated with surgical resection and adjuvant therapy. Positron emission tomography/computed tomography demonstrated high uptake of 18F-fluorodeoxyglucose in the tumors. Regarding the surgical procedure, dissection of the azygos vein was useful to obtain not only a good exposure of the surgical field but also mobilization of the superior vena cava, which led to safe separation of the tumors from the major mediastinal structures. The dissection and reconstruction of the superior vena cava was required due to extranodal invasion of the tumor in one case. Since the middle mediastinal carcinoma of unknown primary may be T0N2M0 NSCLC, the surgery alone seems to be insufficient treatment for this type of tumors. To evaluate whether the adjuvant therapy is associated with an improved prognosis for the patients with middle mediastinal carcinoma of unknown primary, a further accumulation of cases is required.

Persistent left superior vena cava (PLSVC) is one of the cardiac system abnormalities with a 0.3-0.5% incidence and caused by inadequate obliteration of the left anterior cardinal vein during embryonic development. Prognosis of PLSVC is generally assumed to be good if it is not accompanied by other cardiac system abnormalities. During the routine ultrasound control of a patient at 25th week of pregnancy at the Obstetrics and Gynecology Department of Mersin University, PLSVC anomaly was detected in an intrauterine fetus. Then, intrauterine death occurred and after removal of the deceased fetus, PLSVC diagnosis was confirmed by autopsy. According to the autopsy findings, right superior vena cava (SVC) and azygos vein were found in normal course. PLSVC opened into the right atrium via enlarged coronary sinus. There was no connection between the two SVCs. On the left side of posterior mediastinum, instead of hemiazygos or accessory hemiazygos veins, a vein symmetrical to azygos was opened into PLSVC, similar to the one on the right. No other cardiac anomaly associated with PLSVC or any other pathology in the other parts of body that could be responsible for death was discovered during autopsy. There was no evidence indicating that PLSVC played any role in intrauterine exitus of the present case. However, as mentioned in the literature, the ectopic beats in the atrium wall of patients with isolated PLSVC and enlarged coronary sinus may lead to pathologies in the conduction system of the heart. Considering the intrauterine death of an isolated PLSVC case associated with cardiac conduction pathologies, we recommend that the common assumption of 'isolated PLSVC is not associated with death' should be reviewed by studies on large series and even intrauterine cases should be closely monitored for cardiac arrhythmia.

Background The varices after proximal or total gastrectomy are uncommon because the supplying vessels are all divided. Emergent upper gastrointestinal endoscopy is the cornerstone of first-line management for the diagnosis and treatment of esophageal varices. However, there is no widely accepted standard strategy for esophagojejunal varices. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration. Case presentation A 50-year-old man who had undergone proximal gastrectomy with double-tract reconstruction for esophagogastric junctional cancer 3 months before was admitted to the hospital due to gastrointestinal perforation. We performed emergency surgery and abdominal symptoms and inflammatory response improved postoperative. However, on POD3, he had eruptive bleeding at the just anal side of esophagojejunal anastomosis. Endoscopic clipping was unsuccessful because the mucosa was fragile and easily lacerated. Contrast-enhanced CT scan revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb. Therefore, he was diagnosed as esophagojejunal varices rupture and percutaneous transhepatic obliteration (PTO) was tried for hemostasis. The portal and superior mesenteric veins were catheterized with the percutaneous transhepatic approach. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices. The microcatheter was inserted into the variceal blood supply branch and 10 mL of 5% ethanolamine oleate with iopamidol was injected. After obliteration therapy, the superior mesenteric venogram showed complete occlusion of the variceal supply branch. The patient was discharged from the hospital without any complications after 14 days. Conclusion PTO can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites.

Background/aim Azygos vein aneurysm (AVA) is a rare thoracic pathological entity that mimics a posterior mediastinal mass as well as a right paratracheal mass. Usually asymptomatic, AVA is often accidentally discovered during routine chest x-rays; however, depending on the aneurysm size and complications, some symptoms may be present. The aim of this paper is to report a case of idiopathic AVA and to discuss its aetiology, embryonic origin, symptoms, complications, diagnostic methods and treatments. Case report A 74-year-old female was investigated for diffuse thoracic pain and submitted to standard chest x-ray, which identified a right paratracheal, well-defined, homogenous opacity, considered to be part of the mediastinal shadow. The patient was further submitted to thoracic computed tomography, which confirmed the presence of a tumoral mass at the level of the right paratracheal area. The patient was submitted to surgery and the tumoral mass was resected; however, the tumor proved to be a completely thrombosed aneurism of the azygos vein arch. Conclusion AVA is a rare pathology that must be taken into consideration during the differential diagnosis of right postero-superior mediastinal masses.

Introduction Supine positioning during late pregnancy causes the gravid uterus to compress the inferior vena cava, resulting in dramatic hemodynamic changes. The maintenance of placental perfusion requires maternal circulatory and autonomic adaptations. Women with supine hypotensive syndrome (defined as a drop in systolic blood pressure of anything between 15 and 30 mmHg or an increase in heart rate of 20 bpm, with or without symptoms) may have reduced ability to compensate for the effects of supine positioning. Material and methods Twelve women with uncomplicated pregnancies and no symptoms of supine hypotension (normal) and 10 women with uncomplicated pregnancies who reported symptoms of supine hypotension between 34 and 38 weeks' gestation underwent magnetic resonance imaging in the supine and left lateral positions. Phase contrast images were evaluated to measure blood flow through the aorta, inferior vena cava, superior vena cava and azygos vein. Results Women with symptoms of supine hypotension showed significant reductions in azygos venous flow rate compared with the normal group (-0.15 (-0.30 to -0.01) L/min). Those with symptoms showed no statistically significant compensatory changes in heart rate compared with the normal group (heart rate change 4.5 (-3.1 to 12.1) bpm). Hemodynamic changes in response to positioning were similar across both groups including: a reduction in inferior vena cava blood flow, reduction in cardiac output and an increase in azygos blood flow. Conclusions Maternal hemodynamic adaptations were found to be consistent across groups irrespective of whether the women had symptoms of supine hypotension. In both groups a reduction in blood flow through the inferior vena cava occurred in the supine position with a subsequent reduction in cardiac output. Both groups showed a compensatory increase in blood flow through the azygos vein in order to partially compensate for this. Taking into account the effect of maternal position, women with symptoms were found to have reduced azygos flow compared with asymptomatic women. There was a significant increase in heart rate when the women were supine than when they were in the left lateral position.

We present the case of a child with congenital heart disease repaired in infancy with diffuse central venous occlusions resulting in central venous insufficiency, superior vena cava (SVC) syndrome, and intracranial bleeds. He presented to the catheterization laboratory for multiple transcatheter interventions to recanalize central venous channels which were unsuccessful by conventional methods. Therefore, extravascular venous channels were created to decompress his upper body by creation of a neo-SVC and his lower body with a neo-azygos vein to the neo-SVC. The latter procedure required direct percutaneous access from a paraspinal approach in order to obtain continuity with the azygos vein. At latest follow-up the patient is clinically well and asymptomatic.

The azygos system is the most important pathway for decompression of the superior vena cava (SVC) when a blood flow obstruction to the right atrium is present. Thoracic and mediastinal malignancies, mainly lung cancers, are responsible for 60%-85% of superior vena cava syndrome (SVCS) cases. An uncommon origin of SVCS is primary malignant mediastinal germ cell tumor (PMMGCT) which represent 1%-4% of all mediastinal tumors and can be divided into two broad groups: seminomas and nonseminomatous germ cell tumors (NSGCTs). Primary mediastinal seminomas clinical presentation is often nonspecific, even if the majority of patients present with superior vena cava involvement. Here, we present the radiologic features of asymptomatic azygos system overflow in a patient with primary mediastinal seminoma.

Interruption of the inferior vena cava (IVC) with azygos continuation is a rare congenital anomaly, in which the IVC is interrupted below the hepatic vein and venous return beyond this point is restored by the dilated azygos and hemiazygos veins draining into the superior vena cava. A case of the interruption of the IVC with azygos/emyazygos continuation for the absence of the hepatic segment of IVC, left renal vein duplication, and polysplenia is reported. The embryologic, clinical, and radiological significance are discussed.The diagnosis is suggested by X-ray, but contrast-enhanced multidetector computed tomography is the method of choice to diagnose this venous anomaly and reveals the aberrant vascular structures.Awareness of different congenital anomalies of IVC is important to surgeons and cardiologists and is necessary for radiologists to avoid diagnostic pitfalls and for preoperative planning: they should be remembered because they can influence several surgical interventions and endovascular procedures. Accidental ligation of the azygos vein is fatal and cardiac catheterization using the lower extremity vein is troublesome in patients with this condition. Keywords: Azygos, Hemiazygos vein, IVC interruption, Polysplenia

A 29-year-old non-smoking female with a history of recurrent AML presented with worsening dyspnea. A CT scan revealed an 8 X 7 mm polypoid soft tissue nodule 8 mm distal to the carina in the left mainstem bronchus. She was brought to the operating room and a nearly obstructing soft fleshy tumor in the left mainstem bronchus just distal to the carina was removed with bronchoscopy. Pathology revealed a low grade mucoepidermoid carcinoma 0.8 cm in largest dimension with negative margins. The patient returned for a resection and was intubated with a right mainstem double lumen tube and placed in left lateral decubitus. After posterolateral thoracotomy, the azygos vein was divided to mobilize the esophagus and retract it laterally. Level 4 and 7 lymph node dissection were performed to obtain access to the anterior tracheal and subcarinal spaces. There was minimal dissection lateral to the trachea to minimize risk of ischemia. One centimeter of trachea just proximal to the carina was circumferentially isolated with umbilical tape for retraction. We bronchoscopically confirmed the location for transection and advanced a jet ventilator catheter distally. We resected one centimeter of left mainstem bronchus. We inspected the lumen of the airway to confirm no gross residual disease and confirmed negative pathologic margin before performing an end-to-end anastomosis with interrupted absorbable sutures under both jet and cross-table ventilation. Postoperatively, the patient had an uncomplicated course and was discharged without any supplemental oxygen on postoperative day 6. Final pathology was low grade mucoepidermoid carcinoma, T1aN0.

Objective To assess early complications, mortality rate, and cement leakage in elderly patients who had undergone navigation-based pedicle screw placement of the thoracic and lumbar spine. Methods Eighty-six patients older than 65 years of age who had received cement-augmented pedicle screws for various conditions were retrospectively included between May 2008 and December 2016. Complications, mortality, and cement leakage were determined. All patients had a radiograph as a control. In patients with cement leakage seen on radiographs, a computed tomography scan of the surgical area was also obtained. Results Average age was 73.4 years (range 65–86 years). A total of 319 vertebral bodies with 637 screws were inserted, of which 458 screws were cement-augmented; 348 (76%) of the augmented screws were placed in the lumbar spine and 110 (24%) in the thoracic spine. Cement leakage occurred in 55 of 86 patients, of whom 52 (60%) were asymptomatic. In all cases with cement leakage (asymptomatic or symptomatic), cement could be found in the perivertebral veins: in the inferior vena cava in 25%, in the epidural space in 7%, in the azygos vein in 5%, and in pulmonary arteries in 7%. Conclusions Our study confirms that the use of cement correlates with a high risk of cement leakage in elderly patients. Using computed tomography navigation for screw placement did not reduce the risk of venous cement leakage, but leakage into the epidural space or through a cortical defect seems to be low.