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 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.