Hemiazygos Research Articles

Double Inferior Venacava with Anomalous Hemiazygos Vein – A Case Report

ObjectiveDuplication of the inferior venacava (IVC) is a rare variation that is caused by an alteration in the embryogenesis of the cardinal venous system. It is found in 0.3 to 3% of the population. There are various types of double IVC and this case is reported since it is unique among them.Materials and methods: During dissection of an eighty seven year old female cadaver, presence of an IVC was noted on either side of the abdominal aorta. The course and the termination of both the IVCs were dissected. The azygos and the hemiazygos veins were traced into the thoracic cavity till their termination.Results: In the posterior abdominal wall, the right IVC was found to be the continuation of the right common iliac vein and its course and termination was normal. On the left, the common iliac vein continued as the left IVC. Both the IVCs were connected by a venous bridge which coursed deep to the abdominal aorta. The left IVC passed through the medial arcuate ligament and entered the thoracic cavity as the hemiazygos vein. It was the only hemiazygos vein and drained into the azygos vein which was smaller than the hemiazygos vein.ConclusionThe most common type of the double IVC is the termination of the left IVC in the left renal vein which drains into the right IVC. This case had a normal termination of the right IVC and continuation of the left IVC as the hemiazygos vein, which is a rarely reported variant. Double IVC is usually asymptomatic but if unnoticed, may lead to severe hemorrhage in the retroperitoneal surgeries. In the imaging studies, a thrombosed left IVC might mimic retroperitoneal lymphadenopathy. Adequate knowledge of this variant aids in the proper interpretation of radiological images and avoids intraoperative complications.

The impact of aging on the course of the azygos vein.

The human azygos vein (AV) generally runs on the right side of the vertebral column. However, a shift in its course to the middle/left side of the vertebral column, potentially as a result of aging, has been reported. The aim of this study was to understand the relationship between AV displacement and aging. Forty-seven adult cadavers were dissected. When an AV left shift was observed, long axis AV length was measured by calculating the number of vertebral bodies under the vein. We also investigated whether a crossover vein existed between AV and hemiazygos vein at the extreme left shifting point, and whether osteophytes existed along the vertebral column. Forty-four cadavers (94%) had left-shifted AVs. A weak positive correlation between age and the length of the left shift was observed (r = 0.3061, P = 0.0364). Thirty cadavers (64%) had crossover veins at the extreme left shifting point, and 24 cadavers (51%) had osteophytes along the vertebral column. There was no significant relationship between the length of left-shifted AVs and the existence of crossover veins or osteophytes. The possibility of AV displacement to the left as part of the aging process is suggested.

A case of misplaced permacath dialysis catheter

Central venous placement using ultrasound has significantly reduced the complications associated with blind puncture. The central venous catheter can still get misplaced if it follows an anomalous route after appropriate puncture of desired vessel. We report a case of misplaced dialysis catheter into the accessory hemiazygos vein which resulted in a large hemothorax, and we recommend the routine use of a fluoroscope for placement of dialysis catheters so as to avoid serious complications.

Large Paraesophageal Varices Causing Recurrent Hepatic Encephalopathy

Paraesophageal varices connect the coronary vein with the azygos and hemiazygos veins and the vertebral plexus.1 On computed tomographic scans, the prevalence of paraesophageal varices is 10% to 22% in cirrhotic patients with portal hypertension.1,2 Large paraesophageal varices appear to be associated with a higher risk of developing recurrent varices and rebleeding.3 However, little information was provided regarding the relationship between hepatic encephalopathy and large paraesophageal varices.

CT of the bronchopulmonary veins in patients with superior vena cava or left brachiocephalic vein obstruction.

The purpose of this study was to show the arrangement and connections of the bronchopulmonary veins (i.e., vessels draining the bronchi, bronchioles, and pleura in patients with chronic superior vena cava (SVC) or left brachiocephalic vein (LBCV) obstruction using CT. Contrast-enhanced CT scans of the chest of 16 patients with chronic SVC or LBCV obstruction were analyzed retrospectively. Scans were acquired using various standard protocols. The mean age of the patients (10 men and six women) was 63 years (range, 41-86 years). The causes of obstruction were malignancy (7/16, 44%), catheter-related thrombosis (7/16, 44%), chronic fibrosing mediastinitis (1/16, 6%), and unknown (1/16, 6%). The following sites were obstructed: SVC (9/16, 56%), SVC below the azygos vein (4/16, 25%), and lower LBCV (3/16, 19%). The bronchopulmonary veins were opacified via the brachiocephalic, azygos, or accessory hemiazygos veins or their branches. We observed long vessels that could be traced along the lateral mediastinum or alongside the trachea and central bronchi to their termination in the central pulmonary veins from the level of the ostia to segmental divisions. These vessels intercommunicated and gave rise to smaller veins contiguous with the walls of the bronchi and pulmonary arteries. The pulmonary venous connections of the bronchopulmonary veins were more frequent with the lower lobe pulmonary veins. Pericardial and esophageal veins were also opacified through the brachiocephalic or azygos veins and anastomosed commonly with the bronchopulmonary veins. The arrangement and connections of the bronchopulmonary veins in patients with chronic SVC or LBCV obstruction can be depicted by CT; these vessels form an intricate network connecting the systemic and pulmonary venous circulations and can act as systemic-pulmonary shunts.

Effects of simvastatin on heat hock protein 70 after spinal cord ischemia reperfusion injury

Objective To investigate the protective effect of simvastatin on spinal cord ischemia/reperfusion injury through the observation of the changes of heat shock protein 70 (Hsp70).Methods 24healthy adult Tibet mini-pigs of either sex,weighted 20-30 kg,were randomly divided into three groups (n =8),including sham operation group (group C),ischemia/reperfusion group (group I/R) and simvastatin experimental group (group Sim).In group I/R and Sim,the models of spinal cord ischemia/reperfusion were established by the occlusion of thoracic aorta and subclavian artery (70 min).The accessory hemiazygos vein was isolated and the distal end was ligated.In group I/R,1000 ml lactated ringer solution were pumped into the vein and the rate was 860 ml/h during the ischemia time.In group Sim,1000 ml simvastatin solution were pumped into the vein and the dose was 0.25 mg/kg during the ischemia time.Feed the swines of the experimental group simvastatin tablets 80 mg/d,orally for 30 days.After the operation,the motor function scores were recorded at 6,24,48 h (see Taylor motor function scoring system).All eight swines of each group were killed at 30 days after reperfusion,taking the L2-L5 and sacral spinal cord as quickly as possible.The hematoxylin and eosin (HE) staining method and the NISSLE staining method were adopted to observe the morphological changes of neurons and the immunohistochemical method was adopted to detect the changes of Hsp70.Results In group Sim,the 24,48 h motor function scores (3.2 ± 0.3,3.6 ± 0.2 respectively) after operation were significantly higher than that in group I/R (2.2 ±0.4,2.8 ± 0.4 respectively) (P ＜ 0.05).Compared with group I/R,the morphology of neurons in group Sim had a slight damage and higher expression changes of Hsp70 can be found in group Sim (P ＜ 0.05).Conclusion Simvastatin has a significant protective effect on the spinal cord ischemia reperfusion injury and the potential mechanism may be related to the up-regulation of Hsp70. Key words: Simvastatin; Spinal cord; Ischemia/reperfusion injury; Heat shock protein 70; Protection

A giant azygos venous aneurysm caused by the resection of hemangioma.

A 28-year-old man with a persistent cough and a mild fever was transferred to our institution. Computed tomography angiography showed a giant azygos venous aneurysm associated with the dilation of lumbar veins, azygos veins, hemiazygos veins, and intercostal veins (A-D). At the ages of 3 and 18 years, the man had undergone resection of angiomas in the chest wall (approximately 8 8 7 cm) and on the back (approximately 10 8 8.5 cm), respectively. The pathologic diagnosis showed cavernous hemangioma and lymphangioma. After the second operation, he was subsequently injected with ureaphil every 3 months for 18 times in total. However, the computed tomography scan at that time did not show the visible dilation of azygos veins and fertile varicose veins including intercostal veins, lumbar veins, and partial visceral veins, which was significantly different from that of 10 years later. Azygos venous aneurysms are extremely rare. Nakamura et al reported three main types of azygos venous aneurysms caused by different factors. One of them was dilation of the azygos vein induced by increased venous pressure and volume load, as in the cases of heart failure, portal hypertension, right atrial mural thrombosis, and inferior vena caval occlusion. In this case, we believe it was induced by resection of hemangioma, which increased pressure and volume load. To the best of our knowledge, the giant azygos venous aneurysm caused by resection and embolization of cavernous hemangioma in the chest wall and back has never been reported. Azygos venous aneurysms may also be related to traumatic pseudoaneurysm and idiopathic saccular aneurysm. Its differential diagnosis should include other posterior mediastinal masses. However, Gomez et al reported that if it is thrombosed, surgical therapy is necessary to prevent pulmonary embolism. A video-assisted thoracoscopic excision is recommended as the best technique.

Transcatheter Occlusion of Azygos/Hemiazygos Vein in Patients with Systemic Venous Collateral Development after the Bidirectional Glenn Procedure

Objectives: To elucidate the feasibility and treatment effects of transcatheter occlusion of the azygos/hemiazygos vein in patients with progressive cyanosis after performing the bidirectional Glenn procedure. Methods: From January 2007 to May 2011, transcatheter closure was performed on 9 patients (7 males and 2 females) aged 5-15 years (median 9 years). Results: A total of 7 azygos veins and 3 hemiazygos veins were occluded successfully. Coils were employed in 4 of the procedures, patent ductus arteriosus (PDA) occluders in 3, atrial septal defect occluders in 2 and a PDA occluder together with coils in 1 procedure. Immediate complete occlusions were achieved in 9 (81.8%) procedures and trivial residual shunt in 2 (18.2%). The femoral artery oxygen saturation (SaO₂) rose from 81 [interquartile range (IQR) 75-86%] to 88% (IQR 84-91%). Conclusions: Patients with superior vena cava azygos vein collateral channels can be treated successfully by transcatheter occlusion with multiple devices. The device for embolization depends on the extent of the severity of the shunt, the size of the lumen of the azygos vein/hemiazygos vein and the candidate location for occlusion.

One and a half ventricle repair in association with tricuspid valve repair according to "peacock tail" technique in patients with Ebstein's malformation and failing right ventricle.

The aim of this study was to evaluate the outcome in a series of patients with Ebstein's anomaly and a failing right ventricle (RV) undergoing tricuspid valve (TV) repair and bidirectional Glenn cavopulmonary anastomosis (BDG). Between January 2006 and September 2013, 11 consecutive patients diagnosed with severe forms of Ebstein's anomaly and a failing RV underwent TV surgery and BDG. The mean age was 16.5 ± 7 years. Most frequently found symptoms were cyanosis, dyspnea, and arrhythmias. The azygos or hemiazygos veins were left open. The TV was repaired using the "peacock tail" technique, which consisted of total detachment of the anterior and posterior leaflets of the TV and rotation in both directions reimplanting them to the true annulus. The mean follow-up was 3.8 ± 2.4 years (range three months to six years). Hospital mortality was 9% (one patient). TV repair was possible in 10 patients. None of the patients had AV block postoperatively. At one year after surgery, the indexed RV and RA diameter were reduced significantly versus the preoperative data (p = 0.003 and p < 0.001). The mean TVR and indexed TV area were 1.2 ± 0.42 and 1.6 ± 0.6 (mm/m2), significantly lower than preoperatively (p = 0.001 and p = 0.008, respectively). The mean NYHA functional class, SaO2 , and cardiothoracic ratio were significantly improved. The peacock tail technique for TV repair in combination with BDG in patients with Ebstein's malformation and depressed RV function results in TV preservation, a low incidence of recurrent regurgitation, favorable functional status and RV function, and resolution of cyanosis.

Case report: left superior vena cava with associated heart and venous anomalies (719.13)

Cadaveric dissection by first year medical students is an important educational tool in learning normal anatomy, however dissection also provides the opportunity to discover anatomical variations. During a routine heart dissection of a 61‐year‐old male cadaver the superior vena cava (SVC) was found to be on the left side (LSVC), with an absent right SVC. The right brachiocephalic vein passed from right to left to join the left internal jugular and subclavian veins at the LSVC. Upon removal of the heart, it was found that a portion of the right atrium circumscribed posteriorly to the left atrium, where the LSVC entered and connected to an unroofed coronary sinus. The azygos vein presented on the left with a hemiazygos vein on the right. Discovery of this rare anomaly provides a learning tool by exploring its embryological origins and clinical relevance (such as challenges with surgery and placing central lines).

Blood supply of anterior longitudinal ligament: an approach to understand diffuse idiopathic skeletal hyperostosis (543.3)

Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier’s disease is a common entity among elderly and is characterized by ossification of the anterior longitudinal ligament (ALL) of the spine and various extraspinal ligaments.The pathogenesis of abnormal bone growth in DISH is not fully understood. In an attempt to figure out an anatomical explanation of the etiology of such a debilitating disease, the present study investigated the role of blood supply of the ALL.In cadavers of the anatomy lab in Libyan International Medical University, fine dissection of vessels supplying ALL was performed in the vicinity of azygos, hemiazygos veins and descending thoracic aorta; starting from the level T5 till T12 vertebrae. The current work elucidated that the blood vessels supplying ALL ran in ascending manner ranging from oblique to nearly vertical in direction.The present study demonstrated that poor blood supply reaching certain regions of the spine caused by antigravity‐directed blood vessels supplying ALL, may lead to ischemic changes caused by hypoperfusion and thereby ossification of ALL leading to DISH disease. The current results open a new era of investigation of the probable etiology of this disease.Grant Funding Source: Supported by the Libyan International Medical University

VARIOUS ANOMALIES OF THE THORAX

Abstract:During routine dissection of the thoracic region of a 55-year old male cadaver, in the department of Anatomy, Kasturba Medical College, Manipal, various anomalies were noticed in the thoracic region.a) The arch of aorta gave rise to four branches, the right common carotid artery, left common carotid artery, left subclavian artery and a right subclavian artery. The origin of the right subclavian artery was to the left of the midline and in order to reach the right arm, the artery coursed behind both the trachea and oesophagus.b) Cervical rib was present on both the sides.c) Thoracic duct coursed on the same side without crossing to the left at the T5 vertebral level.d)Hemiazygos vein was underdeveloped.

Inferior vena cava anomaly: A risk for deep vein thrombosis

Context:Inferior vena cava (IVC) anomalies have a 0.5% incidence rate and could be associated with other congenital abnormalities. In later stage of the disease, trophic ulcers with or without deep vein thrombosis (DVT) is consistent finding.Case Report:A 29-year-old male patient presented with recurrent lower extremity ulcers. Further workup revealed an absent infrahepatic inferior vena cava, prominently dilated azygos and hemiazygos veins with enlarged retroperitoneal collaterals without DVT.Conclusion:IVC anomaly should be suspected in a young patient presenting with unexplained venous thrombosis and recurrent ulcers of a lower extremity. IVC anomaly would inherently lead to blood flow stasis and endothelial injury. Thus per Virchow's triad, other risk factors for hypercoagulability such as physical inactivity, smoking tobacco, oral contraceptive pills should be avoided and when hereditary thrombophilias or other irreversible risk factors are present, lifelong anticoagulation should be considered.

A Case of Misplaced Permacath Dialysis Catheter

Central venous placement using ultrasound has significantly reduced the complications associated with blind puncture. The central venous catheter can still get misplaced if it follows an anomalous route after appropriate puncture of desired vessel. We report a case of misplaced dialysis catheter into the accessory hemiazygos vein which resulted in a large hemothorax and we recommend the routine use of fluoroscope for placement of dialysis catheters so as to avoid serious complication.

Heterotaxy syndrome associated with left ventricular non-compaction

A 20-year-old asymptomatic man was referred to our clinic for the evaluation of a 2/6 grade systolic cardiac murmur. The ECG was normal. On his transthoracic echocardiography (TTE), subaortic membrane causing peak 25 mm Hg gradient on left ventricular outflow tract as the cause of the murmur (Fig. 1A) and an enlarged coronary sinus (CS) (Fig. 1B) were detected. We also suspected left ventricular non-compaction (Fig. 1C, D). We performed agitated saline injection via left antecubital vein for diagnosis of persistent left superior vena cava (PLSVC) and bubbles reached to CS before right atrium, indicating PLSVC. The injection was repeated via right antecubital vein to evaluate the right superior vena cava (RSVC) because of that the absence of RSVC may be associated with PLSVC. After the injection, the coronary sinus was opacified before right atrium, indicating the absence of RSVC. Left ventricular non-compaction was confirmed with cardiac magnetic resonance imaging (Fig. 2A, B). Thoracal computed tomographic (CT) venography was performed, and it confirmed the PLSVC and also revealed the absence of RSVC (Fig. 3A). Surprisingly, it also demonstrated absent inferior vena cava (IVC). Therefore, it forced us to perform abdominal CT angiography. It revealed the venous return of lower limbs and abdomen maintaining with dilated hemiazygous vein, indicating absent IVC. His abdominal CT faced us to another interesting findings, polysplenia (Fig. 3B). Subsequently, all findings in the entire story reached us to diagnose heterotaxy syndrome (HS). Coexistence of HS, subaortic membrane and left ventricular non-compaction has not been reported in the literature.

Unusual Metastatic Sites From Renal Cell Carcinoma Detected by 18F-FDG PET/CT Scan

Here we describe 2 cases of renal cell carcinoma where we found the unusual metastatic sites from renal cell carcinoma on 18F-FDG PET/CT scans in post-radical nephrectomy status. The first case resolves the venous migration of the tumor as a malignant thrombus arising from a remnant stump of the left renal vein, passing through hemiazygos vein further into the azygos vein and finally into the superior vena cava just before entering into the right atrium. The second case demonstrated extensive skeletal muscle deposits involving the muscles of the trunk as well as upper and lower extremities.

Vena Caval Anomalies

Anomalous vena cavae can have significant implications for procedures on the right side of the heart. We report a rare anatomical configuration in a 44-year-old female, which to the best of our knowledge, is the first report of such an association. She had a bicuspid aortic valve in conjunction with a persistent left superior vena cava (PLSVC) draining into the coronary sinus, and a left-sided inferior vena cava (IVC) draining into a left superior vena cava via the hemiazygos vein. Comprehensive assessment of these anomalies is crucial given the widespread use of invasive cardiac procedures.

English

A rare variant of duplication of inferior vena cava was observed during routine dissection of posterior abdominal wall of a middle aged cadaver. During dissection of the thorax, a large diameter vena azygos was noticed. After completion of thorax dissection, the thoracic cage was removed by cutting at 7th thoracic vertebra .During dissection of the abdomen two Inferior Vena Cava, Right and Left were observed .Right and left inferior vena cava were seen arising from an inter-iliac venous channel present transversely in front of the body of 4th lumbar vertebra. Right inferior vena cava followed its normal course through the liver to the right atrium, while left inferior vena cava after its formation received left renal vein, behaved like hemiazygos vein as it passed behind aorta, then through the aortic opening of diaphragm ascended as vena azygos and terminated in the superior vena cava. Embryogenesis of such an anomaly suggests persistence on the left of one of the longitudinal channels (supra cardinal or subcardinal veins) which normally disappear in early fetal life. Inter post cardinal anastomosis remains persistent in this case as interiliac venous channel. Caval malformations are considered as a new etiologic factor for thrombosis because of venous stasis. Double Inferior Vena Cava is mostly diagnosed accidently while doing radiographic imaging for other reasons. These type of anomalies if thrombosed can be mistaken as pathological lesions such as Lymphadenopathy, Left pyelo-ureteric dilatation or Metastatic testicular carcinoma. Thus knowledge of such anomalies are of immense importance to surgeons and radiologists to avoid

Percutaneous closure of an anomalous vertical vein

We report the case of a 39-year-old male with a history of untreated arterial hypertension. He presented to a community hospital with pulmonary edema and anasarca, and was transferred to our heart center for further investigation and therapy. Echocardiography revealed the enlargement of all four heart chambers including a severely compromised systolic function of both ventricles. Coronary angiography ruled out coronary artery disease. Computer tomography of the thorax was performed to exclude pulmonary embolism. Surprisingly, an anomalous left vertical vein was found, connecting left upper pulmonary veins to the left innominate vein as well as to the left atrium (Fig. 1a). Magnetic resonance tomography confirmed the diagnosis of this anatomical large left partial anomalous pulmonary venous connection (PAPVC) with a pulmonary stroke volume of 86 ml and a systemic stroke volume of 68 ml. The resulting left-to-right shunt was relatively small with a pulmonary to systemic cardiac index (Qp:Qs) of just 1.26 and a shunt stroke volume in the vertical vein of 12 ml. Furthermore, a mild coarctation of the aorta and a minimal late enhancement of the left ventricle could be demonstrated, the latter finding was consistent with hypertensive heart disease. Right heart catheterization revealed moderate pulmonary hypertension with a mean pulmonary pressure of 34 mmHg and a mean pulmonary capillary wedge pressure of 29 mmHg. We decided to close the vertical vein percutaneously. After retrograde intubation of the vertical vein, repetitive angiograms at various heights of the vein were performed to define size and target zone of the closure device. Thereby, a further connection to the right atrium via the accessory hemiazygos vein was found, explaining the missing 6 ml of calculated shunt stroke volume (Fig. 2a). Afterwards, this finding of a strictly posterior originating additional connection could be confirmed by re-evaluation of the initial CT scan (Fig. 1b, c). We decided to use an 18-mm Amplatzer vascular plug II (St. Jude Medical, St. Paul, MN, USA) to occlude both anomalous connections. After positioning the Amplatzer TorqVue 2 Delivery Sheath (St. Jude Medical) in the left atrium, the vascular plug II was advanced. While pull-back of the sheath the plug was positioned in the target zone, which was the distal vertical vein at the orifice of the accessory hemiazygos vein, just above the orifice of the left pulmonary veins. After deployment of the device, there was no more washout into the left innominate vein: neither from the accessory hemiazygos vein nor from pulmonary veins (Fig. 2b), and a pulmonary angiogram confirmed successful closure of the anomalous vertical vein also. Fetal venous circulation is very variable and complex. During normal development of the human fetal venous system the left supracardinal vein connects the accessory hemiazygos vein and the left atrium with the left innominate vein. Normally, this vein occludes before birth. However, in cases of left PAPVC, one or more left pulmonary veins can drain into the left innominate vein via a Electronic supplementary material The online version of this article (doi:10.1007/s00392-013-0597-7) contains supplementary material, which is available to authorized users.

Internal jugular vein duplication with absent carotid sheath detected during ultrasound-guided pediatric central venous catheter placement

To the Editor: Internal jugular vein (IJV) duplication is rare and is often found only incidentally during surgery [1] or imaging [2, 3] or during anatomical studies on cadavers [4]. We encountered an IJV duplication by chance during ultrasound-guided pediatric central venous catheter (CVC) placement. A 4-year-old girl (height, 97 cm; weight, 13.6 kg) presented for repair of tetralogy of Fallot complicated by dextrocardia, polysplenia, right side descending aorta, inferior vena cava defect, partial anomalous pulmonary venous return, and persistent left superior vena cava (SVC). The right SVC led to the coronary sinus and right atrium and the left IJV, confluent with the hemiazygos vein, connected to the left-sided SVC. The patient’s parents provided informed consent for all procedures and for publication of the case report. For CVC placement, the patient was supine with small rolled towels under her shoulders, and her neck extended and rotated approximately 15 to the right. The ultrasound apparatus, equipped with a 6/13 MHz probe (NanoMaxx ; SonoSite, Tokyo, Japan), was kept perpendicular to all planes of the skin. We discovered a 6.3 mm wide 9 4.6 mm thick 9 10.0 mm deep lateral lower left IJV and a 3.4 mm 9 2.7 mm 9 8.2 mm medial upper left IJV (Fig. 1a) at the mid-portion of her neck. The lateral and medial IJV joined caudally near the clavicle (Fig. 1b). The distance between the common carotid artery (CCA) and the duplicate IJVs gradually increased toward the periphery. The lateral lower IJV was successfully punctured (Fig. 1c) with a Jelco Plus 24-G catheter-over-needle device (Smith Medical, Tokyo, Japan). A 0.018-inch guidewire (SafeGuide Microneedle Seldinger Kit; Covidien Japan, Tokyo) was advanced through the outer catheter (Fig. 1d) and the CVC was placed over the guidewire with placement confirmed by chest radiography. There were no complications during placement or after removal of the CVC. IJV duplication has been reported as an incidental finding [1–4]. In this case, we discovered the IJV duplication during ultrasound-guided CVC placement. Our patient was a child with a complex set of congenital anomalies. We speculated that in her case, the IJV duplication was related to polysplenia. Cardiac anomalies in patients with polysplenia are mainly shunting anomalies. In addition, bilateral SVCs have been observed in 6 of 12 previously reported cases, 4 in patients with interruptions of the inferior vena cava. On the other hand, approximately 5–10 % of infants with polysplenia may have no associated anomalies [5]. As noted, in this case the distance between the CCA and the duplicate IJVs gradually increased. The CCA and the IJV usually run parallel and have some overlap in the carotid sheath; in our patient, however, it seemed there was no carotid sheath. In cases of IJV duplication that involve overlap between the lateral or medial IJV and the CCA, which would result in greater risk of mispuncture, ultrasound can enable detailed examination of the anatomical relationships between the IJV and the CCA and promote quality outcomes. K. Kayashima (&) K. Imai K. Murashima Department of Anesthesia, Kyushu Kosei Nenkin Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu-city 806-8501, Fukuoka, Japan e-mail: ken5ji5ka5ya5shi5ma@nifty.com