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Everything you need to know about Computed Tomography (CT) & CT Scanning

Vascular: Ivc Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Vascular ❯ IVC

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  • “The most common variants in IVC anatomy are a duplicated IVC and a left IVC. A duplicated IVC results when both the right and left supracardinal veins persist. This variant is seen in 0.2–3% of the population. Generally, when a duplicated IVC is present, the left moiety drains into left renal vein, which in turn usually joins with the right IVC, leading to the normal suprarenal anatomy. Iliac venous inflows into the duplicated system may be isolated to each respective side or may join at the inferior origin of the duplicated IVC.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Renal cell carcinoma (RCC) is the most common malig- nancy to involve the IVC, with caval extension seen in 4–10%. Any venous tumor thrombus is consid- ered Robson Stage IIIa, while in the Internal Union Against Cancer tumor-node-metastasis (TNM) classification, renal vein only, infradiaphragmatic IVC, and supradiaphragmatic IVC involvements correspond to T3b, T3c, and T4b, respec- tively. CT has been shown to have negative and positive predictive values for venous extension of 97% and 92%, respectively, with the corticomedullary phase of enhancement being most useful.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Adrenocortical carcinoma (ACC) is a rare malignancy of the adrenal gland and may be endocrinologically functional. Age distribution is bimodal, with one peak before 5 years of age and the second in the 4th to 5th decades of life. At diagnosis, ACC tumors tend to be larger than 5 cm, enhance heterogeneously, and have irregular shape with blurred margins. In 9–19% of patients, there is invasion of the tumor into the IVC , which is considered Stage III disease. MRI can be helpful for identifying IVC extension, as well as in differentiating ACC from adenoma or pheochromocytoma.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Involvement of the IVC and right atrium by hepatocellular carcinoma (HCC) is not uncommon in advanced disease, either due to intracaval extension of hepatic venous tumor thrombus or direct invasion of the IVC wall. Caval involvement is associated with a poor prognosis in most patients due to increased risk of distant metastases. While direct IVC invasion can be seen with cholangiocarcinoma and metastatic disease, hepatic venous tumor thrombus is uncommon in other primary or secondary hepatic malignancies, and thus is a differentiating feature of HCC.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Leiomyosarcoma, the primary malignancy arising from the IVC, originates from the smooth muscle cells of the caval wall media and is much less common than secondary tumors. Given the rarity of the tumor, the true incidence of primary IVC leiomyosarcoma is unclear. The malignancy most commonly affects women in their fifth or sixth decade. The pattern of tumor growth is extraluminal in 59–76%, intraluminal and extraluminal in 16%, and exclusively intraluminal in 20–25%. Central necrosis is common."
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Etiologies of IVC thrombosis include congenital IVC anomalies and acquired conditions. Although congenital anomalies of the IVC are relatively uncommon and usu- ally accompanied by well-developed collaterals, thrombosis can ensue and become symptomatic if venous hypertension or stasis develops in these collaterals. Acquired IVC thrombosis can occur for a number of reasons. Examples include external compression of the IVC (e.g., adjacent tumor), malignancies involving the IVC wall and lumen, extension of deep vein thrombosis (DVT) from the iliac veins, and damage to the endothelium (e.g., penetrating or iatrogenic injury; presence of a catheter or IVC filter)”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Fistula formation between the aorta and IVC can be an acute complication of abdominal aortic aneurysm rupture or repair, or rarely due to trauma. Spontaneous aortocaval fistula may present with abdominal or back pain, pulsating abdominal mass, continuous abdominal bruit, pelvic and lower extremity venous hypertension, shock, or congestive heart failure. This diagnosis is suggested on contrast- enhanced CT when there is early enhancement of the IVC similar to the aorta. Fistulous communication between the aorta and IVC may be directly visualized. Treatment can be surgical or endovascular.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “IVC injury is a rare event for both blunt and penetrating traumas and has a high mortality rate. While some patients with IVC trauma are too unstable for imaging, CT signs of IVC injury include retroperitoneal hematoma with or without IVC contour abnormality and active contrast extravasation. Hepatic laceration may coexist, and injuries of the retrohepatic IVC carry a poor prognosis. Given the low intraluminal pressure, self-tamponade can occur in the absence of significant concomitant disruption of the surrounding soft tissues.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • ”Flattened IVC constitutes one of the CT signs of clinically significant hypoperfusion in adult blunt trauma patients (i.e., hypoperfusion complex) along with flattened renal veins, active contrast extravasation, free peritoneal fluid, and small bowel enhancement and dilation. Collapsed IVC may also be a helpful predictor of clinical outcome in pediatric and elderly trauma patients, in whom heart rate and blood pressure may be less reliable indicators of hypovolemia.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Primary tumors of the IVC are exceedingly rare. Leiomyosarcoma of the IVC is a tumor of mesenchymal origin arising from the smooth-muscle cells found in the vessel wall and is associated with a poor prognosis, with a reported 10-year survival of 14%. Most leiomyosarcomas are large at presentation and manifest with nonspecific complaints of abdominal pain, a palpable right upper quadrant mass, or progressive lower extremity edema.”

    Imaging of the Inferior Vena Cava with MDCT
    Sheth S, Fishman EK
    AJR 2007; 189:1243–1251 
  • “Leiomyosarcomas of the IVC are classified according to their location [11–13]. Data gathered from a compiled review of 218 cases from the world literature reveal that approxi- mately 37% of tumors occur in segment I, be- low the level of the renal veins and above the iliac vein bifurcation; 43% involve segment II, between the renal veins and the level of the hepatic veins; and 20% form in segment III at or above the hepatic veins level and may extend into the right atrium .”

    Imaging of the Inferior Vena Cava with MDCT
    Sheth S, Fishman EK
    AJR 2007; 189:1243–1251 
  • “At imaging, exophytic leiomyosarcomas appear as large retroperitoneal masses with heterogeneous contrast enhancement. Cystic necrotic areas are not rare. Because the origin of these large tumors may be difficult to as- certain on imaging, percutaneous biopsy is valuable to achieve a definitive diagnosis.”

    Imaging of the Inferior Vena Cava with MDCT
    Sheth S, Fishman EK
    AJR 2007; 189:1243–1251 
  • “The IVC is formed by the confluence of the right and left common iliac veins draining blood from the lower extremities and pelvis. As it ascends in the retroperitoneum to the right of the abdominal aorta, the IVC receives major tributaries including the lumbar veins, the left and right renal veins, the right gonadal vein, and the hepatic veins. The azygos venous system connects to the IVC either directly or through the renal veins. The IVC and its branches are best seen in the coronal plane .”

    Imaging of the Inferior Vena Cava with MDCT
    Sheth S, Fishman EK
    AJR 2007; 189:1243–1251 
  • “Four of 18 (22%) retroperitoneal masses were IVC leiomyosarcomas. The IVC was imperceptible at the interface with the mass in three of the four (75%) IVC leiomyosarcomas (κ = 0.88) and in no alternate diagnosis (p < 0.02). No IVC leiomyosarcoma showed a positive embedded organ sign versus one of 14 masses of alternate origin (p = 1.0, κ = 0.56). The negative embedded organ sign was seen in most primary retroperitoneal masses (11/14 or 79%, κ = 0.85) but in no case of IVC leiomyosarcoma (p = 0.01). Intraluminal tumor was seen in one of four (25%) IVC leiomyosarcomas and in two of 14 other retroperitoneal masses (p = 1.0, κ = 1.0).”.

    Can CT features differentiate between inferior vena cava leiomyosarcomas and primary retroperitoneal masses?
    Webb EM et al.
    AJR Am J Roentgenol. 2013 Jan;200(1):205-9
  • “An imperceptible IVC at the point of maximal contact with a retroperitoneal mass was the most useful CT feature for predicting the origin of IVC leiomyosarcoma. A negative embedded organ sign was useful for excluding IVC origin. Knowledge of these CT features may assist with preoperative planning.”

    Can CT features differentiate between inferior vena cava leiomyosarcomas and primary retroperitoneal masses?
    Webb EM et al.
    AJR Am J Roentgenol. 2013 Jan;200(1):205-9
  • Arteriovenous (AV) Grafts and Fistulas for Hemodialysis Access—The Role of MDCT with CT Angiography and 3-D Reconstructions in Delineating Anatomy and Identifying Complications

    Sameer Ahmed MD, Siva P. Raman MD, Elliot K. Fishman MD
  • Introduction

    871,000+ people are being treated for end-stage renal disease, and account for 6% of the Medicare budget ($29 billion).
    - Complications of hemodialysis access account for a sizable proportion of these costs

    AV fistulas and grafts are placed for long-term hemodialysis access.
    - General guidelines: 1) Autogenous hemodialysis access is favored over prosthetics, 2) Distal extremity access sites should be utilized first in order to preserve more proximal options, 3) Upper extremity access is preferred over lower extremity. 
  • “Intravenous leiomyomatosis (IVL) is a rare gynecologic disease characterized by overgrowth of histologically benign smooth muscle within the lumen of pelvic and systemic veins. IVL was originally described in 1896 in an autopsy case by Birch-Hirschfeld . Subsequently, in 1907, Durk reported the first case of IVL with intracardiac extension. Yet it was not until 1959 that the earliest case by Marshall and Morris was described in the English literature.”
    Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
    Low G et al
     Radiology. 2012 Dec;265(3):971-5.
  • “IVL generally occurs in premenopausal parous white women (median age, 44 years; age range, 28–80 years) (8). It has a recognized association with a history of prior hysterectomy for uterine leiomyomas. In a review, Lam et al (6) found a history of hysterectomy in 38 (55.9%) of 68 patients with IVL with intracardiac extension.”
     Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
    Low G et al
     Radiology. 2012 Dec;265(3):971-5.
  • “Aside from IVL, the differential diagnosis for a contiguous intracaval and intracardiac soft-tissue mass includes bland thrombus, primary caval leiomyosarcoma, and tumor thrombus (from renal cell carcinoma, adrenal cortical carcinoma, or hepatocellular carcinoma in adults and from Wilm tumor in children).”
    Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
    Low G et al
     Radiology. 2012 Dec;265(3):971-5.
  • “Aside from IVL, the differential diagnosis for a contiguous intracaval and intracardiac soft-tissue mass includes bland thrombus, primary caval leiomyosarcoma, and tumor thrombus (from renal cell carcinoma, adrenal cortical carcinoma, or hepatocellular carcinoma in adults and from Wilm tumor in children).”
    Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
    Low G et al
     Radiology. 2012 Dec;265(3):971-5.
  • “Surgery is the treatment of choice for IVL. This involves total hysterectomy, bilateral salpingo-oophorectomy (as the tumor is estrogen dependent), and removal of the intravenous tumor. IVL typically adheres to but does not invade the vessel wall. Thus, if IVL extends into the IVC only, it can usually be removed by downward traction from the ovarian vein, iliac vein, or IVC at venotomy. However, a multidisciplinary surgical approach is required if there is intracardiac extension.”
    Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
    Low G et al
     Radiology. 2012 Dec;265(3):971-5.
  • "Patients with renal cell carcinoma in whom multidetector computerized tomography fails to detect tumor thrombus are unlikely to have a tumor thrombus found at surgery that would change the surgical approach."

    The Accuracy of Multidetector Computerized Tomography for Evaluating Tumor Thrombus in Patients With Renal Cell Carcinoma
    Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME
    J Urology Vol 181,486-491 February 2009

  • " Multidetector computerized tomography with 3-dimensional mapping is an effective imaging modality for accurately characterizing the level of venous thrombus in patients with renal cell carcinoma."

    The Accuracy of Multidetector Computerized Tomography for Evaluating Tumor Thrombus in Patients With Renal Cell Carcinoma
    Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME
    J Urology Vol 181,486-491 February 2009

  • Tumor Thrombus vs Bland Thrombus?
    - Tumor thrombus typically
    - Have gross invasion of tumor parenchyma into adjacent vein
    - Abnormal arterial vascularity (within the thrombus) of the thrombus
    - Irregular venous lumen expansion
  • Which tumors have the highest risk for venous thrombosis?
    - Uterus
    - Brain
    - leukemia
  • Acute vs Chronic Venous Thrombosis

    Acute thrombosis

    • Thrombi are homogeneous
    • expand the lumen
    • Located centrally in the vessel
    • Peripheral residual flow common 

      Chronic thrombosis

    • Thrombi are heterogeneous
    • Decreased vein diameter
    • Are peripherally attached to the vessel wall  
  • Venous Thrombosis in Cancer Patients
    - Hypercoagulability states due to indirect pathway activation by production of procoagulents
    - Venous stasis due to reduced mobility (cachexia, surgery) or to compression by tumors
    - Vessel wall damage by direct invasion of vessels on by indwelling catheters
  • "The purpose of this article is to review the imaging of venous thrombosis in patients with cancer."

    Imaging Presentation of Venous Thrombosis in Patients With Cancer
    Khosa F et al.
    AJR 2919; 194:1099-1108
  • "High speed MDCT has the potential to replace traditional imaging techniques in the evaluation of pathologic processes involving the IVC. The ability to acquire near isotrophic data allows high-quality reconstructions in the sagittal and coronal planes and thus overcomes one of the major limitations of CT in evaluating the IVC."

    Imaging of the Inferior Vena Cava with MDCT
    Sheth S, Fishman EK
    AJR 2007;189:1243-1251
  • Splanchnic Artery Aneuyrsms: Sites of Origin

    - Splenic artery 60%
    - Hepatic artery 20%
    - SMA 5.5%
    - Celiac artery 4%
    - Pancreatic aa. 2%
    - GDA 1.5%
  • "The performance characteristics of CTV and deep venous sonography were similar when compared with a clinical standard. The results support the use of indirect CTV after CT pulmonary angiography as an alternative to sonography in the ICU patient."

    Prospective Comparison of Indirect CT Venography Versus Venous Sonography in ICU Patients
    Taffomi MJ et al. AJR 2005; 185:457-462
  • "Retrograde opacification of the inferior vena cava or hepatic veins on CT is a specific but insensitive sign of right sided heart disease at low contrast injection rates, but the usefullness of this classic sign decreases with high injection rates."

    Clinical Relevance of Retrograde Inferior Vena Cava or Hepatic Vein Opacification During Contrast Enhanced CT Yeh BM et al. AJR 2004; 183:1227-1232
  • Retrograde IVC or Hepatic Vein Opacification: Causes

    - High injection rates
    - Tricuspid atresia
    - Pulmonary hypertension
    - Right ventricular systolic dysfunction
  • Factoid: The left ovarian vein arises off the left renal vein while the right ovarian vein arises directly off the IVC.
© 1999-2019 Elliot K. Fishman, MD, FACR. All rights reserved.