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Left‐sided inferior vena cava: an intraoperative challenge during aortobifemoral bypass for juxtarenal aortoiliac occlusion

A 65-year-old man presented to our outpatient department with rest pain in the toes. The patient had a history of coronary artery disease, and he had undergone coronary artery bypass 6 months earlier. He was a chronic smoker with a history of 35 pack-years and had stopped smoking for the last 7 months. No other associated comorbidities were found. Clinical evaluation revealed absent pulsations in bilateral lower limb femoral and distal arteries. The ankle brachial index score in bilateral lower limbs was 0.6. His computed tomography (CT) angiogram revealed juxtarenal aortoiliac occlusion (Fig. 1) with left-sided inferior vena cava (IVC) (Fig. 2). His cardiac evaluation revealed patent coronary bypass grafts, good left ventricular function and ejection fraction of 56%. He was considered for aortobifemoral bypass. The standard midline approach was used for bypass. The IVC was first encountered as the retroperitoneum was opened, on the left side of the aorta. It was looped with silicone tapes to retract it to the left and anteriorly while dissecting the aorta. Following clamping of the suprarenal aorta and renal arteries, the infrarenal aorta was transected 1.5 cm below the renal ostia and cleared of the thrombus and atheromatous material. The aortic clamp was then shifted below the renal arteries after a duration of 10 min of suprarenal aortic cross clamp. End-toend anastomosis was performed using the main body of the coated polyester bifurcated graft (16 × 8 Uni-Graft KDV-B; Braun, Berlin, Germany), and distal limbs were anastomosed to the femoral arteries in an end-to-side manner to complete the aortobifemoral bypass (Fig. 3). The patient had an unremarkable recovery from surgery and is doing well at 1 year of follow-up with an ankle brachial index score of 1.0 bilaterally. The normal infrarenal IVC originates from the right supracardinal vein, and an anomalous left-sided IVC, which is usually asymptomatic, results from the regression of the right supracardinal vein with persistence of the left supracardinal vein. Typically, the left IVC joins the left renal vein, which crosses anterior to the aorta and joins with the right renal vein to form a normal right-sided IVC, as in our present case (Fig. 3). A complete transposition of the IVC to the left with hemiazygos continuation is extremely rare. The major clinical significance of this anomaly is a therapeutic challenge of filter placement, right heart catheterization and risk of injury while handling infrarenal aorta during aortic bypass or aneurysmorrhaphy. CT angiogram is routinely performed for planning aortobifemoral bypass in aortoiliac occlusion and repair of abdominal aortic aneurysm cases. This venous anomaly can be detected easily with CT imaging (Fig. 2), and the risk of the operation can be minimized, such as in our case. CT has proven to be superior to ultrasound and conventional venogram for detecting IVC anomalies.