Surgical Resection of a Giant Azygos Vein Aneurysm

Azygos vein aneurysm is a rare finding with sparse documentation in the medical literature. We present case of large thrombosed azygos and its successful treatment by surgical resection. The size, shape, nature as well symptomatic presentation substantiated management, which we propose safe effective management strategy for similar cases. (AVA) often diagnosed incidentally on chest imaging. Because presentation, there are no existing guidelines AVA. Management options have been described about 60 reports only handful review articles.1Kreibich M. Siepe Grohmann J. Pache G. Beyersdorf F. Aneurysms vein.J Vasc Surg Venous Lymphat Disord. 2017; 5: 576-586https://doi.org/10.1016/j.jvsv.2016.12.012Abstract Full Text PDF PubMed Scopus (16) Google Scholar In this report, aim to large, AVA management. drains posterior wall thorax parts abdomen. It passes through aortic hiatus diaphragm arches over right bronchus drain into superior vena cava (SVC). 3 major causes acquired, traumatic, iatrogenic. Acquired AVAs thought be due high central venous pressure. They can also occur from neoplasm-induced compression SVC or pregnancy-induced physiologic changes. arise after traumatic injury iatrogenically catheter insertion.2Takamori S. Oizumi H. Utsunomiya A. Suzuki Thoracoscopic removal an thrombus formation.Gen Thorac Cardiovasc Surg. 2021; 69: 1335-1337https://doi.org/10.1007/s11748-021-01652-yCrossref (2) Patients may experience coughing, wheezing, pain, dyspnea asymptomatic. diagnosis frequently made Follow-up imaging consists contrast-enhanced computed tomography (CT) scans.3Savu C. Melinte Balescu I. Bacalbasa N. mimicking mediastinal mass.In Vivo. 2020; 34: 2135-2140https://doi.org/10.21873/invivo.12019Crossref (11) controversial because low incidence lack established guidelines. Conservative oral anticoagulation prevent thromboembolism formation. Definitive include interventional approaches. Indications severe symptoms, formation aneurysm, contraindications anticoagulation.4Mochimaru T. Kawada Chubachi Tsutsumi Hasegawa Betsuyaku Edoxaban pulmonary arterial associated azygous aneurysm.Respirol Case Rep. 5e00223https://doi.org/10.1002/rcr2.223Crossref (0) Interventional approaches primarily propagation stenting coil embolization.5Favelier Estivalet L. Pottecher P. Loffroy R. Successful endovascular stent-graft implantation.Ann 2015; 99: 1455https://doi.org/10.1016/j.athoracsur.2014.11.022Abstract (7) A 57-year-old man past history chronic kidney disease stage 2, hypertension, hyperlipidemia, obstructive sleep apnea presented emergency department chief complaint several weeks radicular midthoracic back pain when breathing dyspnea. He experienced wheezing but cough hemoptysis. Pulmonary cardiovascular examination findings were unremarkable. Of note, varicosital changes noted lower extremities peripheral edema; pulses normal. addition, paraspinal rib tenderness was noted. underwent radiography, showed paravertebral mass. follow-up CT scan intravenous administration contrast material (pulmonary embolism [PE] protocol) 5.5 × 4.6 3.8-cm well-defined, oval, homogeneous enhancing mass centered paratracheal region, main (Figure 1). No Positron emission tomography/CT demonstrated low-density non–fluorodeoxyglucose-avid suggestive AVA, patient scheduled surgery resect General anesthesia double-lumen endotracheal tube used. approach posterolateral mini-thoracotomy left lateral decubitus position. upper lobe adherent pleura overlying confirmed 2). At level intermedius, esophagus separated ascending branch vein, 1 cm diameter. Both structures encircled stapled Echelon vascular stapler (Ethicon). then mobilized removed entirety. measured approximately 6 5 3).Figure 3Surgical specimen.View Large Image Figure ViewerDownload Hi-res image Download (PPT) postoperative course unremarkable, discharge home day 2. Outpatient evidence recurrent varicosities chest. 6-month appointment, incision fully healed, original complaints resolved. This noteworthy relatively novel Although clear AVAs, indications lent credence optimal case. saccular nature. Saccular more progressive growth patterns, higher rates compared fusiform aneurysms.6Ko S.F. Huang C.C. Lin J.W. et al.Imaging features outcomes 10 cases idiopathic aneurysm.Ann 2014; 97: 873-878https://doi.org/10.1016/j.athoracsur.2013.10.029Abstract (20) Thus, series reported resection 50% favored patient’s had undergone formation, carries theoretical risk traveling lungs. These factors represented AVA-induced complications, determined operative (ie, embolization) conservative pharmacologic Possible portal hypertension inferior occlusion plays important role return.3Savu Little known aneurysms other thoracic veins. Fewer than 40 literature.7Morales M.M. Anacleto Ferreira Leal J.C. Greque V.G. Souza Jr., A.S. Wolosker aneurysm: report comprehensive review.Ann 72 (666.e23-e32)https://doi.org/10.1016/j.avsg.2020.10.033Abstract (1) terms complications these aneurysms, thrombosis PE seem slightly common frank rupture, recent showing that 24% thrombosed, half those deemed source PE.7Morales similarly mostly mitral valve dysfunction.8Coffman Pence K. Khaitan P.G. Chan E.Y. Kim M.P. asymptomatic aneurysm.Respir Med 2016; 20: 7-9https://doi.org/10.1016/j.rmcr.2016.10.016Crossref caval thrombi likely enter systemic circulation cause strokes. consideration risks, our pursued urgent Not symptomatic, saccular, thrombosed. Whereas few statistical data relate location, rate, shape rupture PE, it belief best served Other forms literature Currently, evidence-backed recommend one option another. patients who not candidates, appropriate. AVAs. conclusion, extremely treatment. giant hoped thorough workup, used identify manage Future directions research natural progression development evidence-based authors funding sources disclose.