Year : 2002 | Volume
: 18 | Issue : 2 | Page : 164--166
Duplication of the inferior vena cava: Clinical implication during live donor nephrectomy and the role of preoperative CT angiography
Raj Shekhar Gupta, Waheed uz Zamman, Aneesh Srivastava, Anant Kumar
Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Department of Urology and Renal Transplantation, SGPGIMS, Rai Bareilly Road, Lucknow (U.P) - 226 014
|How to cite this article:|
Gupta RS, uz Zamman W, Srivastava A, Kumar A. Duplication of the inferior vena cava: Clinical implication during live donor nephrectomy and the role of preoperative CT angiography.Indian J Urol 2002;18:164-166
|How to cite this URL:|
Gupta RS, uz Zamman W, Srivastava A, Kumar A. Duplication of the inferior vena cava: Clinical implication during live donor nephrectomy and the role of preoperative CT angiography. Indian J Urol [serial online] 2002 [cited 2020 May 27 ];18:164-166
Available from: http://www.indianjurol.com/text.asp?2002/18/2/164/37628
Anomalies of the Inferior Vena Cava (IVC) are uncommon with an incidence of 0.5% to 3%.  Duplication of IVC during live donor nephrectomy has not been reported earlier. We report on two cases of IVC duplication encountered during live donor nephrectomy and their management.
Case Report 1:
A 32-year-old male voluntary kidney donor's CT angiography had showed single renal artery and vein bilaterally. A large prominent vessel was seen to the left of aorta, which was reported as dilated gonadal vein or a possibility of duplication of inferior vena cava (IVC) [Figure 1]a. During left live donor nephrectomy the renal vein was seen draining in the duplicated IVC, which continued superiorly to join the dominant right inferior vena cava anterior to the aorta [Figure 1]b. The gonadal and the adrenal vein drained normally into the left renal vein; however the lumbar vein drained into the duplicate IVC. The renal artery originated from the aorta normally. The graft was harvested with the standard technique, however a cuff of the duplicated IVC was taken with the renal vein to increase the length and facilitate venous anastomosis in the recipient. The inferior vena cava was closed with continuous suture of polypropylene 4'0'. The transplant operation was carried out uneventfully. Postoperative course was uneventful.
Case Report 2:
Our second case was a 29-year-old female who underwent left laparoscopic live donor nephrectomy. CT angiography had showed duplication of the IVC, which continued entirely as the left renal vein [Figure 2]. Preoperatively the findings were confirmed. Both the gonadal vein and the lumbar vein were draining into the renal vein and the origin of the renal artery was normal. After complete dissection of the kidney and the vessels, the ureter was clipped and divided proximal to the clips. Finally the renal artery was divided between clips and the renal vein fired with endo GIA stapler as distally as possible to gain extra length of the renal vein. An 8 to 9 cm incision was made joining the two upper ports and the graft taken out. Postoperative recovery was uneventful.
The incidence of IVC anomalies is 0.5% to 3%.  The most commonly used classification is based on the segment of the final vena cava that is abnormal.  Formation of the IVC begins in the 6 th week and is completed by 10 th week of gestation. Three paired venous structures (posterior, subcardinal and supracardinal) appear sequentially and regress selectively to complete the formation of the IVC. Duplication of inferior vena cava occurs as a result of persistence of both the right and the left supracardinal veins.  There is duplication below the renal veins; however, variation in the anatomy is commonly noted. Usually the right vena cava is dominant and the left vena cava anastomoses to it in front or behind the aorta as in our first case. Alternatively the IVC may drain directly into the left renal vein as was seen in our second case. This condition has been described in association with horseshoe kidney and cloacal exstrophy; however it has not been reported during live donor nephrectomy previously.
The left kidney is preferred for donor nephrectomy due to its longer renal vein, which contributes to the technical case during nephrectomy and transplantation. Presence of duplication of the inferior vena cava shortens the length of the available renal vein. In such a situation a cuff of the inferior vena cava should be taken along with renal vein to facilitate venous anastomosis in the recipient. Gentle retraction rather than extensive dissection has been recommended to prevent the potential thrombosis of the IVC. 
Although vena caval anomalies are rare, preoperative identification can prevent morbidity and allow better planning of the procedure. Duplicated inferior vena cava may be mistaken and ligated on the presumption that the vessel is anomalous variant of the gonadal vessel. IVC duplication also increases the risk of vascular injury. Identification of venous anomalies has particular relevance during laparoscopic live donor nephrectomy. In our second case, no difficulty was encountered as the anomaly was identified preoperatively on CT angiography.
Preoperative 3D CT angiography, which is the preferred mode of evaluation of the donors at our center, provides a fast and accurate noninvasive evaluation of the vena cava and the renal vasculature and is recommended.  Donor surgeon should be aware of these anomalies and the surgical procedure should be planned as per the individual case.
|1||Brener BJ, Darling RC, Frederick PL, Linton RR. Major venous anomalies complicating abdominal aortic surgery. Arch Surg 1974: 108: 159-165.|
|2||Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the inferior vena cava. Review of embryogenesis and presentation of a simplified classification. Br J Radiol 1974: 47: 206-213.|
|3||Mathews R. Smith PA, Fishman EK, Marshall F. Anomalies of the inferior vena cava and the renal veins : embryologic and surgical considerations. Urology 1999; 53: 873-880.|
|4||Rubin GD. Alfrey EJ, Dake MD et al. Assessment of living renal donors with spiral CT. Radiology 1995: 195: 457-462.|