Anatomical Science International (2006) 82, 121–125 doi: 10.1111/j.1447-073x.2006.00153.

Case Report
Blackwell Publishing Asia

Duplication of the inferior vena cava associated with other

variations
Hao-Gang Xue, Chun-Ying Yang, Mitsuo Asakawa, Kumiko Tanuma and Hitoshi Ozawa
Department of Anatomy and Neurobiology, Nippon Medical School, Tokyo, Japan

Abstract
Multiple vascular variations, including duplication of the inferior vena cava, double renal arteries and
anomalies of the testicular blood vessels, were observed during dissection of the retroperitoneal region of a
cadaver of an 87-year-old Japanese man. The right inferior vena cava arose from the union of right common
iliac veins and a thinner interiliac vein. This interiliac vein ascended obliquely from right to left and joined the
left common iliac veins to form the left inferior vena cava. The right and left inferior venae cavae were of
approximately equal width. The right testicular vein consisted of medial and lateral venous trunks. The two
venous trunks coalesced to form a single vein, which drained into the confluence of the right inferior vena
cava and right renal vein. The left testicular vein was composed of the medial and lateral testicular veins,
which drained into the left renal vein. Double renal arteries were seen bilaterally, which originated from the
lateral aspects of the abdominal aorta. The right testicular artery arose from the right inferior renal artery and
accompanied the lateral trunk of the right testicular vein running downwards. The left testicular artery arose
from the ipsilateral inferior renal artery and ran downwards accompanied by the left lateral testicular vein. In
addition, the bilateral kidneys showed multicystic changes.
Key words: inferior vena cava, renal artery, testicular artery, testicular vein, variations.

Introduction arteries have aortic origins caudal to the renal arteries.

The inferior vena cava (IVC) and the arteries and
veins of the kidneys and gonads are typically single
blood vessels in the retroperitoneal space. The IVC
is the largest vein that returns blood from the inferior
limb, perineum and viscera of the retroperitoneum and
pelvis. The right testicular vein opens cranially into
the IVC, whereas the left testicular vein drains into
the ipsilateral renal vein (Ahlberg et al., 1966). Con-
genital anomalies of the IVC are not very rare; they
are occasionally found in routine dissection studies
(Nakatani et al., 1998), retroperitoneal surgeries
(Habuchi et al., 1993) or computed tomography
scanning (Kokubo et al., 1990). The renal segment
of the IVC has the same origin as the gonadal vein
in embryogenesis (McClure & Butler, 1925; Itoh et al.,
2001); therefore, variations in the IVC are often
accompanied by anomalies of the gonadal vein
(Sarma, 1966; Takagi et al., 1982).
The renal arteries usually arise from the lateral
aspects of the abdominal aorta and the testicular
Correspondence: Hao-Gang Xue, Department of Anatomy and
Neurobiology, Nippon Medical School, Sendagi 1-1-5,
Bunkyo-ku, Tokyo 113-8602, Japan. Email: xuehg@nms.ac.jp
Received 13 May 2006; accepted 3 July 2006.
© 2006 Japanese Association of Anatomists
The level of their origin generally varies from the first
to the third lumbar vertebrae. The renal and gonadal
arteries originate from different branches of the lateral
mesonephric arteries during the embryonic stage
(Felix, 1912). Vascular and developmental variations
of the kidneys can result in anomalies of the gonadal
arteries (Nathan, 1963). Mindfulness of the possible
presence of variations in the IVC and the vessels of
the kidneys and gonads is of great importance during
retroperitoneal surgical procedures. Herein, we describe
a rare case with complex vascular variations involv-
ing the IVC, testicular vessels and renal arteries. The
embryological and clinical significance of the multi-
ple variations in the present case is also discussed.
Case Report
During the gross anatomy course for second year
medical students of Nippon Medical School, dissec-
tion of the retroperitoneal region revealed multiple
vascular variations, including a duplicate IVC, double
renal arteries and anomalies of the testicular blood
vessels associated with multicystic changes in the
kidneys, in a cadaver of an 87-year-old Japanese man
(cadaver no. 2210). The dissection was approved by
the Ethics Committee of our institution and the present
work conformed to the provisions of the Declaration
of Helsinki in 1995 (as revised in Edinburgh 2000).
122 H.-G. Xue et al.
Figure 1. Photograph (a) and schematic drawing (b) showing
duplication of the inferior vena cava and variations of the renal
arteries and testicular blood vessels accompanied by multicystic
kidneys. Arrows indicate communicating veins between the
duplicate testicular veins. AA, abdominal aorta; IMA, inferior
mesenteric artery; IV, interiliac vein; LCIA, left common iliac
artery; LCIV, left common iliac vein; LIPA, left inferior polar
artery; LIRA, left inferior renal artery; LIVC, left inferior vena
cava; LK, left kidney; LLTV, left lateral testicular vein; LMTV, left
medial testicular vein; LRV, left renal vein; LSRA, left superior
renal artery; LT, lateral trunk of the right testicular vein; LTA, left
testicular artery; LU, left ureter; MT, medial trunk of the right
testicular vein; RCIA, right common iliac artery; RCIV, right
common iliac vein; RIPA, right inferior polar artery; RIRA,
right inferior renal artery; RIVC, right inferior vena cava; RK,
right kidney; RSPA, right superior polar artery; RSRA, right superior
renal artery; RRV, right renal vein; RTA, right testicular artery;
RU, right ureter.
Duplication of the IVC was observed in the
present case (Fig. 1). The right common iliac vein
(10 mm in width) and a thinner interiliac vein (3 mm
in width) joined to form the right IVC at the level
of the fifth lumbar vertebra (Fig. 1). The right IVC
© 2006 Japanese Association of Anatomists
ascended along the right side of the abdominal aorta
and the left renal vein drained into its left medial
aspect (Fig. 1) at the level of the inferior edge of the
second lumbar vertebra. The right IVC was 11 mm
in diameter and 120 mm in length from its origin to
the drainage point at the right renal vein, and its
diameter increased to 24 mm after receiving the right
testicular and renal veins (Fig. 1). The right IVC con-
tinued to ascend and ended at the inferior part of
the right atrium of the heart. The left IVC arose by
union of the left common iliac vein and interiliac vein
at the level of the superior edge of the fifth lumbar
vertebra (Fig. 1). The interiliac vein between the
duplicate IVC ran obliquely upwards from right to left
and its middle part gave rise to two branches or
middle sacral veins that were anastomosed with the
venous plexus in front of the sacrum. The left IVC
coursed cranially along the left side of the abdominal
aorta and terminated on the left renal vein (Fig. 1).
It was 90 mm long and approximately equal in width
to the right IVC. The left renal vein was 8 mm wide
before coalescence with the left IVC and 15 mm wide
in the segment between the right and left IVC.
The right testicular vein was an incompletely dupli-
cated vein that consisted of thick medial and thin
lateral venous trunks (Figs 1,2a). The two venous
trunks left the internal inguinal ring and crossed ante-
riorly over the ureter. The lateral trunk ran upwards,
accompanied by the right testicular artery. The medial
trunk was 190 mm in length. It coursed cranially and
obliquely and drained into the confluence of the right
IVC and the right renal vein after receiving the lateral
trunk at the level 30 mm below the right renal vein
(Figs 1,2a). A communicating vein between the medial
and lateral trunks was also detected (Fig. 1). The left
testicular vein was a completely duplicated vein that
was composed of the medial and lateral testicular
veins (Figs 1,2b). The lateral testicular vein had a
relatively thin diameter, accompanied the left testic-
ular artery to ascend spirally and drained perpen-
dicularly into the left renal vein 20 mm from the medial
edge of the left kidney. Along its course, several
communicating veins arose from the lateral testicular
vein and anastomosed with the medial testicular vein
(Fig. 1). The medial testicular vein had an equal length
(165 mm) and was threefold the width of the lateral
testicular vein. The medial testicular vein take a
course similar to the lateral testicular vein and finally
opened into the left renal vein medial to the lateral
testicular vein (Figs 1,2b).
Double renal arteries were seen in bilateral sides
(Fig. 1). The right double renal arteries originated
from the right lateral aspect of the abdominal aorta
and were of similar caliber. The right superior renal
artery coursed laterally and gave rise to superior and
inferior polar arteries that entered the right kidney
 Duplicate inferior vena cava 123

Figure 2. Higher magnification photographs of variations of the renal arteries and testicular blood vessels on the right (a) and left (b)
sides. The arrow in (b) indicates a communicating vein between the left medial and left lateral testicular veins. AA, abdominal aorta;
LIPA, left inferior polar artery; LIRA, left inferior renal artery; LIVC, left inferior vena cava; LK, left kidney; LLTV, left lateral testicular
vein; LMTV, left medial testicular vein; LRV, left renal vein; LSRA, left superior renal artery; LT, lateral trunk of the right testicular vein;
LTA, left testicular artery; LU, left ureter; MT, medial trunk of the right testicular vein; RIPA, right inferior polar artery; RIRA, right inferior
renal artery; RIVC, right inferior vena cava; RK, right kidney; RSPA, right superior polar artery; RSRA, right superior renal artery; RRV,
right renal vein; RTA, right testicular artery; RU, right ureter.

through the superior and inferior poles of the kidney,
respectively (Figs 1,2a). The right inferior renal artery
ran parallel and just inferior to the right superior renal
vein. The major trunks of the double renal arteries
entered the kidney through the renal hilum behind the
right renal vein (Figs 1,2a). The left superior renal artery
had a wider diameter and originated from the left lateral
aspect of the abdominal aorta 15 mm above the left
renal vein (Figs 1,2b). The left superior renal artery ran
laterally vertical to the abdominal aorta and divided
into two branches before entering the left kidney. The
aortic origin of the left inferior renal artery was located
3 mm below the left superior renal artery (Figs 1,2b).
The left inferior renal artery had a relatively thin diameter,
which ran lateroinferiorly, dorsal to the left renal vein,
and entered the left kidney. An inferior polar artery
arose from the left inferior renal artery and reached
the inferior pole of the left kidney (Figs 1,2b).
Atypical origins and courses of the testicular arteries
were observed. The right and left testicular arteries
originated from the inferior surface near the middle
of the ipsilateral inferior renal arteries (Figs 1,2). The
right testicular artery accompanied the lateral trunk
of the right testicular vein and ran downwards
(Figs 1,2a). The left testicular artery descended ven-
tral to the left renal vein, converged with the left lat-
eral testicular vein 15 mm below the left renal vein
and ran downwards accompanied by the left lateral
testicular vein (Figs 1,2b).
The kidneys were present in the bilateral sides of
the vertebrarium from the 12th thoracic to the third
lumbar vertebrae. The left kidney was somewhat lower
than the right kidney and many cystic changes were
observed on the surface of the two kidneys (Fig. 1a).
Discussion
The present report revealed variations of the IVC,
renal arteries and testicular blood vessels. Duplication
of the IVC is a common anomaly in developmental
variations of the IVC, with an incidence of 0.2–3.0%
(Freidland et al., 1992). Both the renal segment of
the IVC and/or the testicular vein are derived from
anastomosis of the subcardinal and supracardinal
veins (McClure & Butler, 1925). Generally, the right
gonadal vein drains into the IVC and the left gonadal
vein opens into the left renal vein, revealing an
apparent asymmetry that is caused by the regression

© 2006 Japanese Association of Anatomists

124 H.-G. Xue et al.
of the left IVC. The development of the right suprac-
ardinal and subcardinal veins is strikingly different
from that of the left side, which it is important for
understanding the development of the gonadal vein
and IVC (Pansky, 1982). The duplicate IVC results
from persistence of the bilateral supracardinal veins
or a failure of regression of the left supracardinal
veins, whereas the left IVC is relatively smaller (Naka-
tani et al., 1998; Itoh et al., 2001). Because the IVC
is closely related to the testicular vein in embryogen-
esis, variations in the IVC often result in anomalies
of the testicular vein (Takagi et al., 1982; Nakatani
et al., 1998).
The duplicate IVC in the present case had a nearly
equal width and arose from the union of the ipsilateral
common iliac veins and interiliac vein. A similar anomaly
has been described previously (Sarma, 1966). Although
the embryological mechanism remains unclear, the
right gonadal vein tends to drain into the right IVC
and renal vein, and the left gonadal vein tends to
open into the left renal vein in cases of duplicate IVC
(Sarma, 1966; Itoh et al., 2001). The duplicate IVC
may reduce the double gonadal veins (Takagi et al.,
1982). Bilateral duplicate testicular veins were also
observed in the present case. The right duplicate
testicular veins coalesced to a single vein before
draining into the confluence of the right IVC and renal
vein, whereas the left duplicate testicular veins ter-
minated on the left renal vein. Bilateral duplicate
gonadal veins accompanied by double IVC have
been reported previously (Takagi et al., 1982; Osawa
et al., 2002). Bilateral ovarian veins in the case of
Takagi et al. (1982) were a complete duplication and
drained into the ipsilateral IVC and renal veins.
Osawa et al. (2002) reported bilateral testicular veins
with incomplete duplication. The right and left testic-
ular veins bifurcated in their central part and recon-
joined to form single veins that terminated on the
ipsilateral renal veins. The drainage and course of the
duplicate gonadal veins in the previous cases were
strikingly different from those in the present case.
The variations of the arterial system in the present
case included double renal arteries and an unusual
origin and course of the testicular arteries in the bilat-
eral sides. The double renal arteries arose from the
lateral aspects of the abdominal aorta. Variations in
the number of renal arteries are often encountered
during dissection of the posterior abdominal wall;
double renal arteries occur in approximately 20–23%
of cases (Satyapal et al., 2001; Bordei et al., 2004).
Anomalies related to the origin and course of the
gonadal arteries have been investigated previously
(Notkovich, 1956; Mijac et al., 1983). The present
case revealed that the right and left testicular arteries
originated from the ipsilateral inferior renal arteries
or accessory renal arteries, respectively, which has
© 2006 Japanese Association of Anatomists
not been described previously. According to Felix
(1912), nine lateral mesonephric arteries of the embryo
can be divided into the cranial, middle and caudal
groups. The renal artery usually originates from the
middle group, whereas persistence of an extra branch
from the lateral mesonephric arteries may result in
an accessory renal artery in addition to the main
renal artery. The gonadal artery generally originates
from the caudal group; however, any of the lateral
mesonephric arteries may also become the gonadal
artery. Thus, both the renal and testicular arteries in
the present case may have originated from the mid-
dle group of the lateral mesonephric arteries. The
double renal arteries may have been formed by one
of the middle group arteries persisting as the acces-
sory renal artery, whereas the testicular arteries
developed as branches of the accessory renal arteries.
An atypical origin and course of the gonadal arteries
may be associated with vascular and developmental
variations of the kidneys (Machnicki & Grzybiak, 1997).
Kidneys with bilateral multicystic changes were also
detected in the present case. The multicystic kidney
is the result of an abnormality in renal development,
which may be inherited in an autosomal dominant
fashion (Srivastava et al., 1999). The presence of the
multicystic kidney may coincide with a high inci-
dence of hydronephrosis and infections of the upper
urinary tract and may result in deterioration of late
renal function and secondary hypertension.
Duplication of the IVC and vascular variations of
the kidneys and gonads are important not only from
the developmental point of view, but also have impor-
tant clinical implications. These anomalies can man-
ifest various clinical symptoms and can affect the
approach to surgical procedures. The presence of
duplicate IVC poses hazards during abdominal aortic
surgery. The double renal arteries, renal arterial ori-
gin of the testicular arteries and atypical drainage of
the testicular veins increase the complexity of renal
transplantation and lead to a higher percentage of
transplant failures. Thus, familiarity with these ana-
tomical anomalies is vital for vascular surgeons and
urologists to reduce the risk of serious hemorrhage
during surgical treatment and to avoid operative
complications.
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