Venous Shunt Research Articles

VENOUS CONDUITS IN CORONARY SURGERY: OLD PROBLEMS — NEW SOLUTIONS

The introduction of autovenous coronary artery bypass grafting (CABG) marked the era of surgical revascularization in patients with coronary artery disease. It provided effective treatment for angina and significantly improved the long-term prognosis. Venous transplants today remain the most popular conduits in coronary surgery due to their availability, ease of harvesting, and the absence of length restrictions. Despite the advantages of autovenous CABG, the main disadvantage is the high incidence of venous graft failure, which represents an important and unresolved problem in cardiac and cardiovascular surgery. On the other hand, the traditional allocation of a large saphenous vein implies the dissection of soft tissues throughout the length of the isolated conduit. Traumatic dissection causes a long-lasting persistent pain syndrome after surgery, frequent abnormalities in skin sensitivity, and a high incidence of wound complications in the lower extremities. These complications lengthen the period of rehabilitation of patients and worsen the quality of life. There is an approach of isolating the vein in a block with surrounding tissues to optimize the long-term functioning of the venous shunt, however, this technique is even more traumatic than the traditional method, and therefore its use is limited in practice. On the other hand, the introduction of minimally invasive methods of isolation allowed to reduce the incidence of wound complications and to improve the cosmetic result, but there is no convincing data regarding the effect on the consistency of shunts in the long-term postoperative period. The problems associated with the use of venous conduits in CABG are multifaceted, and their solutions are necessary to improve the effectiveness of surgical revascularization.

VENOUS CONDUITS IN CORONARY SURGERY: OLD PROBLEMS — NEW SOLUTIONS

The introduction of autovenous coronary artery bypass grafting (CABG) marked the era of surgical revascularization in patients with coronary artery disease. It provided effective treatment for angina and significantly improved the long-term prognosis. Venous transplants today remain the most popular conduits in coronary surgery due to their availability, ease of harvesting, and the absence of length restrictions. Despite the advantages of autovenous CABG, the main disadvantage is the high incidence of venous graft failure, which represents an important and unresolved problem in cardiac and cardiovascular surgery. On the other hand, the traditional allocation of a large saphenous vein implies the dissection of soft tissues throughout the length of the isolated conduit. Traumatic dissection causes a long-lasting persistent pain syndrome after surgery, frequent abnormalities in skin sensitivity, and a high incidence of wound complications in the lower extremities. These complications lengthen the period of rehabilitation of patients and worsen the quality of life. There is an approach of isolating the vein in a block with surrounding tissues to optimize the long-term functioning of the venous shunt, however, this technique is even more traumatic than the traditional method, and therefore its use is limited in practice. On the other hand, the introduction of minimally invasive methods of isolation allowed to reduce the incidence of wound complications and to improve the cosmetic result, but there is no convincing data regarding the effect on the consistency of shunts in the long-term postoperative period. The problems associated with the use of venous conduits in CABG are multifaceted, and their solutions are necessary to improve the effectiveness of surgical revascularization.

Safety and efficacy of transcatheter embolization in patients with massive hemoptysis due to intercostal pulmonary venous shunts.

Bronchial hemoptysis induced by intercostal pulmonary venous shunt (IPVS) is clinically rare. Pulmonary lesions on pleural surface may facilitate opening of vascular network. This retrospective study investigated safety and efficacy of embolization agents with small-particle embolization treating patients with massive hemoptysis due to IPVS. Patients with massive hemoptysis (n = 207) underwent computed tomography angiography of bronchial artery. Depending on results, selective or superselective digital subtraction angiography and embolization were performed. Polyvinyl alcohol (300-500μm), or microcoils combined with polyvinyl alcohol, was utilized according to IPVS volume. Vital signs of each patient were closely monitored. Of 207 patients with massive hemoptysis, 24 (11.6%) had IPVS syndrome. Patients with IPVS had concomitant bronchiectasis (54.2%), followed by tuberculosis (25.0%). Embolizations were performed in 39 culprit intercostal arteries; 37 (94.9%) of these were successfully embolized. Of the latter, 30 and 7 arteries were embolized, respectively, by polyvinyl alcohol alone or polyvinyl alcohol particles combined with microcoils. Embolization failed in one case because the agents could not enter the intercostal artery. If artery dissection occurred during procedure, microcoils were utilized to embolize the main artery. No skin necrosis, spinal artery embolization, or death occurred. Immediate clinical success was achieved in 22 patients (91.7%) after embolization. Two patients (8.3%) experienced recurrence of hemoptysis. Only four patients experienced mild hemoptysis during the 24-month follow-up with the efficiency of 75.0%. Intercostal artery embolization with 300-500μm alone or combined with microcoils is a safe and effective procedure in patients with IPVS-induced bronchial hemoptysis.

Anatomical characterization of the inferior petrosal sinus and adjacent cerebellopontine angle cistern for development of an endovascular transdural cerebrospinal fluid shunt

Background and purposeWe evaluated the inferior petrosal sinus (IPS) and adjacent cerebellopontine angle (CPA) cistern as a potential implantation site for a novel venous endovascular transdural CSF shunt concept to...

Prenatal sonographic characteristics and postnatal outcomes of umbilical-portal-systemic venous shunts under the new in-utero classification: A retrospective study.

An in-utero re-classification of umbilical-portal-systemic venous shunt (UPSVS) has recently been proposed. We retrospectively reviewed the sonograms of a large cohort of fetuses, identified and analyzed UPSVS cases, and presented the prenatal sonographic characteristics, birth outcomes, and follow-up results following the new classification system.Sonograms and clinical data of all participants who visited our departments from April 2016 to July 2018 were retrospectively reviewed. Identified cases of UPSVS were analyzed according to the new classification: Type I: umbilical-systemic shunt (USS); Type II: ductus venosus-systemic shunt (DVSS); Type IIIa: intrahepatic portal-systemic shunt (IHPSS) and Type IIIb: extrahepatic portal-systemic shunt (EHPSS). Postnatal follow-ups ranged from 3 months to 1 year.A total of 10 UPSVS cases were identified in 61,082 fetuses: 4 with Type I, 3 with Type II and 3 with Type IIIa. All 4 cases of USS had complete agenesis of the portal venous system, and had the umbilical vein drained into the inferior vena cava. Two USS cases also had trisomy 21. Pregnancy was terminated in all cases with a Type I shunt. Two fetuses with DVSS had normal portal venous system and were born full term. The pregnancy of 1 DVSS case was terminated due to the detection of trisomy 21. Three cases were IHPSS with full-term birth. One had chromosomal abnormality and 1 had surgery to repair the shunt 12-days post birth. In the 2 cases that did not receive repair surgery, sonographic examination revealed the portal-hepatic venous shunt was not closed at the 6-month follow-up period. However, the 1 case that had repair surgery appeared healthy at the 3-month follow-up period.UPSVS is extremely rare. Type I shunts have the poorest prognosis, and the presence of the intrahepatic portal venous system is key to live birth in UPSVS regardless of types. Chromosomal abnormalities and other organ anomalies can occur in any types of UPSVS. Therefore, karyotyping and examination of other organs should be performed once UPSVS is detected.

Intrahepatic Portosystemic Venous Shunt in a Non-Cirrhotic Adult Female with Encephalopathy

Introduction: Intrahepatic portosystemic venous shunts (IPSVS) are rare anomalous vascular connections within the liver that are often asymptomatic. However, significant shunting of blood may present as encephalopathy. Cross sectional imaging and Doppler studies are essential to characterize the shunt and determine portosystemic shunt ratios. High flow shunts may be treated using coil embolization or surgery. Result: We present the case of a 57-year-old previously asymptomatic lady who was admitted for confusion and behavioral change. Work-up revealed deranged liver function and hyperammonemia. Triphasic CT scan showed an aneurysmal connection between the right anterior portal vein and the middle hepatic vein measuring 1.9 cm in widest diameter. The left portal vein was small. The liver had homogenous parenchyma and smooth borders. Aside from small hepatic cysts, there were no other lesions detected. Doppler ultrasound showed turbulent flow across the connection with a portovenous shunt ratio of 73%. The size of the shunt precluded safe coil embolization. Surgical treatment was then opted for and she underwent a hepatotomy from the superior border of the liver until the aneurysmal shunt connection was identified and isolated. The connection was then divided between clamps and the stumps sutured close. Blood flow in the left portal vein then increased immediately. Her postoperative course was unremarkable and she was discharged improved. She remains well 8 months after surgical correction of the shunt. Conclusion: A high index of suspicion should prompt the search for IPSVS in patients presenting with encephalopathy in the absence of liver cirrhosis. Imaging studies are essential in assessing the type and severity of the portovenous shunting and in guiding the management. Symptomatic patients with high shunt ratios should be treated promptly using interventional radiologic procedures or surgery.

Extended left hepatectomy with temporary porto-caval shunt under total hepatic vascular exclusion and liver cooling

Background: We report the case of a 79-year-old patient with voluminous cholangiocarcinoma that was located in the left liver extended to segment V. A left extended hepatectomy is planned, under temporary porto-caval shunt (TPCS) and Liver Cooling (LC) Methods: The patient was operated on 5 days before from left portal vein ligation. The first step is preparing for TPCS: the right suprahepatic and the trunk of the main and left suprahepatic veins are controlled and the liver is fully mobilized to expose and control the infra and suprahepatic inferior vena cava with a tape. The pedicle is prepared dissecting the portal vein independently from the artery and bile duct. Results: The second step is to realize porto-caval shunt: the graft is sutures between the inferior vena cava and the main trunk of the portal vein. The film reports step by step this operative procedure, until the cannulation of the portal vein. The third step starts with the extended left hepatectomy. The transaction is realized using conventional bipolar electrocautery and ultrasonic dissection. The mains segmental pedicles were controlled using ligation, in particular the pedicle of segment VIII that must be preserved. Conclusion: Liver is rewarmed, cannula is removed. The interest of this film is: i) the realisation of the venous shunt using a vascular graft and ii) the major hepatic resection, which can be managed safely, taking the time to attentively perform a meticulous haemostasis, thanks to the temporary portacaval shunt.

Hepatic encephalopathy - current considerations

Hepatic encephalopathy (EH) is a syndrome involving a series of neuropsychiatric abnormalities in patients with hepatocellular damage and/or portosystemic venous shunts in the absence of other cerebral diseases. It is the late consequence of portal hypertension with a high degree of spontaneous or surgically created portosystemic shunts. The pathogenic substrate is the diffuse disturbance of cerebral metabolism due to insufficient processing or shunting of the liver by intestinal toxic nitric products. The clinical evaluation by psychometric tests may reveal minimal EH for an adequate early management and preservation of the integrity of cerebral functions in patients with cirrhosis.

A New Surgical Approach to the Treatment of Renovascular Hypertension by Intervention on the Renal Vein. An Experimental Study

Renovascular hypertension produced by stenosis of the renal artery and its branches is the most common curable form of secondary hypertension. The pathophysiological background is based on activation of the renin-angiotensin-aldosterone system (RAAS), with imbalance between renin production by the kidney and renin degradation by the liver. The aim of this experimental study was to examine whether deviation of renin-rich blood from the renal vein of the affected kidney into the portal circulation by splenorenal venous anastomosis can ameliorate renovascular hypertension. Pigs were used as the experimental model because, in addition to the similarity to humans of their anatomy and physiology, they have been found capable of developing chronic renovascular hypertension. After the establishment of unilateral left renal artery stenosis and hypertension in the pigs, we created a renal-portal venous shunt by means of a splenorenal anastomosis. Ultrasonography (U/S) and angiography were used to evaluate the renal artery stenosis and the renal-portal shunt. Successive measurement was made of arterial blood pressure (BP) and the level of renin in blood samples collected at every stage of the experiment, to evaluate the effectiveness of the procedure. Histological examination was used to evaluate the effects of the renal-portal shunt on the kidney and the liver two months after the surgical procedure. Following the creation of the left renal artery stenosis, both blood renin levels and mean BP increased, as expected, from 1.23±0.06 ng/ml/h and 85.6±0.5 mm Hg at baseline to 4.59±0.02 ng/ml/h and 126±1.76 mm Hg, respectively. After deviation of the renal vein the blood renin levels returned to normal (1.59±0.07 ng/ml/h) with a concomitant reduction of the mean BP to 91±2 mm Hg. Significant correlation was observed between changes in renin levels and mean BP. Both the kidney and the liver remained macroscopically and histologically intact at the end of the experiment. Deviation into the portal system of the renal venous blood from the kidney affected by renal artery stenosis can result in total degradation by the liver of the high amounts of renin generated by the RAAS and ameliorate renovascular hypertension. This surgical strategy could be of benefit to individuals with fibromuscular or atheromatous lesions in the distal region of the renal artery or its branches, which are not amenable to balloon angioplasty or surgical revascularization.

Asymptomatic Intrahepatic Portosystemic Venous Shunt: Case Report and Review of Literature

A spontaneous portosystemic shunt is a rare malformation of the liver vessels. The etiology of these shunts is controversial. They can be divided into acquired (most commonly associated with liver cirrhosis) and congenital. Vascular shunts are asymptomatic in the majority of the patients, and when symptomatic were presented by severe complications. The specific way of management can be selected depended on whether the patient was symptomatic or not, and also on the size of the shunt, shunt ratio and whether it was associated with cancer. We will present a clinical case and discuss the importance of the radiological imaging in the screening, diagnosis and follow up of these anomalies.

Abernethy malformation: Our experience from a tertiary cardiac care center and review of literature.

Abernethy malformation, also called as congenital extrahepatic portosystemic venous shunt, is a rare anomaly involving the portal venous system. Although rare, it is increasingly being reported and is important to diagnose given the adverse clinical consequences in untreated patients. It has myriad of clinical presentations, from being completely asymptomatic to causing hepatic carcinoma, hepatic encephalopathy, severe pulmonary hypertension, and diffuse pulmonary arteriovenous malformation. We describe our experience with five cases in a tertiary pediatric cardiac care center with Abernethy malformation, with review of literature and also discuss possible therapeutic implications.

Current status of endovascular treatment for dural arteriovenous fistulae in the anterior cranial fossa: A systematic literature review.

Anterior cranial fossa (ACF) dural arteriovenous fistulae (DAVFs) are rare, and a systematic review of the literature is lacking. Such a review is necessary, however, so a systematic PubMed search of related studies was performed. Twenty-four studies were identified, reporting on 48 patients, of whom 39 had definite age and sex information and 33 (84.6%, 33/39) were male. The afflicted patients were between 37 and 80 years old (mean 55.6). Among the 48 patients, 28 (58.3%, 28/48) primarily presented with intracranial hemorrhage, 47 (97.9%, 47/48) had feeding arteries from the anterior ethmoidal artery (AEA) of the ophthalmic artery (OA), and 40 (83.3%, 40/48) had bilateral feeding arteries. All of the cases had high-grade Cognard classifications (III-IV). Among the 48 patients, 43 (89.6%, 43/48) had drainage into the superior sagittal sinus (SSS). In addition, 36 (75%, 36/48) patients were treated via transarterial embolization (TAE). Of these patients, 28 (77.8%, 28/36) were managed via the AEA of the OA. Another 12 (25%, 12/48) patients were treated via transvenous embolization (TVE), 11 of whom (91.7%, 11/12) were treated with the trans-SSS approach. Complete angiographic cure was achieved in 44 (91.7%, 44/48) patients, with 4 (8.3%, 4/48) patients suffering from postprocedural complications. All 48 patients had clear descriptions of follow-up outcomes, with 45 (93.8%, 45/48) patients having a good outcome. Thus, when treating ACF DAVFs, endovascular treatment (EVT) can completely obliterate the fistula point and correct the venous shunting. EVT is therefore an effective treatment for ACF DAVF. Although many complications can occur, this approach achieves good outcomes in most cases.

PROGRESS IN SURGICAL TREATMENT OF CHRONIC LOWER LIMB ISCHEMIA

Aim. The study was conducted to expand the variety of ways for surgical treatment of chronic ischemia of lower limbs complicated by the involvement of the femoropopliteal and pedidial arterial segment. Materials and methods. The experience of surgical interventions in 43 male patients aged 52-75 suffering from chronic ischemia of lower limbs complicated by the atherosclerotic involvement of the femoropopliteal and pedidial segment has been summarized. According to the classification by A.V. Pokrovskiy, ischemia of the 3rd stage has been determined in 24 patients (55,8%), while ischemia of the 4th stage complicated by necrosis of the toes (critical ischemia) has been determined in other 19 patients (44,2%). All examined patients have undergone the reconstructive interventions using the prepared lateral subcutaneous vein of the upper extremity as a shunt.Results. During the first day after the operation, the regression of pain syndrome as well as the warming of the lower extremity was indicated in 93% of patients. In 8-12 days after the reconstructive operation, the patients have undergone the 15 necrectomy or toe amputation. In the nearest postoperative period (less than 6 months) no thrombotic complications in the reconstructed segment have been determined. Within the observation period from 6 months to 5 years the bypass patency has been preserved in 71% of patients; ischemia of the 2nd B type has been revealed in all patients with the preserved bypass patency by the clinical examination.Conclusion. Despite the “forced” character of usage of the prepared V. cephalica due to the absence of “traditional” venous shunts as well as the labor intensity of the method, it allows to expand the variety of ways for surgical treatment of patients suffering from chronic ischemia of lower limbs of the 3rd-4th stages complicated by occlusive involvements of the femoropopliteal and pedidial segment.

A rare case of successful recanalization of the anterior interventricular artery through a mammary-coronary graft in a patient 15 years after coronary artery bypass grafting

Progression of atherosclerosis in patients with coronary artery disease (CAD) who underwent surgical treatment, manifests itself in the development of dysfunction of the shunts, and in worsening of the condition of native coronary arteries. Accordingly, there is an increase in the number of patients who require repeated aggressive treatments. In cases where it is technically possible to perform repeated coronary artery bypass graft (CABG) and/or percutaneous interventions (PCI), there is no question of treatment tactics. But there are times when implementation of interventions is associated with a high risk and optimal medication therapy does not have the proper effect. In a patient with multiple lesions of the coronary arteries 15 years after CABG in connection with the progression of atherosclerosis, the occlusion of anterior interventricular artery (AIVA) is distal to the mammary-coronary anastomosis, the occlusion of the venous shunt to the right coronary artery. Effort angina (class III) is caused by myocardial ischemia in the AIVA territory. Patient underwent surgery for recanalization of AIVA through mammary-coronary shunt.

Distal splenorenal and mesocaval shunting at the time of pancreatectomy

BackgroundWhen pancreatic neoplasms occlude or encase the superior mesenteric-portal-splenic vein confluence with abutment of the posterior lateral wall of the superior mesenteric artery, a mesocaval shunt with or without a distal splenorenal shunt allows for safe dissection of the porta hepatis and separation of the pancreatic tumor from the superior mesenteric artery. Herein we report long-term results of the largest known series of portosystemic shunts performed at the time of pancreatectomy. MethodsAll patients who underwent pancreatic resection with a mesocaval shunt or distal splenorenal shunt were identified from our prospective database. Demographics, perioperative treatment, and outcomes were reviewed. ResultsA total of 34 patients underwent mesocaval shunt or distal splenorenal shunt, including 25 at the time of pancreatoduodenectomy, 6 during total pancreatectomy, and 3 after prior pancreatectomy. There were 15 mesocaval shunts, 16 distal splenorenal shunts, 2 combined mesocaval/distal splenorenal shunts, and 1 distal splenoadrenal vein shunt. The mesocaval group included 11 temporary and 6 permanent (3 delayed) shunts. Median operative time was 9 hours (range 6.5–13), median estimated blood loss was 950 mL (range 200–5,000), and median duration of hospital stay was 11 days (range 7–35). Four patients experienced complications that required intervention (Clavien-Dindo grade ≥III), but there were no 90-day mortalities. For patients with adenocarcinoma, median overall survival was 31 months at a median follow-up of 19 months. All but 1 shunt (distal splenorenal) were patent at last follow-up. ConclusionMesenteric venous shunting facilitates a safe and complete tumor resection in patients who require a complex pancreatectomy, many of whom would otherwise be deemed inoperable.

Rare Complications of Portal Hypertension in a Patient With Underlying Focal Nodular Hyperplasia

Introduction: Esophageal variceal ligation (EVL) and sclerotherapy are both considered standards of care in management of esophageal variceal hemorrhage. Minor complications are not uncommon but occasionally, severe and potentially life-threatening sequelae may develop. Case presentation: Patient is a 30-year-old female with history of variceal bleeding due to portal hypertension secondary to noncirrhotic focal nodular hyperplasia (FNH) and resultant portal vein thrombosis that began at age 13 until she underwent banding at age 20. She was also treated with a splenorenal shunt as well as a superior mesenteric vein to inferior vena cava shunt to help reduce portal venous pressure. Evaluation for anemia with esophagogastroduodenoscopy (EGD) revealed an extremely large esophageal varix in the distal esophagus with active bleeding, which initially improved with sclerotherapy. Ten days after, she vomited blood and fainted. Methods: Repeat EGD noted profuse variceal bleeding, requiring intubation for airway protection. Attempts to band the varices were unsuccessful, requiring repeat sclerotherapy. 27 mL of sodium tetradecyl was injected throughout the esophagus. Post-procedure chest X-ray revealed a large left-sided pneumothorax, requiring a chest tube, and esophageal perforation. Portal venous shunt was attempted; however, the anastomosis was thrombosed, so the cryopreserved vein was ligated. Post-operative esophagram showed no obvious leak. CT chest/abdomen/pelvis showed bilateral pleural effusions. Left pigtail catheter was placed and drained 150 mL and grew E. faecalis as well as Candida kefyr; patient was placed on zosyn and fluconazole. Results: Patient was transferred to medical ICU intubated on CPAP, hemodynamically stable. Patient recovered with all catheters removed following prolonged antimicrobial support. She was stable on discharge and placed on beta blocker therapy without further incident. Conclusion: This case is unusual for many reasons. Firstly, the etiology of portal hypertension secondary to FNH; secondly, the continuous complications of portal hypertension despite previous shunting; and thirdly, her development of a massive upper gastrointestinal bleed a week after successful EVL. Although sclerotherapy is still occasionally used after unsuccessful EVL, we must be cognizant of rare but potentially devastating complications. For this patient, prompt recognition followed by appropriate and aggressive management fortunately resulted in a successful outcome with long-term survival.

Ultrasound with Doppler evaluation of congenital hepatic vascular shunts.

Congenital aberrant hepatic vascular communications result from intrahepatic or extrahepatic errors in vascular development or involution during the transition from fetal to newborn hepatic circulation. These hepatic vascular shunts can be fortuitously discovered and asymptomatic, or can cause symptoms of varying severity, often presenting diagnostic dilemmas. Some hepatic vascular shunts resolve spontaneously while others require interventional radiologic or surgical closure. Affected patients are often first studied with real-time and Doppler ultrasound, so radiologists should familiarize themselves with the expected ultrasound findings of these vascular shunts for effective diagnosis, triage and management. In this review, the authors focus on ultrasound and Doppler findings of hepatic vascular shunts with underlying embryology, clinical features and management strategies. Broadly, these aberrant hepatic vascular communications include portosystemic venous shunts (which can be intra- or extrahepatic and include persistent patent ductus venosus), arterioportal, arteriovenous or mixed shunts.

Role of ultrasound doppler examination in choice of surgical tactics in portal hypertension

Introduction: Сhoice of surgical tactics in complicated portal hypertension (PH) is actual.More than 400 examinations of hepatic blood flow in patients with complicated PH, including 16 patients, operated by the method of liver tunneling, were fulfilled. Methods: One hundred protocols were chosen randomly. Comparison of distribution indices revealed different occurrence frequency of ultrasound symptoms of PH, having different etiology. Seventy patients with viral etiology of PH prevailed. Varix dilatation of cardia is revealed in 47% of patients. Splenorenal venous shunt (SRVS) is visualized in 43%, recanalization of umbilical vein - in 23% of patients. All types of anhepatic portosystemic shunts are visualized in majority of patients with cirrhosis of ethanol etiology. Liver is always enlarged in fatty hepatosis. In spite of low linear blood flow velocity in PV, its compensatory dilatation is not typical. Damage of PV architectonics is revealed in patients with subhepatic PH, enlargement of PV diameter is naturally absent, splenorenal venous shunt is always observed. Results: Ultrasound Doppler examination is the method of early diagnosis of PH type, its stage and prognosis of bleeding risk. It permits to choose optimal treatment method and evaluate its efficiency by comparison of indices before and after treatment. Conclusion: Indications to application of splenorenal venous anastomosis are doubtful due to natural formation of shunt in 43% of patients with viral hepatitis and 62% - with ethanol liver cirrhosis. Formation of SRVS in anhepatic PH is a compensatory mechanism. In this situation splenectomy or application of splenorenal venous anastomosis can be fatal.

Sonographic Evaluation of Umbilical Vein

To evaluate intraabdominal course of umbilical vein, its relation with portal vein and ductus venosus and its anomalies. All pregnant women were examined during midtrimester anomaly scan between January 2015 and December 2017. With evaluation of umbilical vein in its intraabdominal course, size of umbilical vein, its relation to the stomach and the gallbladder and origin of ductus venosus were studied in middle and upper abdominal axial and sagittal planes by two dimensional and colour doppler sonography. Anastomosis of umbilical vein with portal vein and its further course was examined and detailed anatomical survey was made to look for associated anomalies. Fetal and neonatal outcome was assessed after delivery. Twelve cases of umbilical vein abnormalities were evaluated. Of them, there were three cases of umbilical vein varix, four cases of persistent right umbilical vein and five cases of abnormal umbilical–portal–systemic venous shunt were noted. Examination of the intraabdominal course of umbilical vein and ductus venosus should be a part of second trimester anomaly scan. Proper knowledge of umbilical portal venous system is mandatory.

Ductus venosus agenesis and fetal malformations: what can we expect? - a systematic review of the literature.

Background The ductus venosus agenesis (DVA) is a rare condition with a variable prognosis that relies partly on the presence of associated conditions. The purpose of our study was to analyze the literature regarding the post-natal outcome of fetuses with DVA associated with fetal malformations, in order to discuss the best management options for couples. Methods We performed a systematic review of the literature of MEDLINE and SCOPUS electronic databases in a 25-year period from 1992 to September 2017. Methods We found 340 cases of DVA associated with fetal abnormalities. The most common chromosomal abnormalities were: monosomy X (12/48, 25%), trisomy 21 (11/48, 22.9%) and trisomy 18 (6/48, 12.5%). From the 340 cases with DVA, in 31 cases the umbilical venous shunt type was not reported. Of the fetuses, 60.8% (188/309) had an extrahepatic umbilical venous drainage while 39.2% (121/309) presented an intrahepatic connection. The DVA was associated in 71 cases (23.0%) with cardiac abnormalities, in 82 cases (26.5%) with extracardiac abnormalities and in 85 cases (27.5%) with both cardiac and extracardiac abnormalities. Conclusion DVA associated with both cardiac and extracardiac malformations may confer a poorer fetal outcome, a clinically relevant fact that should clarify what can be expected from this entity and help prenatal counseling.