A case of idiopathic azygos vein aneurysm
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1 CLINICAL IMAGES PEER REVIEWED OPEN ACCESS A case of idiopathic azygos vein aneurysm Adrian Iordache, Mary Bernadette Stevenage, Javed Sultan, Andrew Carne ABSTRACT Abstract is not required for Clinical Images International Journal of Case Reports and Images (IJCRI) International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties. Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. IJCRI publishes Review Articles, Case Series, Case Reports, Case in Images, Clinical Images and Letters to Editor. Website: (This page in not part of the published article.)
2 Iordache et al. 786 CASE Clinical REPORT Images Peer Reviewed OPEN ACCESS A case of idiopathic azygos vein aneurysm Adrian Iordache, Mary Bernadette Stevenage, Javed Sultan, Andrew Carne Case report A 93-year-old male presented to the emergency department with a few day history of worsening cough and shortness of breath. Examination showed a mildly raised JVP and scattered bilateral lung crepitations. A plain chest film confirmed cardiomegaly and signs of pulmonary congestion. Blood tests were generally unremarkable. Patient was given oxygen and started on Furosemide however due to on-going hypoxia a CT pulmonary angiogram was performed and ruled out pulmonary emboli however revealed a vascular abnormality which had 5x3 cm sac situated behind the trachea at the level of the bifurcation, consistent with a large azygos vein aneurysm (Figure 1). The patient s symptoms gradually improved over the coming days and he was eventually discharged home on Furosemide. The vascular abnormality was managed conservatively and is felt to be an incidental finding that requires no dedicated follow-up in this particular case given the patient s age and co-morbidities. Figure 1: Computed tomography pulmonary angiogram showing an azygos aneurysm arising from the SVC with a 5x3 cm sac (arrow) situated behind the trachea at the level of the bifurcation displacing the esophagus to the left. Adrian Iordache 1, Mary Bernadette Stevenage 1, Javed Sultan 2, Andrew Carne 3 Affiliations: 1 MBBS, FY1 Doctor, Department of Surgery, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom; 2 MBBS MD FRCSed, Consultant Oesophagogastric Surgeon, Department of Surgery, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom; 3 MBBS FRCR, Consultant Radiologist, Department of Radiology, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom. Corresponding Author: Adrian Iordache, Surgery Department, Upper GI secretary office, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom, GU2 7XX; adrian. iordache@nhs.net Received: 08 October 2015 Accepted: 04 November 2015 Published: 01 December 2015 DISCUSSION Aneurysms of the azygos vein are rare findings and the aetiology is often unclear. They can be idiopathic or can occur in patients with congenital malformation of the inferior vena cava or more commonly secondary to high central venous pressures due to heart failure or portal hypertension [1]. Patients are usually asymptomatic however if the aneurysm gradually becomes enlarged, it can cause pressure effects on adjacent structures such as the superior vena cava or the right main bronchus. Patients with this pathology are often identified after having a chest radiograph that shows an incidental paratracheal density, mimicking a mediastinal mass. The size of the aneurysm may fluctuate with respiration, especially if a chest radiograph is taken whilst the patient performs the Valsalva maneuver. Contrast enhanced cross-sectional imaging is important in establishing its
3 vascular nature so as to prevent potentially hazardous diagnostic procedures such as endobronchial ultrasoundguided transbronchial needle aspiration. There is no consensus as for the management of azygos aneurysms. It is generally felt that conservative management with long-term follow-up is most appropriate if the aneurysm is asymptomatic and uncomplicated, however surgical resection should be considered if the patient starts experiencing compression symptoms or the aneurysm develops intra-luminal thrombosis or thromboembolic disease (especially in the case of saccular aneurysms which pose a greater risk of complications) [2, 3]. Endovascular therapy can be considered as a successful alternative to surgery. However few cases have been documented in literature given the low prevalence of this pathology [4]. CONCLUSION Azygos vein aneurysms are rare occurrences and are often diagnosed incidentally. Conservative management with long-term follow-up is usually indicated if the aneurysm is uncomplicated. Keywords: Azygos vein, Aneurysm, Vascular abnormality How to cite this article Iordache A, Stevenage MB, Sultan J, Carne A. A case of idiopathic azygos vein aneurysm. Int J Case Rep Images 2015;6(12): Iordache et al. 787 Guarantor The corresponding author is the guarantor of submission. Conflict of Interest Authors declare no conflict of interest. Copyright 2015 Adrian Iordache et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information. REFERENCES 1. Gallego M, Mirapeix RM, Castañer E, Domingo C, Mata JM, Marín A. Idiopathic azygos vein aneurysm: a rare cause of mediastinal mass. Thorax 1999 Jul;54(7): Ko SF, Huang CC, Lin JW, et al. Imaging features and outcomes in 10 cases of idiopathic azygos vein aneurysm. Ann Thorac Surg 2014 Mar;97(3): Kurihara C, Kiyoshima M, Asato Y, al. Resection of an azygos vein aneurysm that formed a thrombus during a 6-year follow-up period. Ann Thorac Surg 2012 Sep;94(3): Irurzun J, de España F, Arenas J, García-Sevila R, Gil S. Successful endovascular treatment of a large idiopathic azygos arch aneurysm. J Vasc Interv Radiol 2008 Aug;19(8): doi: /ijcri cl ********* Author Contributions Adrian Iordache Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published Mary Bernadette Stevenage Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published Javed Sultan Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published Andrew Carne Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
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