Images in Vascular Medicine: Collateral damage–Complications related to compensatory drainage pathways in inferior vena cava atresia - Summary - MDSpire
To describe procedural and hemodynamic complications associated with collateral venous drainage in a patient with IVC atresia and severe postthrombotic syndrome.
Approach:
Assessment: CT venography, venography, and IVUS showed IVC hypoplasia, bilateral iliocaval obstruction, extensive collateral veins, and a prior stent traversing an iliolumbar collateral.
Reconstruction: After blunt crossing failed, sharp recanalization was performed with a transseptal needle. IVUS-guided venoplasty and stenting reconstructed the IVC and iliac pathways.
Follow-up: The patient underwent staged superficial venous procedures. Stent patency, symptoms, Villalta scores, and collateral veins were assessed by ultrasound and CT.
Key Findings:
At six weeks, reconstructed stents were patent and bilateral Villalta scores had decreased from 15 to 7.
At six months, CT showed continued stent patency and fewer collateral veins.
Orthostatic hypotension with compensatory tachycardia developed; duplex showed persistent epigastric venous enlargement and reflux, with residual leg varicosities.
The authors describe enlarged collaterals as potential sources of inadvertent stent placement and, after deep venous flow is restored, a possible venous reservoir contributing to orthostatic hypotension.
Interpretation:
The authors note that enlarged collaterals may resemble native venous anatomy and that reliance on fluoroscopy alone can lead to inadvertent stent misplacement; IVUS with rotational fluoroscopy can reduce this hazard. They propose that persistently dilated collaterals may act as a venous reservoir after deep venous flow is restored, sequestering blood on standing and decreasing cardiac preload. The authors state that excision of redundant collaterals may be required to resolve orthostatic hypotension after reconstruction.
Limitations:
The report describes a single case.
Conclusion:
This case illustrates potential procedural and hemodynamic complications of collateral venous drainage in IVC atresia.
