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Weekly Chest CasesCases by Disease Category

Case No : 1342 Date 2023-07-10

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  • Courtesy of Yura Ahn, Han Na Noh, Jooae Choe, Kyung-Hyun Do / Asan medical center
  • Age/Sex 66 / F
  • Chief ComplaintIncidental finding
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Azygos vein aneurysm (AVA)
Radiologic Findings
Fig 1. Chest PA shows no significant abnormality
Fig 2. Chest CT scanogram which was obtained with supine position shows ovoid-shaped mass-like opacity in right lower paratracheal area.
Fig 3,4. Precontrast and contrast-enhanced CT scans show 3.3-cm contrast-filling space along the course of azygos arch, which is compatible with azygos vein aneurysm
Brief Review
- Very rare, only a few cases have been described in literature
- Cause: idiopathic (m/c), aplasia of inferior vena cava, portal hypertension, thrombosis, congenital
- Embryology: azygous arch is confluence of three embryologic veins (right supra cardinal vein, right posterior cardinal vein, and right anterior cardinal vein); therefore, it is prone to develop aneurysm
- Clinical manifestation:
- Related to their morphological characteristics, and large saccular aneurysms tend to present with chest symptoms because of the mass effect in the mediastinum
- Sluggish blood flow through the saccular AVA allows slow sedimentation and accumulation of thrombi within the lumen, leading to partial or eventual total thrombosis and progressive gradual enlargement of the AVA.

- Chest radiograph
- Well-defined mass in the area of the right tracheobronchial angle or as an enlargement of the right upper mediastinum
- Size can be changed by upright position, deep inspiration, or performing Valsalva maneuver

- CT:
- Primary modality for noninvasive diagnosis.
- Poor enhancement of the azygos vein on CT may lead to misinterpretation of AVA as neurogenic tumors or lymphadenopathies.
- Additional delay scan with optimal venous enhancement is facilitates the diagnosis of AVAs with a patent lumen
- The different levels of contrast in the aneurysm were seen with the highest density in the most posterior part
- MRI: identify thrombus or organized hematoma

- Treatment: not established. Conservative management is preferred due to meticulous ligation of azygos system and need to prevent migration of thrombus and pulmonary thromboembolism during surgery or intervention.
References
1. Ko S-F, Huang C-C, Lin J-W, Lu H-I, Kung C-T, Ng S-H, et al. Imaging Features and Outcomes in 10 Cases of Idiopathic Azygos Vein Aneurysm. The Annals of Thoracic Surgery 2014;97:873-878
2. Savu C, Melinte A, Balescu I, Bacalbasa N. Azygos Vein Aneurysm Mimicking a Mediastinal Mass. In Vivo 2020;34:2135-2140
3. Braun P, Guilabert JP, Olaso LT, Aneurysm of the azygos arch, European Journal of Radiology Extra 2004:50:71-74
Keywords

No. of Applicants : 94

▶ Correct Answer : 65/94,  69.1%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - , Japan HIROAKI ARAKAWA
  • - The University of Tokyo Hospital , Japan JUN KANZAWA
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - , Japan KYOKO NAGAI
  • - Ulsan University Hospital , Korea (South) SOYEOUN LIM
  • - Chonnam National University Hwasun Hospital , Korea (South) SEONGWOO CHO
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - Chonnam National University Hospital , Korea (South) CHAEWON SONG
  • - Chonnam National University Hospital , Korea (South) HYUNJIN KIM
  • - Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
  • - Yonsei University College of Medicine , Korea (South) INSUNG CHO
  • - Chonnam National University Hwasun Hospital , Korea (South) DONGHUN HAN
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - , Korea (South) JIN YOUNG LEE
  • - , Korea (South) HYUNSU CHOI
  • - Secomedic Hospital , Japan FUMINORI MIYOSHI
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Samsung Medical Center , Korea (South) JUHYUN KIM
  • - The University of Tokyo Hospital , Japan WATARU GONOI
  • - Ajou University Hospital , Korea (South) HAEIN LEE
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - Ajou University Hospital , Korea (South) HYUNSEUNG LEE
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Hukuda memorial hospital , Japan SHINTARO KANO
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - Other , Korea (South) CHAEHUN LIM
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - , Japan SHUNJIRO NOGUCHI
  • - , Korea (South) HEONSEOK LEE
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
  • - University of the Ryukyus , Japan Nanae Tsuchiya
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Seoul National University Hospital , Korea (South) SUNGHO HONG
  • - Chonnam National University Hospital , Korea (South) GYERYEONG PARK
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Paras hospital, Panchkula , India SHALEEN RANA
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Hyogo Prefectural Kobe Children , Japan SHUHEI NORIMOTO
  • - Seoul National University Bundang Hospital , Korea (South) YOONAH DO
  • - Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
  • - Fukuoka university , Japan KEISUKE SATO
  • - Kantou Rousai Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
  • - Matsunami General Hospital , Japan TARO TAKEDA
  • - Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
  • - , Korea (South) JIYEONG AN
  • - Toyota Kosei Hospital , Japan YUKI HAYASHI
  • - The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
  • - , Korea (South) HM PARK
  • - Kyoto university , Japan AKIHIKO SAKATA
  • - Chonnam National University Hospital , Korea (South) EUN JU KIM
  • - Other , Korea (South) YONG HO JANG
  • - , Korea (South) JIN WOO YOON
  • - Juntendo University , Japan YUTAKA IKENOUCHI
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 7/94,  7.4%
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Korea University Guro Hospital , Korea (South) HEEJUN PARK
  • - OITA UNIVERSITY , Japan FUMIKA ISHITOBI
  • - , Japan YUKIKO USUI
  • - Other , Korea (South) SEONG WON JANG
  • - Kyoto University , Japan SHO KOYASU
  • - Chonnam Hospital , Korea (South) JAEHYUN PARK
▶ Semi-Correct Answer : 5/94,  5.3%
  • - Seoul National University Hospital , Korea (South) HYUNGIN PARK
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - Shiga University of Medical Science , Japan RYO UEMURA
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
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