title: Alveolar echinococcosis of the liver: sequelae of chronic inferior vena cava obstructions in the hepatic segment.
abstract: BACKGROUND
  The clinical pattern and long-term course of chronic inferior vena cava (IVC) obstructions are variable and depend on the underlying cause, the segment involved, and the extension of secondary thrombosis. Pertinent data on IVC obstructions in well-defined series of patients are lacking. We report the sequelae of chronic IVC obstructions in the hepatic segment in 11 consecutive patients derived from a cohort of 104 patients with alveolar echinococcosis of the liver.
  
  
  METHODS
  Based on the results of computed tomography scans, 11 patients (7 men, 4 women; mean age, 53.4 years) with IVC obstructions were selected from an ongoing prospective long-term chemotherapy trial comprising 104 patients with alveolar echinococcosis studied at yearly intervals according to a protocol. Obstruction of the IVC in the 11 patients existed for a mean duration of 8.6 years. In these patients, magnetic resonance imaging was performed to assess the morphologic features and extension of the IVC obstruction, as well as the collateral venous pathways. Patency and valvular function of the femoropopliteal veins were analyzed by color-coded duplex ultrasonography.
  
  
  RESULTS
  Total occlusions of the IVC were evident in 8 patients (73%) and subtotal stenoses in 3 patients (27%). Only 4 patients (36%) exhibited signs and symptoms of chronic venous insufficiency of the lower extremities; 2 (18%) of the 4 had a history of swelling in the lower extremity. Seven patients (64%) had no lower extremity symptoms. One patient had a history of pulmonary embolism. Abdominal collateral veins were documented in 5 patients (45%) by using magnetic resonance imaging; however, they were clinically evident in only 3 patients (27%). In the 8 patients with IVC occlusion, thrombosis ended at the confluence of the hepatic veins. Obstruction of the IVC was limited to the hepatic segment in 2 patients (18%) and extended to the distal IVC or the iliofemoral veins in 6 patients (54%). Chronic venous insufficiency was present only if the femoropopliteal veins had been involved in the thrombotic process, showing residual venous obstruction, valvular incompetence, or both. Bilateral renal vein thrombosis with moderate proteinuria was observed in 2 patients (18%). The main collateral drainage was achieved through the ascending lumbar, azygos, and hemiazygos veins.
  
  
  CONCLUSIONS
  In patients with alveolar echinococcosis, obstruction of the IVC in the hepatic segment often develops asymptomatically and rarely leads to the impairment of renal function. The collateral circulation fully compensates for obstruction of the IVC. Thrombotic involvement and valvular incompetence of the femoropopliteal veins seems to determine the development of chronic venous insufficiency of the lower extremities.
authors.affiliation: Department of Internal Medicine, University Hospital Zurich, Switzerland.
authors.forename: A F
authors.initials: AF
authors.lastname: Fleiner-Hoffmann
authors.forename: T
authors.initials: T
authors.lastname: Pfammatter
authors.forename: A J
authors.initials: AJ
authors.lastname: Leu
authors.forename: R W
authors.initials: RW
authors.lastname: Ammann
authors.forename: U
authors.initials: U
authors.lastname: Hoffmann
mesh_terms: D000328:Adult; D000368:Aged; D002908:Chronic Disease; D003097:Collateral Circulation; D003251:Constriction, Pathologic / Q000150:complications / Q000209:etiology; D004444:Echinococcosis, Hepatic / Q000150:complications* / Q000175:diagnosis; D005260:Female; D006801:Humans; D007866:Leg / Q000098:blood supply; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed; D014682:Vena Cava, Inferior / Q000473:pathology*; D014689:Venous Insufficiency / Q000209:etiology