A Story of Migrating Azygous Vein

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SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Azygous continuation of IVC is a rare anomaly and reported incidence is < 0.3 % in general population1. This anomaly is associated with atrial flutter1, increased incidence of lower extremity deep vein thrombosis1 and asplenia/polysplenia syndromes2. CASE PRESENTATION: A 50-year-old Caucasian male presented with worsening dyspnea and fatigue and was found to be in typical atrial flutter with 2:1 block. Flutter ablation was attempted by a femoral venous access but later the procedure was abandoned due to difficulty in advancing catheter into the right atrium. CT scan of the chest with 3-D reconstruction showed retrocrural continuation of inferior vena cava (IVC) as azygous vein (AZV); passing behind the aorta and draining into the coronary sinus (CS) [Figures 1, 2 and 3]. We used CT angiography with 3-D rendition to plan access. The patient subsequently underwent successful atrial flutter ablation with placement of a diagnostic catheter into the CS and right atrial cavotricuspid isthmus (CTI) via the IVC/AZV and placement of an ablation catheter to the CTI through the left subclavian vein. He was discharged in sinus rhythm on dofetilide and warfarin. DISCUSSION: The unusually large AZV can be confused with retrocural adenopathy or right-sided paratracheal mass2. It has been reported with Scimitar syndrome3 and non-compaction cardiomyopathy4. Recognition of this anatomic anomaly is of paramount importance in invasive procedures like radiofrequency catheter ablation and during cardiopulmonary bypass. CONCLUSIONS: A high index of suspicion shoud be present for patients requiring ablation procedures if operator feels a resistance during procedure and use of sophisticated imaging is definitely helpful recognizing this abnormality and can be helpful in avoiding complications.Our case is unique because AZV drained directly into the coronary sinus which has not been reported before in literature to our knowledge so far. Reference #1: Mamidipally S, Rashba E, McBrearty T, Poon M. Azygous continuation of inferior vena cava. J Am Coll Cardiol. 2010; 56(21):e41. Reference #2: J. Edward Bass, MD, Michael D. Redwine, MD, Larry A. Kramer, MD, Phan T. Huynh, MD, John H. Harris Jr, MD, DSc. Spectrum of Congenital Anomalies of the Inferior Vena Cava: Cross-sectional Imaging Findings. RadioGraphics, 2000; 20,639-652. Reference #3: Celik M, Celik T, Iyisoy A, Ayten O. Scimitar syndrome and azygos continuation of the inferior vena cava diagnosed in an adult--an unusual association. Congenit Heart Dis. 2012: E85-8. DISCLOSURE: The following authors have nothing to disclose: Ali Ghani, Sadaf Mirrani, Ghazi Mirrani, Rizwan Sardar, Ahsan Raza No Product/Research Disclosure Information