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Imaging of the Inferior Vena Cava with MDCT

¹ Both authors: The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 N Wolfe St., Nelson B176D, Baltimore, MD 21287.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —36-year-old asymptomatic female renal donor. Coronal reconstruction image from contrast-enhanced CT shows normal anatomy of inferior vena cava and its tributaries. LRV = left renal vein, HV = hepatic veins.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —41-year-old asymptomatic male renal donor. Coronal reconstruction image from contrast-enhanced CT shows incidentally noted circumaortic left renal vein with posterior retroaortic branch coursing inferiorly (arrow).

View larger version (98K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —46-year-old woman with epigastric pain. Coronal reconstruction image from contrast-enhanced CT shows infrarenal left-sided inferior vena cava (IVC) with interrupted suprarenal IVC and azygos continuation. Note right renal vein drains into azygos vein.

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —46-year-old woman with epigastric pain. Axial CT image of chest shows azygos vein (arrow) is enlarged, confirming diagnosis.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —46-year-old woman with epigastric pain. Artist rendering of left-sided IVC. (Courtesy of Corl FM, Baltimore, MD)

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —61-year-old man with history of resection of carcinoid tumor. Coronal reconstruction image from contrast-enhanced CT shows there is duplication of inferior vena cava (IVC) with azygos continuation. Note that each renal vein drains into ipsilateral IVC.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —61-year-old man with history of resection of carcinoid tumor. Artist rendering of double IVC. (Courtesy Corl FM, Baltimore, MD)

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —50-year-old man with history of inferior vena cava (IVC) occlusion. Coronal reconstruction image from contrast-enhanced CT shows there is lack of opacification of midportion of IVC (arrows), which is consistent with occlusion by thrombus. Extensive retroperitoneal collaterals are seen bypassing occluded segment (arrowheads). There is stent in suprarenal portion of IVC.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Axial contrast-enhanced CT images of 57-year-old man with abnormal liver function test results. There is prominent fat posterior to caudate lobe (arrow).

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Axial contrast-enhanced CT images of 57-year-old man with abnormal liver function test results. This fat projects into inferior vena cava (IVC) creating apparent low-attenuation filling defect (arrow).

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —Axial contrast-enhanced CT images of 57-year-old man with abnormal liver function test results. IVC is normal, which confirms this case is pseudolesion due to partial volume averaging.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —65-year-old man with large left renal mass. Coronal reconstruction image from contrast-enhanced CT in venous phase shows there is large hypervascular mass (arrows) in mid upper pole of left kidney. Thrombus (arrowheads) extends into renal vein and infrahepatic inferior vena cava (IVC).

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —65-year-old man with large left renal mass. Axial contrast-enhanced CT image in late arterial phase shows hypervascularity in left renal vein thrombus (arrowheads), which is consistent with tumor thrombus. Patient underwent left nephrectomy for Fuhrman grade IV clear cell renal carcinoma and thrombectomy of 2-cm mobile clot (arrows) in IVC.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —51-year-old man with shortness of breath. Coronal reconstruction image from contrast-enhanced CT in venous phase shows there is hypervascular infiltrating mass (black arrows) in right kidney that is extending into and occluding right renal vein. Thrombus extends into inferior vena cava (IVC), obstructing and expanding it. Note neovascularity within thrombus and extension into right atrium (white arrow). Inferior to level of right renal vein, clot in IVC (arrowhead) is lower in attenuation, suggesting small portion is bland thrombus.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —51-year-old man with shortness of breath. Image obtained in arterial phase shows there is neovascularity in main thrombus (arrowheads), which confirms finding is tumor thrombus. Embolus in branch of right pulmonary artery (arrow) is seen. Patient underwent right nephrectomy and removal of tumor thrombus from IVC and right atrium, confirming stage T4b tumor.

View larger version (181K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —56-year-old woman with right-sided back pain and abdominal distention. Coronal reconstruction image from contrast-enhanced CT in venous phase shows large heterogeneously enhancing mass (arrows) displacing right kidney inferiorly and filling defect (arrowhead) in hepatic portion of inferior vena cava (IVC). Appearance is most suggestive of adrenocortical carcinoma with IVC extension. This diagnosis was confirmed at surgery and pathology. Large right adrenal mass was excised, and IVC thrombus was removed.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —75-year-old man with history of bilateral lower extremity edema and shortness of breath. Axial contrast-enhanced CT image shows large homogeneous soft-tissue mass (arrows) anterior to infrarenal inferior vena cava (IVC).

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —75-year-old man with history of bilateral lower extremity edema and shortness of breath. Axial contrast-enhanced CT image shows mass (arrows) is arising from and expanding anterior IVC below level of renal veins and is partially exophytic, compressing adjacent duodenum (arrowhead).

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —75-year-old man with history of bilateral lower extremity edema and shortness of breath. Coronal reconstruction image from contrast-enhanced CT shows large, partially exophytic soft-tissue mass (arrows) is occluding IVC and extends from below renal veins to hepatic IVC. Note superior border of mass in hepatic IVC does not extend into right atrium. These findings were confirmed on axial CT (not shown).

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10D —75-year-old man with history of bilateral lower extremity edema and shortness of breath. There is abundant neovascularity within IVC mass (arrowheads). Note early enhancement of distal IVC and extension into left renal vein (arrow). Diagnosis of leiomyosarcoma was established by percutaneous biopsy.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —54-year-old man with newly developing hypertension. Axial contrast-enhanced CT image shows there is homogeneous mass (arrows) expanding suprarenal inferior vena cava.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —54-year-old man with newly developing hypertension. Photograph shows gross specimen. Diagnosis of caval high-grade leiomyosarcoma was confirmed at surgery.

View larger version (172K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —50-year-old woman with right flank mass. Coronal reconstruction image from contrast-enhanced CT shows there is large heterogeneously enhancing mass (arrows) displacing right kidney inferiorly. Note calcifications within mass. Inferior vena cava (IVC) is not visualized. Mass was displacing aorta (not shown). Because of large size of tumor, its origin could not be definitely ascertained. Differential diagnosis included adrenocortical cancer, gastrointestinal stromal tumor, or retroperitoneal sarcoma. Diagnosis of leiomyosarcoma was obtained by sonographically guided percutaneous biopsy.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —50-year-old woman with right flank mass. Photograph shows gross specimen. At surgery, tumor was found to engulf IVC and portion of right kidney.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —21-year-old woman with coagulopathy. Axial contrast-enhanced CT image obtained in venous phase shows liver is enlarged and exhibits heterogeneous enhancement with enlarged caudate lobe and peripheral fatty infiltration. Regenerating nodules are seen in right lobe. Hepatic veins are not visualized.

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —21-year-old woman with coagulopathy. Neither hepatic nor infrahepatic inferior vena cava is visualized on this coronal reconstruction image from contrast-enhanced CT. Note prominent periaortic venous collaterals (arrow). Diagnosis of Budd-Chiari syndrome was confirmed by histologic analysis of liver at liver transplantation.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —50-year-old man with history of recurrent deep vein thrombosis and ulcerative colitis. Coronal reconstruction image from contrast-enhanced CT shows inferior vena cava (IVC) filter is in place with its tip at level of renal veins, which are patent. Small thrombus (arrowhead) is present just above tip of filter. There is thrombus in IVC (arrow) distal to filter.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —56-year-old woman with history of inferior vena cava (IVC) filter migration. Coronal reconstruction image from contrast-enhanced CT shows birdcage IVC filter is in suprarenal IVC, with its tip extending into hepatic IVC. Inferior portion of filter is very close to junction of IVC and renal veins (arrows).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —56-year-old woman with history of inferior vena cava (IVC) filter migration. Coronal reconstruction image from contrast-enhanced CT shows one of filter's prongs (arrow) may be embedded in medial wall of IVC.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16A —45-year-old woman with history of congestive heart failure and abnormal findings on CT performed at outside institution. Coronal reconstruction image from contrast-enhanced CT in arterial phase shows there is early filling of dilated left iliac vein and inferior vena cava. Note tangle of vessels (arrows) in pelvis.

View larger version (91K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16B —45-year-old woman with history of congestive heart failure and abnormal findings on CT performed at outside institution. Axial reconstruction image from contrast-enhanced CT in arterial phase shows there is tangle of vessels (arrow) in left adnexa.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16C —45-year-old woman with history of congestive heart failure and abnormal findings on CT performed at outside institution. Single image from selective left iliac arteriography confirms early filling of left iliac vein (arrow) and tangle of tortuous arteries and prominent veins (arrowheads). This large arteriovenous malformation may have been responsible for patient's congestive heart failure.

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