Portal de Periódicos da CAPES

Varicose pericardial vein: An unusual cause of right paracardiac opacity

2005; Elsevier BV; Volume: 129; Issue: 2 Linguagem: Inglês

10.1016/j.jtcvs.2004.05.027

1097-685X

Daniel Pop, Nicolas Vénissac, Francesco Leo, Dorothé Ducreux, B. Padovani, Jérôme Mouroux,

Cardiac tumors and thrombi

In case of portal hypertension, mediastinal veins can be varicose, and they might be interpreted on chest radiography or scanning as mediastinal or pulmonary masses.1Millward S.F. Ramsewak W. Joseph G. Jones B. Zylak C.J. Pericardial varices demonstrated by computed tomography.J Comput Assist Tomogr. 1985; 9: 1106-1107Crossref PubMed Scopus (5) Google Scholar When no portal hypertension is present, the obstruction of the inferior vena cava might cause the presence of a dilated azygos-hemiazygos system2Podbielski F.J. Sam A.D. Halldorson A.O. Iasha-Sznajder J. Vigneswaran W.T. Giant azygos vein varix.Ann Thorac Surg. 1997; 63: 1167-1169Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar or, more rarely, a left varicose pericardiophrenic vein.3Chung J.W. Im J.G. Park J.H. Han J.K. Choi C.G. Han M.C. Left paracardiac mass caused by dilated pericardiacophrenic vein: report of four cases.AJR Am J Roentgenol. 1993; 160: 25-28Crossref PubMed Scopus (21) Google Scholar We report the first case of varix of the right pericardiophrenic vein without portal hypertension explored by means of video-assisted thoracoscopy because it was misinterpreted as a pleuropericardial cyst. A right mass in the right cardiophrenic angle was discovered on chest radiography in a 60-year-old man after an episode of acute bronchitis. He stopped smoking in 1998 when his ischemic cardiac disease was discovered and treated with angioplasty and interventricular artery stenting. In 2002, a needle biopsy showed postalcoholic micronodular cirrhosis. Two months later, respiratory symptoms were solved, but the radiologic image was unmodified. No anomaly was evident at clinical examination. No sign of portal hypertension was present. At this time, hematology showed no abnormality but a moderately increased level of γ-glutamyl transpeptidase (251 U/L). The results of electrocardiography were normal. Chest scans showed 2 contiguous round lesions in the right cardiophrenic angle that were hypodense with regular borders and probably interconnected in their lower part (Figure 1). The largest nodule was the posterior one, and it measured 23 mm in diameter. Contrast injection showed no enhancement in both. Mild hepatomegaly was present. We decided to perform a right video-assisted thoracoscopy for the clinical suspicion of a pleuropericardial cyst. At exploration, on the pericardium, a varicose and serpiginous network from the pericardiophrenic vein was found, extending from the diaphragm to the upper paracaval region with a maximum diameter of approximately 1 cm (Figure 2). The postoperative period was uneventful, and the patient was discharged 2 days after the operation. An abdominal echocardiographic Doppler examination was performed 1 month later. It showed a membranous obstruction of the inferior vena cava 18 mm below the diaphragm in its retrohepatic portion, and only the right suprahepatic vein was visualized. A course of simple surveillance was decided on in the absence of other abnormalities. The varix of the pericardiophrenic vein might represent a diagnostic pitfall because it can be erroneously interpreted as a pulmonary or mediastinal mass. The absence of contrast enhancement and hypodensity on computed tomographic scanning usually suggests the diagnosis of cystic lesions. Opacification of the thoracic collateral veins can be very difficult to obtain, and it depends on the amount of contrast material, the injection rate, and the timing of the administration.4Trigaux J.P. vanBeers B. Thoracic collateral venous channels: normal and pathologic CT findings.J Comput Assist Tomogr. 1990; 14: 769-773Crossref PubMed Scopus (25) Google Scholar In the present case the site and density of the mass were consistent with the diagnosis of a pleuropericardial cyst. The possibility of a mediastinal varix was not considered for the absence of other varicose abnormalities and the absence of clinically evident portal hypertension. The possibility of a membranous obstruction of the inferior vena cava was considered after surgical exploration and confirmed by means of echocardiographic Doppler examination. The site of this rare abnormality was atypical. Of the 4 cases of paracardiac mass caused by mediastinal varices reported by Chung and colleagues,3Chung J.W. Im J.G. Park J.H. Han J.K. Choi C.G. Han M.C. Left paracardiac mass caused by dilated pericardiacophrenic vein: report of four cases.AJR Am J Roentgenol. 1993; 160: 25-28Crossref PubMed Scopus (21) Google Scholar all were on the left side, and the pattern of drainage was from the hepatic veins through the left inferior phrenic vein to the left pericardiophrenic vein. In the presented case, on the basis of surgical exploration, it was reasonable to assume that the drainage was from the right inferior phrenic vein through the right pericardiophrenic vein into the right thoracic vein.5Lawler L.P. Fishman E.K. Pericardial varices: depiction on three-dimensional computed tomographic angiography.AJR Am J Roentgenol. 2001; 177: 202-204Crossref PubMed Scopus (13) Google Scholar This observation suggests that isolated varicose abnormality of the pericardiophrenic vein should be considered in the differential diagnosis of mediastinal plurilobate masses. In this case a different timing in image uptake after contrast injection could support such a diagnosis and justify magnetic resonance, venocavography, or both, to avoid invasive diagnostic procedures such as video-assisted thoracoscopy.