Images in Vascular Medicine: Vena cava syndrome mimicking caput medusae.

During planning for a transcatheter aortic valve replacement for severe aortic stenosis in a 76-year-old man, physical examination showed pronounced varicose veins of the abdomen (Panel A). Thorough clinical history revealed their development after a thymectomy and radiotherapy for thymic carcinoma about 40 years ago. The patient had long accepted the varicosities as a mere cosmetic issue. Liver cirrhosis and portal hypertension were ruled out and the patient was prepared for aortic valve replacement. However, in the preprocedural CT angiography, the contrast agent injected into the left cubital vein drained via the superficial epigastric veins into the femoral veins before entering the inferior vena cava (Panel B; CT reconstruction). Panels C and D show coronal CT images with arrows pointing at the occluded superior vena cava (AO, aorta; LA, left atrium; PA, pulmonary artery; RA, right atrium; SVC/IVC, superior/inferior vena cava; VJI, internal jugular vein). Clinical relevance emerged, when, after successful aortic valve replacement, implantation of the temporary pacemaker lead through the