Inferior Vena Cava on the Left Side: Its Relationshipto the Right Ureter. Report of a Case

Inferior Vena Cava on the Left Side: Its Relationshipto the Right Ureter. Report of a Case

THE JOURNAL OF UROLOGY Vol. 101, Feb. Copyright © 1969 by The Williams & Wilkins Co. Printed ·in U.S.A. INFERIOR VENA CAVA ON THE LEFT SIDE: ITS R...

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THE JOURNAL OF UROLOGY

Vol. 101, Feb.

Copyright © 1969 by The Williams & Wilkins Co.

Printed ·in U.S.A.

INFERIOR VENA CAVA ON THE LEFT SIDE: ITS RELATIONSHIP TO THE RIGHT URETER. REPORT OF A CASE MARVIN R. AGRAN

AND

E. ARTHUR KRATZMAN

From the Department of Radiology, Muhlenberg Hospital, Plainfield, New Jersey Transposition of the inferior vena cava, more commonly described as left-sided inferior vena cava, is rare. However, in this day of specialized medicine, when direct inferior venacavography, lymphangiography and ligation or plication of the inferior vena cava are common procedures, it is necessary to be aware of the anatomical variations of this important structure and its relationship to the adjacent structures.

realizes that bilateral inferior vena cava occurs in only 2 to 3 per cent of examined specimens. 2 Including the case herein reported only 19 cases appear in the literature. 3 - 6 However, in our case there was an associated cong;enital lateral dis-

CASE REPORT

A 19-year-old white man was admitted to our hospital with a 1-month history of discharge from his penis and a 1-day history of gross hematuria. He had taken gantrisin for 5 days prior to admission. Physical examination was unremarkable. There were no ulcerations of the penis or abnormal abdominal masses. Urinalysis revealed the presence of white and red blood cells without albumin. Excretory urography revealed normal function bilaterally with the proximal right ureter bowed laterally. No abnormal mass densities were noted. A right retrograde pyelogram revealed the same appearance of the right ureter (fig. 1). To exclude the presence of a retroperitoneal mass or para-aortic nodes as a cause of this apparent displacement, an inferior venacavogram was performed. The venacavogram demonstrated the presence of the vena cava on the left side with vestigial right inferior vena cava and no evidence of caval displacement to suggest para-aortic nodes or retroperitoneal mass (fig. 2). Abdominal exploration was performed confirming that the vena cava was on the left side. The bowed apappearance of the right ureter was attributed to congenital development. DISCUSSION

The rare incidence of the inferior vena cava on the left side, reported as 0.5 per cent, has been thoroughly documented by Reis and Esenther after reviewing 500 anatomical specimens. 1 This low figure is even more fully appreciated when one Accepted for publication March 1, 1968. Reis, R. H. and Esenther, G.: Variations in the pattern of renal vessels and their relation to 1

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Fm. 1. Bilateral uretero-pyelogram demonstrates lateral bowing of proximal right ureter. the type of posterior vena cava in man. Amer. J. Anat., 104: 295, 1959. 2 Milloy, F. J., Anson, B. J. and Cauldwell, E. W. : Variations in inferior ca val veins and in

their renal and lumbar communications. Surg., Gynec. & Obst., 115: 131, 1962. 3 Davachi, A. A., Thomas, J. and Dale, W. A.: Acute spontaneous rupture of an arteriosclerotic aneurysm into an isolated left-sided inferior vena cava. Amer. J. Cardiol., 15: 416, 1965. 4 Dardik, H., Loop, F. D., Cox, P. A. and Keshishian, J. M.: "C-pattern" inferior vena cava: embryogenesis and clinical implications. J.A.M.A., 200: 248, 1967. 5 Gryska, P. F. and Earthrowl, F. H., Jr.: Left-sided inferior vena cava. Arch. Surg., 94: 363, 1967. 6 Becker, F. F. : A singular left-sided inferior vena cava. Anat. Rec., 143: 117, 1962.

FIG. 2. A, inferior venacavogram in anteroposterior position demonstrates vena cava on left side and vestigial right vena cava associated with bowed right ureter. B, inferior venacavogram in cross-table position demonstrates point of cross-over ventral to aorta.

-----A phren. i.nf.

Fm. 3. Anatomical sketch of inferior vena cava on left side and adjacent structures. (Courtesy of Milloy and associates.') 150

INFERIOR VENA CA VA 01'{ LEF'l' SIDE

placement of the right meter. Yvhether this displacement represe11t~ a new and ,specific radiographic feature associated with a vena cava on the left side or an incidental congenital finding will have to await further investigation. Anatomically the inferior vena cava on the left side is formed from the confluence of the common iliac veins posterior to the left common iliac artery. 2 • 7 It then ascends to the left of the aorta until it reaches the left renal where it crosses ventral to the aorta and caudad to the superior mesenteric artery at the level of the renal vessels to regain its normal position to the right of the aorta (fig. 3). An associated right vestigial inferior vena cava whiel1 is formed by the right internal spermatic vein joining with a vein from the right iliac vein may be present. Also of interest, anatomically, is the elongation of the right renal vein, which is a reversal of the normal occurrence. Roentgenologically, we use a. Seldinger puncture technique of the right femoral vein with insertion of a PE 205 catheter mto the right iliac vein. An injection of 30 cc of 50 per cent hypaque is then made with translumbar and supine anteroposterior films taken. The vena cava on the left side with vestigial right vena ca.va was clearly

visualized and demonstrated tlie so-called pattern" and "streaming effect" of the rnf'erior vena cava as it crosses the aorta to rLs 1101 mal position. 4 • 8 The "streaming effect," at 1,]w cross-over level is due to right common iliac venous blood and the dilution or contrast ciated with renal venous inflow. SUMMARY

A patient with the vena cava on the left side described. The anatomic and features of this entity are reviewed. Inferior cavography should be considered i11 a preopenttive evaluation of this structure. The association of congenital lateral positioning of ihc right ureter as a specific finding is 7 Schobinger, R. A. and Ruzicka, F. F.: cular Roentgenology, Arteriography, Phlebog:raphy, Lymphography. New York: The J\fo.c Millan Co., chap. 34, 1964. 8 Huntington, G. S. and McClure, C.F The development of the veins in the domestic cat (Felis domestica) with especial rcfcrnncc l) to the share taken by the supracardinal veins the development of the post cava and and 2) to the interpretation of the tions of the post cava and its found in the adnlts. A.nat. Rec., 20: l-·:30.