A 56-year-old man presented with a 2-year history of dysphagia. He was diagnosed with a middle thoracic oesophageal squamous cell carcinoma by both a gastroscopy and a biopsy. A chest computed tomography (CT) scan showed an enlarged azygos vein (a diameter of 2.5 cm) that was a continuation of the IVC (Fig. ). A CT scan of the abdomen showed a defect in the suprarenal segment of the inferior vena cava and direct drainage of the hepatic vein into the right atrium.\nAfter consultation with the thoracic surgery department clinicians and the anaesthesiology department, we decided to perform a McKeown oesophagectomy. The patient was anaesthetised with a double-lumen tube and underwent a standard posterolateral thoracotomy by traditional open surgery.\nWe first performed the jugular and femoral vein percutaneous puncture to create a veno-venous bypass and then connected the pressure sensor system to the monitor. The monitor displayed the real-time pressure value of the jugular vein and the femoral vein.\nMacroscopically, the diameter of the azygos arch was approximately 2.5 cm (Fig. ), and the superior edge of the tumour adhered tightly to the arch of the azygos vein. When the arch of the azygos vein was pulled with a rubber hose to dissociate it from the carcinoma, the monitor showed that the femoral vein pressure increased to 52 mmH2O; the pressure returned to a normal value when we opened the bypass between the femoral vein and the jugular vein (Fig. ). The surgery was performed smoothly, without injury to the azygos vein, and the postoperative recovery was uneventful. The pathology of the resected specimen showed a poorly differentiated squamous cell carcinoma and no evidence of malignancy in 15 of the lymph nodes.\nAfter 5 months of follow-up, the patient was asymptomatic, with no evidence of recurrent disease either clinically or on CT.
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 ).