LEFT INFERIOR VENA CAVA IN A LIVING KIDNEY DONOR

Abstract

A healthy 32-year-old male was cleared as per our institution’s protocol for a living related laparoscopic donor nephrectomy. Preoperative evaluation included intravenous contrast enhanced computerized tomography (CT), which generated 5 mm sections of the abdomen and pelvis. The CT scan revealed 2 left renal arteries (fig. 1) and a left inferior vena cava (IVC) (fig. 2). The IVC crossed anterior to the aorta at the level of the renal vasculature, returning to its normal right position on its course to the heart. Because the right kidney was larger and had 3 renal arteries, we elected to proceed with a left nephrectomy. The patient underwent an uneventful laparoscopic left donor nephrectomy and the CT findings were confirmed. The left renal vein was stapled and transected at its junction with the left IVC. Neither donor nor recipient experienced any untoward events during the procedure or hospital stay, and the transplant had an excellent immediate result. During 5 to 7 weeks of gestation the cardinal veins form the main drainage system of the embryo. Bilateral supracardinal and subcardinal veins join to form common cardinal veins before exiting the fetus. The right subcardinal vein forms the suprarenal IVC, while the right supracardinal vein forms the infrarenal IVC. Normally, the left subcardinal and supracardinal veins recede. A left inferior IVC is likely the result of a persistent left supracardinal vein,1 which is often associated with a circumcaval ureter, situs inversus or vena caval duplication.2 However, in our case, the left IVC was an isolated finding, without any other associated abnormalities. A review of the literature revealed a single case report of a left IVC identified incidentally during an open donor nephrectomy in 1987.3 Preoperative imaging, including an excretory urogram and an abdominal aortogram, did not reveal the abnormality. Despite this finding, no adverse effects were reported. This case differed from ours in that we used preoperative CT imaging which demonstrated the anomalous vasculature and we removed the donor kidney laparoscopically. In cases of donor nephrectomy, preoperative imaging studies should be carefully reviewed, and the operation should proceed with attention to the surgeon’s comfort level and to donor safety. In our brief experience a left IVC is not an impediment to a left laparoscopic donor nephrectomy.