Persistence and restoration of the patency of the left duct of Cuvier

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1 Cse report Persistence nd restortion of the ptency of the left duct of Cuvier A. Grcí*, J. Rogondino, F. Londr nd B. Afonso Hospitl Británico de Buenos Aires, Ciudd Autónom de Buenos Aires, Argentin Astrct he incresed pressure in the portl circultion due to chronic liver disese fvors the redistriution of the flow to the systemic circultion. Although rre, reperfusion of emryonic venous chnnels my e possiility. Our im is to report the persistence nd ptency of the ductus venosus, clled the left duct of Cuvier, nd to show its presenttion in imges Sociedd Argentin de Rdiologí. Pulished y Elsevier Spin, S.L.U. This is n open ccess rticle under the CC BY-NC-ND license ( Keywords: Left Cuvier duct ptency; Collterl circultion; Restortion of emryonic veins ptency Cse Report Sixty-seven yer-old femle ptient with cryptogenic cirrhotic disese. Clinicl findings included esophgel vrices nd heptic encephlopthy resulting in repeted hospitliztions. Doppler exmintion of the liver did not revel signs of portl hypertension, nd the flow direction in the portl vein nd the heptic rtery ws heptopetl. The left portl vein showed collterl circultion towrds the systemic circultion from its posterior rnch. No scites ws oserved nd the echocrdiogrm showed no signs of crdic overlod. During hospitliztion, the ptient ws plced on the witing list for liver trnsplnt. Therefore, for n erly detection of heptocellulr crcinom (HCC), the ptient underwent contrst-enhnced mgnetic resonnce imging (MRI) of the domen, s well s n dominl computed tomogrphy (CT) in the rteril, portl nd lte phses to evlute the heptic glnd, nd CT scn of the chest in the portl venous phse. We report this cse to descrie nd lern out the imging presenttion of persistence of n emryologic venous system known s the left duct of Cuvier (LC). This system normlly involutes. In our ptient, the LC hd its ptency restored y cirrhosis (the ptient s seline disese), plying the role of portocvl nstomosis. The dominl scn reveled 35-mm HCC in the heptic segment VII. The scn lso showed tht the left rnch of the portl vein joined vsculr structure of identicl dimeter, with tortuous pth inside the liver segments II nd III (fig. 1). Then, it coursed towrds the chest longside the posterior wll of the left ventricle, outside the pericrdium (figs. 2 nd 3). This finding corresponded to the left duct of Cuvier, which scended to the left crdic venous sinus (without penetrting it) leding into the ipsilterl jugulr-suclvin venous confluence (fig. 4). Figure 1. 2D Reconstruction, xil mximum intensity projection imge shows ptent nstomosis etween the left rnch of the portl vein (red rrow) nd the left duct of Cuvier (white rrow). 95

Persistence nd restortion of the ptency of the left duct of Cuvier c d Figure 2. Axil views of the upper domen. () The Cuvier duct (rrow) emerges from the left rnch of the left portl vein.

(d) The rrow shows the right rnch of the portl vein. The emryologic duct of Cuvier generlly drins into the left crdic venous sinus.

superior intercostl vein (drins the 2 nd nd 3 rd intercostl veins) (fig. 5).

2 Persistence nd restortion of the ptency of the left duct of Cuvier c d Figure 2. Axil views of the upper domen. () The Cuvier duct (rrow) emerges from the left rnch of the left portl vein. () The Cuvier duct courses towrds the chest longside the left heptic loe (rrow). (c) Visuliztion of the union etween the left rnch of the portl vein nd the left duct of Cuvier (rrow). (d) The rrow shows the right rnch of the portl vein. The emryologic duct of Cuvier generlly drins into the left crdic venous sinus. Emryologiclly, the right nd left ducts of Cuvier nstomose nd lood from the left side of the ody is chnneled to the right side, forming in the nterior region the left rchiocephlic vein nd the left superior intercostl vein (drins the 2 nd nd 3 rd intercostl veins) (fig. 5). Discussion The hert nd lood vessels develop from the mesoderm s isolted msses nd cords of mesenchyml cells in order to rpidly deliver the necessry nutrients to the exponentilly proliferting cells nd dispose of wste products through the connection with the mternl lood vessels in the plcent. Cuvier ducts: n emryologic review The term Cuvier ducts refers to the common (right nd left) primitive crdinl veins tht during emryologic development re used y the humn circultory system together with umilicl nd vitelline veins to drin the sinus venosus. At fifth week of gesttion, three sets of lrge-sized veins cn e distinguished (fig. 6): - Vitelline veins, which crry lood from the yolk sc to the sinus venosus. - Umilicl veins, which originte in the chorionic villi nd crry oxygented lood to the emryo. - Crdinl veins, which drin the ody of the emryo. The nterior crdinl veins drin the cephlic portion of the emryo, while the posterior crdinl veins drin the remining 96

A. Grcí et l. c d Figure 3. Axil views of the lower chest.

However, it does not drin into it, ut forms vsculr curl nd continues scending. (c nd d) Emergence of n intercostl rnch towrds the chest wll (rrow). prt of the ody of the emryo.

The right common crdinl vein nd the proximl portion of the right nterior crdinl vein form the superior ven cv 2,3 (fig. 7).

Persistence nd/or restortion of the ptency of this venous structure cuses direct communiction etween the portl venous system nd the systemic veins, forming porto-systemic nstomosis 7, 8.

3 A. Grcí et l. c d Figure 3. Axil views of the lower chest. Pth of the duct of Cuvier, () entering the chest (rrow) nd () pssing ehind the left ventricle (rrow), in (c) towrds the left trium where emryologiclly it should drin (rrow). However, it does not drin into it, ut forms vsculr curl nd continues scending. (c nd d) Emergence of n intercostl rnch towrds the chest wll (rrow). prt of the ody of the emryo. The nterior nd posterior crdinl veins join nd form the common crdinl veins, lso clled right nd left ducts of Cuvier, which nstomose, llowing the pssge of lood from the left to the right 1. The right common crdinl vein nd the proximl portion of the right nterior crdinl vein form the superior ven cv 2,3 (fig. 7). When the Cuvier ducts nstomose, lood from the left flows to the right, forming the left rchiocephlic vein nd the left superior intercostl vein in the nterior region 4-6. Persistence nd/or restortion of the ptency of this venous structure cuses direct communiction etween the portl venous system nd the systemic veins, forming porto-systemic nstomosis 7, 8. Porto-systemic nstomosis The portl system is not solutely closed, ut communictes with venous networks tht re triutry to the ven cv. - Esophgel nstomoses: nstomoses exist etween the left gstric (coronry) vein nd the inferior esophgel veins through the sumucosl plexuses, which re often very thin. Incresed pressure cuses vricose dilttion of the esophgel veins. - Rectl nstomoses: superior rectl veins (portl triutries) nstomose with the middle nd inferior rectl veins (rnches of the internl ilic veins). - Peritonel nstomoses: these nstomoses hve een clled Retzius veins or system. This third group of nstomoses exists long the sides of the intestinl wlls, where 97

Persistence nd restortion of the ptency of the left duct of Cuvier mesenteric veins communicte with smll-sized triutries of the inferior ven cv, forming wht is cliniclly known s cput meduse.

- Accessory portl veins: the liver does not only receive lood from the portl vein, ut lso from other veins known s ccessory portl veins.

Being wre of the possiility of ptent emryologicl venous ducts tht serve s portocvl nstomoses is essentil for the evlution nd tretment of ptients witing liver trnsplnttion, in order to prevent

4 Persistence nd restortion of the ptency of the left duct of Cuvier mesenteric veins communicte with smll-sized triutries of the inferior ven cv, forming wht is cliniclly known s cput meduse. - Fetl nstomosis: ptency of umilicl, prumilicl veins nd ductus venosus connecting the left rnch of the portl vein with the inferior ven cv. - Accessory portl veins: the liver does not only receive lood from the portl vein, ut lso from other veins known s ccessory portl veins. These smll groups of vessels include: gstroepiploic veins, cystic veins, hilr veins or group of nutrient venules, diphrgmtic veins, suspensory ligment veins, nd prumilicl or round ligment veins. Being wre of the possiility of ptent emryologicl venous ducts tht serve s portocvl nstomoses is essentil for the evlution nd tretment of ptients witing liver trnsplnttion, in order to prevent intropertive complictions tht increse moridity nd mortlity Figure 4. 2D reconstruction of the chest nd domen, coronl mximum intensity projection imge showing the entire pth of the Cuvier duct to the jugulr-suclvin confluence (rrow). Addendum Although we performed literture serch, we hve not found pictoril reports. Figure 5. 2D Reconstruction of the chest nd upper domen, () coronl mximum intensity projection nd (v) volume rendering, showing the entire Cuvier duct entering the chest. The rrow points to the intercostl rnch, which runs long the left lterl wll to the left suclvin vein. Conflicts of interest The uthors declre no conflicts of interest. 98

Bhtti S, Hkeem A, Ahmd U, Mlik M, Kosolchroen P, Chng SM. Persistent left superior ven cv (PLSVC) with nomlous left heptic vein dringe into the right trium: role of imging nd clinicl relevnce.

5 A. Grcí et l. Sinus venosus Superior Ven Cv Left Crdinl Vein Right Crdinl Vein ductus venosus Figure 6. Emryologicl development of crdinl veins. Suprcrdinl vein Common Crdinl Vein sucrdinl vein Figure 7. Left crdinl vein regressing nd right crdinl vein forming the Superior Ven Cv. References 1. Bhtti S, Hkeem A, Ahmd U, Mlik M, Kosolchroen P, Chng SM. Persistent left superior ven cv (PLSVC) with nomlous left heptic vein dringe into the right trium: role of imging nd clinicl relevnce. Vsc Med. 2007;12: Gruttduri S, Pgno D, Cintorino D, Burgio G, Echeverri GJ, Mirgli R, et l. Unusul presenttion of left heptic vein in decesed donor: cse report. Trnsplnt Proc. 2010;42: Ricci M, Rosenkrnz ER. Heptic venous nomlies complicting totl cvopulmonry connection. Tex Hert Inst J. 2001;28: Ygel S, Kivilevitch Z, Cohen SM, Vlsky DV, Messing B, Shen O, et l. The fetl venous system. Prt II: ultrsound evlution of the fetus with congenitl venous system mlformtion or developing circultory compromise. Ultrsound Ostet Gynecol. 2010;36: Azum C, Tohno Y, Tohno S, Moriwke Y, Utsumi M, Ymd M. Persistent left heptic venous connection with the right trium nd the ductus venosus. Ant Sci Int. 2002;77: Stoller JK, Hoffmn RM, White RD, Mee RB. Anomlous heptic venous dringe into the left trium: n unusul cuse of hypoxemi. Respir Cre. 2003;48: Msuko S, Inoue K. A cse of the doule superior vene cve nd n nomlous left heptic vein opening directly into the right trium. Kiogku Zsshi. 1982;57: Ymnk J, Immur M, Kurod N, Hirno T, Fujimoto J. Heptic venoplsty to overcome outflow lock in living relted liver trnsplnttion. J Peditr Surg. 2004;39: Kowlski M, Mynrd R, Annthsurmnim K. Imging of persistent left sided superior ven cv with echocrdiogrphy nd multi-slice computed tomogrphy: implictions for dily prctice. Crdiol J. 2011;18: Urz S, Durn C, Blci D, Akin B, Dyngc M, Kurt Z, et l. A very rre venous nomly in living liver donor: left heptic venous connection to the right trium. Trnsplnt Proc. 2007;39: Goyl SK, Punnm SR, Verm G, Ruerg FL. Persistent Left superior ven cv: cse report nd review of literture. Crdiovsc Ultrsound. 2008;6:

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