We present a case of a 54 years old male who initially presented with one month history of worsening epigastric pain and vomiting. He was referred to our care after an ultrasound and CT abdomen showing dilated common bile duct up to 13mm with no obvious intraductal obstruction. An incidental type 1 duplicated IVC was demonstrated on the CT abdomen (Figure and 2).\nNo intra-abdominal mass or lymphadenopathy were detected. Notably, he is a known BRCA2 mutation carrier. Both, his mother and sister had BRCA2-positive breast cancer. One of his great uncles also had male breast cancer. The patient was clinically jaundiced on presentation, with a bilirubin of 106. His other liver function tests were ALT at 465, GGT at 1032 and at ALP 271. His tumour markers CA-125 and CA-199 were 12 and 94 respectively.\nThe patient was subsequently found to be hypotensive and tachycardic with a new drop in haemoglobin from 100 to 72 during his stay. An urgent gastroscopy then revealed a 10mm punched-out ulcer with adherent clot at the ampulla. The lesion was partially obstructed and no active bleeding was seen. Histology on biopsy showed moderately differentiated adenocarcinoma. CT angiography was then performed. No active extravasation was seen and the gastroduodenal artery was empirically embolised with microcoils. An apparent cavitation at the medial aspect of the second part of duodenum was now identified on the CT imaging (Figure ). No metastasis was seen on staging CT imaging.\nA whipple procedure was performed. The duplicated right IVC was visualised intraoperatively with mobilisation of the uncinate process but appeared relatively normal. The left sided IVC was not encountered. No major complications were reported during his inpatient stay. Patient was discharged home and subsequently commenced on adjuvant therapy.
A 17-year-old male with no previous medical illness was admitted to the hospital with abdominal pain. The patient had a long time history of generalized intermittent abdominal pain that increased postprandial without nausea or vomiting. The patient also had a history of fatigue on exertion. Upon checking vital signs, the patient was found to be hypertensive. There was a discrepancy between the upper (155-160/70-75 mmHg) and lower limbs (100-105/65-70 mmHg) readings. Cardiovascular examination showed a systolic ejection murmur best appreciated at the tip of the left scapula, and bracheo-femoral delay. The abdominal examination was unremarkable. His complete blood count, renal profile, liver profile, troponin, and brain natriuretic peptide were normal. Stool analysis and culture were normal. Electrocardiography revealed sinus rhythm and left ventricular (LV) hypertrophy (Figure ). The chest X-ray revealed the classic rib notching sign (Figure ). An echocardiogram revealed a BAV with mild to moderate aortic regurgitation and dilatation of ascending aorta (Figure ). A post-ductal CoA was observed with a systolic gradient of 80 mmHg (Figure ). His LV function was normal with mild eccentric hypertrophy. Cardiac CT was done and confirmed severe post-ductal CoA with extensive collaterals (Figure ). Another incidental finding was a left-sided IVC, which courses anterior to the abdominal aorta between the aorta itself and superior mesenteric artery crossing the midline to the right before joining the right renal vein and the intra-hepatic IVC segment (Figure ). The patient was discussed in a heart team meeting, and it was decided to proceed with transcatheter intervention with stenting.\nThe procedure was done under general anesthesia through the right femoral access. The pre-stenting peak gradient was 60 mmHg, which improved to 4 mmHg using 14 x 39 mm BeGraft aortic stent (Bentley InnoMed, Hechingen, Germany), which is a balloon-expandable covered stent. This was followed by post-stenting dilation with short non-compliant Z-Med balloon (B. Braun Interventional Systems, Bethlehem, PA) (Figure ). No temporary pacing was used for stenting. No periprocedural complications were encountered. The patient stayed in the hospital for two days, then was eventually discharged home on losartan 100 mg daily. Six weeks later, the patient was called for follow up. His symptoms resolved utterly, and blood pressure was well controlled.