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Table of Contents
Year : 2021  |  Volume : 24  |  Issue : 2  |  Page : 234-237
Incidental finding of interrupted inferior venacava during minimally invasive cardiac surgery

1 Department of Cardiac Anaesthesia, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
2 Department of Cardiothoracic and Vascular Surgery, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
3 Department of Interventional Radiology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

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Date of Submission22-Nov-2019
Date of Decision06-Jun-2020
Date of Acceptance22-Mar-2020
Date of Web Publication19-Apr-2021


We report a case of 44-year-old female patient with congenital heart disease, ostium secundum atrial septal defect (ASD) with moderate mitral regurgitation for minimally invasive ASD repair along with mitral valve repair. Venous cannulations were performed through right internal jugular vein and right femoral vein (RFV) and arterial cannulation was accomplished through right femoral artery. Intraoperative transesophageal echocardiography (TEE) could not visualize venous cannula through RFV. However, cardiopulmonary bypass (CPB) was initiated and surgery was proceeded. During surgery, patients abdomen became tense and distened, ontable ultrasound examination of abdomen was done after completion of the surgery to rule out hemoperitoneum but was inconclusive, patient was evaluated further under fluoroscopy in cathlab and found to have interrupted inferior vena cava. Postoperative course of the patient was uneventful. We discuss the importance of preoperative evaluation and the role of TEE in placement of cannulas during minimally invasive cardiac surgery.

Keywords: Azygous vein, interrupted inferior venacava, minimally invasive cardiac surgery, transesophageal echocardiography

How to cite this article:
Singh SS, Palangadan S, Yadav M. Incidental finding of interrupted inferior venacava during minimally invasive cardiac surgery. Ann Card Anaesth 2021;24:234-7

How to cite this URL:
Singh SS, Palangadan S, Yadav M. Incidental finding of interrupted inferior venacava during minimally invasive cardiac surgery. Ann Card Anaesth [serial online] 2021 [cited 2022 Jan 24];24:234-7. Available from:

Interrupted inferior vena cava (IVC) is a rare congenital anomaly with incidence of 0.6–2% of patients with congenital heart disease and <0.3% in normal individuals.[1] Interrupted IVC may go unnoticed during early life and may be incidentally detected during radiological examination or vascular interventions. However, when a patient with interrupted IVC undergoes a minimally invasive cardiac surgery, it becomes a challenging case to the whole team.

A 44-years-old female patient, with New York Heart Association-II heart failure, presented with dyspnea on exertion for 5 months. She was a known case of hypothyroidism on Tab Thyroxine 75 microgram from past 1 year. She was diagnosed to have a large ostium secundum atrial septal defect (ASD) with moderate mitral regurgitation (MR) because of cleft in anterior mitral leaflet (AML). Her baseline laboratory and biochemical investigations were normal. Electrocardiogram (ECG) showed normal sinus rhythm with heart rate of 75/min, right ventricular hypertrophy with incomplete right bundle branch block. Coronary angiography showed normal coronaries. She was planned for minimally invasive closure of ASD and mitral valve repair. Anaesthesia was induced as per institutional protocol and transesophageal echocardiography (TEE) probe (iE33 Philips with X7-2t probe) was inserted. The transthoracic echocardiography findings were confirmed by TEE examination [Figure 1] and [Figure 2]before cardiopulmonary bypass (CPB). CPB was established by right femoral artery (19F Biomedicus), right femoral vein (22F Edwards) and right internal jugular vein (IJV) (16F Edwards) cannulation aided by TEE. The guide wire was not seen passing from IVC to the right atrium (RA); however, the guide wire was seen coilled in the RA and hence femoral vein was cannulated suspecting technical reasons for nonvisualization of guide wire at IVC–RA junction. Full flows was established aided by vacuum assisted venous drainage. A two inch right sub-mammary incision was placed and pleura entered through the 4th intercostal space. Patch preserving antephrenic pericardiotomy was done and pericardium cradled. Superior venacaval (SVC) and IVC snares were placed. Chitwood cross clamp was passed via second intercostal space and aorta cross clamped. Antegrade aortic root delNido cardioplegic arrest was achieved. On snaring the SVC and IVC, there was a reduction in venous return which was managed by addition of volume, cooling with a little reduction in flow. Oblique right atriotomy was done and the cleft in AML was repaired with interrupted 4–0 prolene

sutures and ASD was closed with pericardial patch. About 40 min after cross clamping, significant abdominal distention was noticed and retroperitoneal hematoma was suspected. After closure of the right atriotomy, caval snares were released. On removing the IVC snare, the abdominal distension gradually reduced and venous return significantly improved. De-airing was done, cross clamp was released and the patient was weaned from CPB with mild inotropic support. Total cross clamp time was 127 min and CPB time was 214 min. PostCPB TEE examination showed no residual ASD, mild MR, and femoral venous cannula in abnormal position [[Figure 3] and Video 1], considering the possibility of retroperitoneal hematoma due to cannulation, an emergency on-table ultrasound scan of the abdomen was done and it showed no peritoneal collections. Half dose protamine was given and the femoral artery and right IJV cannulae were removed. Patient was shifted to cath lab with right femoral venous cannula insitu for fluoroscopic study and the initial fluoroscopy confirmed the femoral venous cannula was just above the diaphragm [Figure 4]. A 9F Long sheath was introduced through femoral venous cannula and venocavogram was done which showed dye opacifiction of azygous venous system entering the svc [[Figure 5] and Video 2].

Injection into right iliac vein showed opacification of the bilateral iliac veins, the hepatic part of IVC was not visualized, and contrast was seen filling through the lumbar venous plexus into the azygous venous system [[Figure 6] and Video 3].

Interrupted IVC with iliac veins draining through lumbar venous plexus into azygous venous system was confirmed. There was no contrast leakage into the peritoneum, so remaining protamine was given and femoral venous cannula was removed. After 6 hours of post-operative ventilation, she was extubated, and postoperative period was uneventful. Her postoperative lab values did not show any signs of hepatic congestion. Postoperative follow-up after one year showed favorable outcome.
Figure 1: Mid-oesophageal modified bicaval view showing ostium secundum ASD

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Figure 2: 3D surgeons view showing cleft AML

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Figure 3: Mid-oesophageal hepatic vein view showing femoral venous cannula in abnormal position

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Figure 4: Fluoroscopy image showing femoral venous cannula

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Figure 5: Venogram showing dye opacification of azygous venous system

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Figure 6: Venogram showing contrast filling lumbar venous plexus, azygous venous system with absent hepatic part IVC

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IVC embryogenesis starts during 6th to 8th week of intra uterine life, IVC is formed by fusion and regression of postcardinal, sub cardinal, and supra cardinal veins, failure of the fusion leads to interrupted IVC.[2]

Evaluation of congenital heart disease by trans-thoracic echocardiogram ideally should follow a comprehensive sequential segmental approach, whereby the situs, systemic venous and pulmonary venous drainage, atrial, ventricular and great arterial relations are systematically studied. In our patient, the drainage of IVC to right atrium was not confirmed by preoperative echocardiogram. Intra operative TEE done to guide the cannula position showed the coiled guide-wire in the right atrium, but the course of the guide-wire via IVC to right atrium was not clearly demonstrated.Ideally, the guidewire should be seen first in IVC in mid-esophageal hepatic vein view followed by entry of guide wire in to RA in mid-esophageal bicaval view.[3] In our patient, the guide-wire has probably entered the RA through the SVC via the azygos vein. The presence of azygous and hemiazygos vein can also be appreciated using TEE in mid-esophageal descending thoracic aorta shortaxis view.[4] Retrospectively, we recognized that, instead of the supra-hepatic portion of the IVC, which was absent in this patient, we had clamped the hepatic vein confluence which was directly draining to the RA. This resulted in obstruction of hepatic and portal venous return with resultant hepatic venous congestion and abdominal distension. During surgery we thought abdominal distention was due to retroperitoneal haematoma (RPH), RPH with abdominal compartment syndrome requiring surgical decompression during minimally invasive cardiac surgery (MICS) has been reported.[5]

MICS provides definite advantages to the patient in terms of shorter hospital stay, avoidance of sternotomy, early return to work and improved cosmesis. However, for a MICS to be successful, meticulous preoperative assessment of venous and arterial anatomy and intra-operative TEE are imperative for smooth cannulation and better procedural outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Matsuoka T, Kimura F, Sugiyama K, Nagata N, takatani O. Anomalous inferior vena cava with azygos continuation, dysgenesis of lung, and clinically suspected absence of left pericardium. Chest 1990;97:747-9.  Back to cited text no. 1
Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of inferior vena cava: Review of embryogenesis and presentation of a simplified classification. Br J Radiol 1974;47:206-13.  Back to cited text no. 2
Jha AK, Malik V, Hote M. Minimally invasive cardiac surgery and transesophageal echocardiography. Ann Card Anaesth 2014;17:125-32.  Back to cited text no. 3
[PUBMED]  [Full text]  
Blanchard DG, Sobel JL, Hope J, Raisinghani A, Keramati S, DeMaria AN. Infrahepatic interruption of the inferior vena cava with azygos continuation: A potential mimicker of aortic pathology. J Am Soc Echocardiogr 1998;11:1078-83.  Back to cited text no. 4
Iribarne A, Easterwood R, Yang J, Dayal R, Argenziano M. Retroperitoneal hematoma with abdominal compartment syndrome during minimally invasive mitral valve replacement. Ann Thorac Surg 2010;89:e17-8.  Back to cited text no. 5

Correspondence Address:
Subash Sundar Singh
Department of Cardiac Anaesthesia, Kerala Institute of Medical Sciences, P.B No: 1, Anayara, Trivandrum - 695 029, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_170_19

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]