Download Persistence and restoration of the patency of the left duct of Cuvier

Case report
Persistence and restoration of the patency of the left
duct of Cuvier
A. García*, J. Rogondino, F. Londra and B. Afonso
Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
Abstract
he increased pressure in the portal circulation due to chronic liver disease favors the redistribution of the flow to the
systemic circulation. Although rare, reperfusion of embryonic venous channels may be a possibility.
Our aim is to report the persistence and patency of the ductus venosus, called the left duct of Cuvier, and to show its
presentation in images.
© 2015 Sociedad Argentina de Radiología. Published by Elsevier Spain, S.L.U. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Left Cuvier duct patency; Collateral circulation; Restoration of embryonic veins patency
Case Report
Sixty-seven year-old female patient with cryptogenic cirrhotic
disease. Clinical findings included esophageal varices and hepatic encephalopathy resulting in repeated hospitalizations.
Doppler examination of the liver did not reveal signs of portal hypertension, and the flow direction in the portal vein
and the hepatic artery was hepatopetal. The left portal vein
showed collateral circulation towards the systemic circulation
from its posterior branch. No ascites was observed and the
echocardiogram showed no signs of cardiac overload.
During hospitalization, the patient was placed on the waiting
list for liver transplant. Therefore, for an early detection of hepatocellular carcinoma (HCC), the patient underwent a contrast-enhanced magnetic resonance imaging (MRI) of the abdomen, as well as an abdominal computed tomography (CT)
in the arterial, portal and late phases to evaluate the hepatic
gland, and a CT scan of the chest in the portal venous phase.
We report this case to describe and learn about the imaging
presentation of persistence of an embryologic venous system
known as the “left duct of Cuvier” (LC). This system normally
involutes.
In our patient, the LC had its patency restored by cirrhosis
(the patient’s baseline disease), playing the role of a portocaval anastomosis. The abdominal scan revealed a 35-mm HCC
in the hepatic segment VII. The scan also showed that the
left branch of the portal vein joined a vascular structure of
identical diameter, with a tortuous path inside the liver segments II and III (fig. 1). Then, it coursed towards the chest
alongside the posterior wall of the left ventricle, outside the
pericardium (figs. 2 and 3). This finding corresponded to the
left duct of Cuvier, which ascended to the left cardiac venous sinus (without penetrating it) leading into the ipsilateral
jugular-subclavian venous confluence (fig. 4).
Figure 1. 2D Reconstruction, axial maximum intensity projection image shows patent anastomosis between the left
branch of the portal vein (red arrow) and the left duct of
Cuvier (white arrow).
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Persistence and restoration of the patency of the left duct of Cuvier
a
b
c
d
Figure 2. Axial views of the upper abdomen. (a) The Cuvier duct (arrow) emerges from the left branch of the left portal vein.
(b) The Cuvier duct courses towards the chest alongside the left hepatic lobe (arrow). (c) Visualization of the union between
the left branch of the portal vein and the left duct of Cuvier (arrow). (d) The arrow shows the right branch of the portal vein.
The embryologic duct of Cuvier generally drains into the left
cardiac venous sinus. Embryologically, the right and left ducts
of Cuvier anastomose and blood from the left side of the
body is channeled to the right side, forming in the anterior
region the left brachiocephalic vein and the left superior intercostal vein (drains the 2nd and 3rd intercostal veins) (fig. 5).
Discussion
The heart and blood vessels develop from the mesoderm as
isolated masses and cords of mesenchymal cells in order to
rapidly deliver the necessary nutrients to the exponentially
proliferating cells and dispose of waste products through the
connection with the maternal blood vessels in the placenta.
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Rev. Argent. Radiol. 2015;79(2): 95-99
Cuvier ducts: an embryologic review
The term “Cuvier ducts” refers to the common (right and
left) primitive cardinal veins that during embryologic development are used by the human circulatory system together
with umbilical and vitelline veins to drain the sinus venosus.
At fifth week of gestation, three sets of large-sized veins can
be distinguished (fig. 6):
- Vitelline veins, which carry blood from the yolk sac to the
sinus venosus.
- Umbilical veins, which originate in the chorionic villi and
carry oxygenated blood to the embryo.
- Cardinal veins, which drain the body of the embryo.
The anterior cardinal veins drain the cephalic portion of the
embryo, while the posterior cardinal veins drain the remaining
A. García et al.
a
b
c
d
Figure 3. Axial views of the lower chest. Path of the duct of Cuvier, (a) entering the chest (arrow) and (b) passing behind the left
ventricle (arrow), in (c) towards the left atrium where embryologically it should drain (arrow). However, it does not drain into it,
but forms a vascular curl and continues ascending. (c and d) Emergence of an intercostal branch towards the chest wall (arrow).
part of the body of the embryo. The anterior and posterior
cardinal veins join and form the common cardinal veins, also
called right and left ducts of Cuvier, which anastomose, allowing the passage of blood from the left to the right1. The right
common cardinal vein and the proximal portion of the right
anterior cardinal vein form the superior vena cava2,3 (fig. 7).
When the Cuvier ducts anastomose, blood from the left flows
to the right, forming the left brachiocephalic vein and the left
superior intercostal vein in the anterior region4-6. Persistence
and/or restoration of the patency of this venous structure
causes direct communication between the portal venous system and the systemic veins, forming a porto-systemic anastomosis7, 8.
Porto-systemic anastomosis
The portal system is not absolutely closed, but communicates
with venous networks that are tributary to the vena cava.
- Esophageal anastomoses: anastomoses exist between the
left gastric (coronary) vein and the inferior esophageal
veins through the submucosal plexuses, which are often
very thin. Increased pressure causes varicose dilatation of
the esophageal veins.
- Rectal anastomoses: superior rectal veins (portal tributaries) anastomose with the middle and inferior rectal veins
(branches of the internal iliac veins).
-Peritoneal anastomoses: these anastomoses have been
called Retzius’ veins or system. This third group of anastomoses exists along the sides of the intestinal walls, where
Rev. Argent. Radiol. 2015;79(2): 95-99
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Persistence and restoration of the patency of the left duct of Cuvier
mesenteric veins communicate with small-sized tributaries of
the inferior vena cava, forming what is clinically known as
“caput medusae”.
- Fetal anastomosis: patency of umbilical, paraumbilical veins
and ductus venosus connecting the left branch of the portal
vein with the inferior vena cava.
- Accessory portal veins: the liver does not only receive blood
from the portal vein, but also from other veins known as accessory portal veins. These small groups of vessels include:
gastroepiploic veins, cystic veins, hilar veins or group of nutrient venules, diaphragmatic veins, suspensory ligament veins,
and paraumbilical or round ligament veins.
Being aware of the possibility of patent embryological venous
ducts that serve as portocaval anastomoses is essential for the
evaluation and treatment of patients awaiting liver transplantation, in order to prevent intraoperative complications that increase morbidity and mortality9-11.
Figure 4. 2D reconstruction of the chest and abdomen, coronal maximum intensity projection image showing the entire
path of the Cuvier duct to the jugular-subclavian confluence
(arrow).
a
Addendum
Although we performed a literature search, we have not found
pictorial reports.
b
Figure 5. 2D Reconstruction of the chest and upper abdomen, (a) coronal maximum intensity projection and (v) volume rendering,
showing the entire Cuvier duct entering the chest. The arrow points to the intercostal branch, which runs along the left lateral
wall to the left subclavian vein.
Conflicts of interest
The authors declare no conflicts of interest.
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Rev. Argent. Radiol. 2015;79(2): 95-99
A. García et al.
Superior Vena Cava
Sinus venosus
Left Cardinal Vein
Right Cardinal Vein
ductus venosus
Figure 6. Embryological development of cardinal veins.
Supracardinal vein
Common
Cardinal Vein
subcardinal
vein
Figure 7. Left cardinal vein regressing and right cardinal vein forming the Superior Vena Cava.
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