A 69-year-old male presented to the emergency department with periumbilical pain radiating across his abdomen, with associated nausea and emesis. CT abdomen and pelvis with intravenous and oral contrast revealed an obstructing 5 mm ureteral calculus in the right ureterovesical junction causing severe hydroureteronephrosis of the right portion of the patient’s horseshoe kidney, a delayed right nephrogram, and severe right perinephric stranding. Additionally, there was a 1.3 cm ureteral calculus in the left ureterovesical junction, causing moderate hydroureteronephrosis of the left portion of the horseshoe kidney and mild perinephric stranding. There were also bilateral non-obstructing renal calculi in the horseshoe kidney (Figure ).\nWhile the ureteral and renal calculi accounted for the patient’s presenting symptoms of abdominal pain, the CT scan also revealed the horseshoe kidney having an associated anomalous IVC. The IVC had a “circumrenal” course surrounding the horseshoe kidney. The IVC split above the horseshoe kidney at the level of the L1 vertebral body into a pre-isthmic IVC (anterior to the horseshoe kidney) and a posterior IVC (Figure ). Below the kidney, the IVC rejoined at the level of the L5 vertebral body. On sagittal CT imaging, the IVC closely approximates the anterior and posterior aspects of the horseshoe kidney (Figure ). The right gonadal vein was noted to drain into the pre-isthmic IVC. Additionally, the right ureter took a retrocaval course posterior to the pre-isthmic IVC. There was narrowing of the right retrocaval ureter between the horseshoe kidney and the pre-isthmic IVC (Figure ).
A 41-year-old male patient with a history of IVC anomaly and interatrial communication, diagnosed when he was 15 years old, was asymptomatic, with no hemodynamic repercussion and good exercise tolerance. Recently presented syncopal episodes and progressive dyspnea due to moderate pulmonary hypertension; despite clinical treatment with sildenafil, symptoms persisted, so he consulted a cardiothoracic surgeon who requested complementary tests. Echocardiogram reported pulmonary artery pressure of 36 mmHg (on Sildenafil) and a left ventricular ejection fraction of 72%. Angiography showed an anomalous distal venous drainage with an absence of the IVC and the persistence of the azygos vein draining distal blood to the superior vena cava (SVC) ().\nWith these findings, surgical closure of the atrial septal defect (ASD) was decided; however, due to the IVC anomaly, the surgeon had to modify the surgical technique.\nMedian sternotomy and systemic heparinization were performed with extracorporeal circulation cannulating the aorta and SVC directing the tip of this cannula to the azygos vein. Right atrium (RA) was opened, the suprahepatic venous system drained into the atrial cavity, complicating the surgical exposure due to the large amounts of blood draining; therefore, these veins were cannulated from the inside of the RA, leaving a bloodless field (). Chambers were explored, finding a 2-cm ASD and a separate partial anomalous pulmonary venous drainage from the two right pulmonary veins to the RA. The ASD was enlarged with resection of a septal segment; then, correction of the septal communication was performed doing a baffle technique with bovine pericardium creating a tunnel to redirect the flow from the right pulmonary veins to the left atrium (). Finally, he was removed from extracorporeal circulation and was sent to ICU for postoperative care.