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 35-year-old man with the diagnosis of mitral atresia, a double outlet right ventricle, pulmonary atresia with interrupted inferior caval vein, and azygous continuation to the right superior caval vein underwent a Blalock-Taussig shunt in early childhood and a Kawashima operation at the age of 17 at another institution. He presented to our clinic with progressive cyanosis and fatigue 18 years after his last surgical procedure. His oxygen saturation was 65%.\nCardiac catheterization revealed left pulmonary artery stenosis and a decompressing vein from the right superior caval vein to the left superior caval vein which directly drains to the left atrium. Left pulmonary artery stenting was done via right internal jugular approach (Figures , , and ).\nHe underwent a second catheterization for occlusion of the left superior caval vein via left internal jugular approach. The anomalous vein measured 22 and 20 mm in AP and lateral projections, respectively. Balloon test occlusion resulted in immediate increase in oxygen saturation from 65% to 82% without drop of blood pressure. The mean pressure in the azygous vein remained at 9 mmHg; pressure in the left internal jugular vein increased to 11 mmHg and dropped within a few minutes to 10 mmHg. Angiography showed good venous collateral drainage.\nThe largest available vascular plug, 24 mm in diameter, failed to completely occlude the vessel, which was successfully occluded using a 24 mm ASD occluder (Cera Lifetech, China) via a 12 Fr sheath. Upon completion of the procedure the patient had oxygen saturation of 80%, left internal jugular pressure of 10 mmHg, and right superior caval vein and pulmonary artery pressure of 9 mmHg.\nAfter occlusion, the patient had significant improvement of his exercise intolerance and fatigue. Follow-up hemodynamic study 12 months later showed no increase in venous pressure, no development of venous collaterals, and no decrease in his oxygen saturation.