The Inferior Vena Cava

Topography of Inferior Vena Cava

- At the level of the L5, the right and left common iliac veins, forming the inferior vena
cava.

- Largest vein of the human body.

- Collects blood from the lower half of the bod, below the diaphragm.

- No valves.

- Runs on the right side of the vertebral column.

- Lies on the right side of the abdominal aorta.

- Forms the right sagittal groove on the posterior surface of the liver.

- Goes through the diaphragm through the caval opening, together with the right
phrenic nerve.

Tributaries of Inferior Vena Cava

Visceral Tributaries

- Drain organs.

Hepatic Veins

- 3 large intrahepatic veins:

1. Right Hepatic Vein
2. Intermediate Hepatic Vein
3. Left Hepatic Vein

- Drain the liver parenchyma into the inferior vena cava.

- Blood from the portal system goes into the liver to be filtered and processed then it
flows through the hepatic veins into the systemic circulation.
Right Suprarenal Vein

- Drain the suprarenal gland into the inferior vena cava.

Left Renal Vein

- Drain the left kidney into the inferior vena cava.

- Tributaries (drain into the left renal vein):

1. Left Suprarenal Vein – drain the suprarenal gland.
2. Left Testicular Vein – drain the left testes.
3. Left Ovarian Vein – drain the left ovary.

Right Renal Vein

- Drain the right kidney into the inferior vena cava.

- Tributaries (drain into the right renal vein):

1. Right Testicular Vein – drain the right testes.
2. Right Ovarian Vein – drain the right ovary.

* The ovarian and testicular veins drain into the Pampiniform plexus, which lies on the
posterior aspect of the ovaries and the testes.

Parietal Tributaries

- Drain bones and muscles.

Lumbar Veins

- 4 pairs of lumbar veins, which follow the lumbar arteries (abdominal aorta).

- Communicate with the external and internal vertebral venous plexuses to drain the
spinal cord and with the ascending lumbar veins, which drain into the azygos and
the hemiazygos veins.

Inferior Phrenic Veins

- Drain the inferior side of the diaphragm into the inferior vena cava.
The Portal System

- An arrangement of blood vessels such that blood passes from a capillary, into larger
blood vessels and then into another capillary bed.

- Drain the blood from the unpaired visceral organs of the abdominal cavity; large
intestine, small intestine, pancreas, stomach, spleen, gallbladder.

- Blood from these organs will go to the portal vein within the hepatoduodenal
ligaments into the liver then bifurcate into the right and the left branches and divide
into smaller branches to supply the hepatic lobes.

Portal Vein

- Formed by 3 major veins:

1. Superior Mesenteric Vein
2. Splenic Vein
3. Inferior Mesenteric Vein

Superior Mesenteric Vein Tributaries

- Passes on the right side of the superior mesenteric artery, goes behind the pancreas
and continues down to terminate as the jejunal and ileal veins.

1. Jejunal and ileal veins – drain from the loops of the jejunum and the ilium.

2. Right Colic Vein – drain the ascending colon.

3. Ileocolic Vein – drain the terminal part of the small intestine and the cecum.

4. Appendicular vein – drain the appendix.

5. Middle Colic Vein – drain the transverse colon.

6. Right Gastro-omental Vein – drain the greater curvature of the stomach and the
greater momentum of the peritoneum.

- All of these veins drain into the superior mesenteric which drains into the portal vein.
Inferior Mesenteric Vein Tributaries

- Drain into the splenic vein (mainly), superior mesenteric or portal vein.

1. Superior Rectal Vein – drain the superior part of the rectum or the rectal ampulla.

2. Sigmoid Vein – drain the sigmoid colon.

3. Left Colic Vein – drain the descending colon.

- All of these veins drain into the inferior mesenteric which drains into the splenic vein.

Splenic Vein Tributaries

- Originates from the splenic helium then passes behind the stomach and the
pancreatic body to join the superior mesenteric vein in forming the portal vein.

1. Left Gastro-omental Vein – communicates with the right gastrointel vein.

2. Short gastric Veins – drain the fundus and the upper greater curvature of the stomach.

3. Pancreatic Veins – arise along the surface of the pancreatic body and drain it into the
splenic vein.

- All of these veins drain into the splenic vein which drains into the portal vein.

Tributaries

1. Left Gastric Vein – drain the lesser curvature.

● Anastomose with the right gastric vein to form a venous arch along the lesser
curvature.

2. Esophageal Veins – drain the abdominal part of the esophagus.

3. Right Gastric Vein – drain the lesser curvature.

4. Prepyloric Vein – drain the pyloric part of the stomach.

5. Pancreaticoduodenal Veins – drain the head of the pancreas and the duodenum.
● Empties into the portal vein and superior mesenteric vein.
 6. Cystic Vein – drain the gallbladder.

7. Paraumbilical Veins – drain the anterior part of the abdominal wall and some parts of
the diaphragm into the liver.
● 2 thin veins passing along the round ligament of the liver.

- All of these veins unite to form the portal vein, which then goes into the liver and
branches off to various lobes and then the hepatic veins drain blood from the liver into
the inferior vena cava.

Portal Hypertension Manifestations

- Portal hypertension is an increase in the pressure within the portal vein, which carries
blood from the digestive organs to the liver.

- In the liver, the blood passes through liver sinusoids and finally exits through the
hepatic veins, which empty into the vena cava of the general circulation.

Causes of Portal Hypertension

1. Hepatic causes
● Account for over 95% of cases.
● Cirrhosis, caused by:
➢ Increase in intrahepatic vascular resistance – fibrosis narrows the vessels
causing blood to back up in the portal venous system, therefore increasing
the pressure.
➢ Alcoholic liver damage.
➢ Nonalcoholic fatty liver disease.
➢ Hepatitis C infection.
➢ Other metabolic causes.

2. Pre-haptic causes
● Affect the portal venous system before it enters the liver:
➢ Portal vein thrombosis.
➢ Splenic vein thrombosis.
➢ Tumor.

3. Post-hepatic causes
● Anything that affects the draining of the liver.
 ➢ Hepatic vein thrombosis.
● Right-sided heart failure – blood will start to build up in the superior and the
inferior vena cava which congests the blood inside the portal system.

Consequences of Portal Hypertension

- If the portal system is blocked for any reason, the blood needs to find a way back to
the heart, and so it reverses flow back down the portal system into other veins; the
splenic vein, umbilical vein, hemorrhoidal veins, and esophageal veins.

- Due to portal hypertension, there may be:

1. Upper gastrointestinal bleeding

- These veins are not accustomed to handling such large blood volume and
they dilate, causing varices, which are very fragile, and could easily
rupture, causing massive upper gastrointestinal bleeding.

2. Hemorrhoids
- Veins in the rectum and anal canal enlarge, causing hemorrhoids.

3. Congestive Splenomegaly
- As blood backs up into the spleen, it enlarges (congestive splenomegaly),
and starts overdoing its job, which causes an increased removal of blood
elements and can lead to anemia.

4. Ascites
- Endothelial cells lining the blood vessels release more nitric oxide,
causing the peripheral arteries to dilate, so blood pressure drops.
- This stimulates the release of aldosterone, which tries to bring blood
pressure back up by making the kidneys to retain more sodium and water.
- As plasma volume expands, fluid in blood vessels gets pushed into large
open spaces like the peritoneal cavity, leading to ascites.

Porto-Caval Anastomoses

- Anastomoses between veins of the portal venous system (tributaries of the portal
vein) and veins of the caval venous system (tributaries of the superior or inferior vena
cava).
 - Under normal conditions, there is minimal/no blood
flow through these anastomoses.

- Under portal hypertension, the blood needs to

escape the portal system through the porto-caval
anastomosis as it is not flowing through the liver
efficiently, this causes increased pressure within
the caval veins, leading to varices or ascites.

Esophageal Veins

- Anastomoses between the left gastric vein (portal system) and the azygos and
hemiazygos veins (caval system), which empty into the superior vena cava.

- Manifests esophageal varices in portal hypertension.

Rectum and Anal Canal

- Anastomoses between the:

● Superior rectal vein (portal system) – drain into the inferior mesenteric vein.
● Middle rectal vein (caval system) – drain into the internal iliac.
● Inferior rectal vein (caval system) – drain into the internal pudendal vein.

- Manifests internal hemorrhoids (hemorrhoidal plexus) or anorectal varices in portal

hypertension.

Paraumbilical Veins and the Subcutaneous Veins Around the Umbilicus

- Anastomoses between the paraumbilical veins (portal system) and the superior and
inferior epigastric veins (caval system).

- Manifests caput medusae (enlarged veins around the umbilicus) and ascites in
portal hypertension.

Colonic Veins

- Anastomoses between the colonic veins (portal system) and the retroperitoneal veins
(caval system).

- Manifests colonic varices in portal hypertension.

TIPS Procedure

- Transjugular Intrahepatic Portosystemic Shunt (TIPS) between the portal vein and
hepatic vein relieves portal hypertension by shunting blood to the systemic circulation,
bypassing the liver.

- Patients of portal hypertension may be asymptomatic or symptomatic due to variceal

bleeding, ascites, encephalopathy, or hypersplenism.

- Variceal hemorrhage occurs most commonly at the gastroesophageal junction and

results in death.

- Procedure:
● Incision is made in the neck to access the internal jugular vein.
● Guide wire is inserted to the right hepatic vein and then a catheter is inserted
after.
● Wire is removed and a balloon at the tip of the catheter measures the indirect
pressure.
● After the catheter is removed, a wire is inserted and thrusted against the wall of
the hepatic vein and parenchyma into a major branch of the portal vein to
confirm proper placement.
● Pigtail is inserted and direct pressure is measured in the portal vein.
● Balloon catheter is used to dilate the track between the hepatic and portal veins.
● Stent is placed after the balloon is removed.

The Lymphatic System

- The lymphatic system is a one-direction, open-ended network of vessels acting as a

drainage system that removes excess fluid from body tissues and returns it to the
bloodstream.

- It is a mix of the circulatory and immune system.

Lymphatic Vessels

- Lymphatic vessels begin as lymphatic capillaries made of endothelial cells that

function as a one-way valve.

- As interstitial pressure increases, the endothelial cells are pressed inward, opening
the gaps, thus allowing backflow.
 - As capillary pressure increases, the endothelial cells are pressed outward, closing the
gaps, thus preventing backflow.

- The gaps in lymphatic capillaries are so large that they allow bacteria, immune cells;
macrophages, to enter the bloodstream.

- The recovered fluid that enters the lymphatic vessels is called lymph.

- Lymph flow is enabled by the same forces that facilitate blood flow in the veins, it
goes from lymphatic capillaries to larger and larger lymphatic vessels and eventually
drains into the bloodstream via the subclavian veins.

- Lymphatic vessels ultimately converge as 2 large trunks:

1. Thoracic Duct
● Begins in the abdomen at the cisterna chyli, which is the dilated junction of
the intestinal, lumbar, and descending intercostal trunks.
● Drains the lower limbs, pelvis, abdomen, left sides of the thorax, upper
limb, head and neck.
● Passes through the aortic opening of the diaphragm and ascends through
the posterior mediastinum between the aorta and the azygos vein.
● Arches laterally over the apex of the left pleura and between the left
carotid sheath in front and the vertebral artery behind, runs behind the left
internal jugular vein, and then empties into the junction of the left internal
jugular and subclavian veins.

2. Right Lymphatic Duct

● Drains the right sides of the thorax, upper limb, head, and neck.
● Empties into the junction of the right internal jugular and subclavian veins.

Lymph Nodes

- Lymph nodes are small bean-shaped structures, which serve as filters, scattered
throughout the lymphatic network, most prominent in the areas where the vessels
converge.

- Lymph passes through lymph nodes to cleanse it before it reaches the bloodstream.
- Lymph nodes contain:
● Macrophages
● Dendritic cells – directly “swallow up” any pathogens.
 ● Lymphocytes – T-cells and B-cells, which are involved in adaptive immune
response to produce activated lymphocytes and antibodies specific to the
invading pathogen, which are then carried by the lymph to the bloodstream to
be distributed.

Lymphoid Organs

- Primary lymphoid organs – sites of lymphocyte production, maturation and selection:

● Thymus
● Bone marrow

- Selection – the process in which lymphocytes distinguish between self and non-self,
so they can recognize and destroy pathogens without attacking the body’s own cells.

- Secondary lymphoid organs:

● Lymph nodes
● Spleen
● Lymphoid nodules

The Diaphragm

- Structures perforating diaphragm:

● At T8 – IVC, right phrenic nerve.
● At T10 – esophagus, vagus (CN 10; 2 trunks).
● At T12 – aorta, thoracic duct, azygos vein.