Complexities in Managing Wolf-Parkinson-White Syndrome: A Case of Congenital Inferior Vena Cava Anomaly With Azygos Continuation

The inferior vena cava (IVC) is a critical structure for venous return to the heart, and congenital anomalies of the IVC, though rare, can have significant clinical implications during procedures like catheter ablation for arrhythmias. In this case, a 26-year-old male presented with left-sided chest pressure after a routine exercise. Electrocardiography (ECG) revealed a delta wave and shortened PR interval, consistent with Wolf-Parkinson-White (WPW) syndrome, which involves an accessory electrical pathway leading to supraventricular tachycardia. Catheter ablation was planned to treat WPW syndrome; however, during the procedure, access to the right atrium via the IVC was obstructed due to an undiagnosed congenital IVC anomaly. Imaging revealed that the IVC was interrupted at the abdominal level, with venous return rerouted through an enlarged azygos vein into the superior vena cava. This anomaly prevented the use of the standard transvenous approach for ablation, and alternative approaches requiring specialized equipment and a highly skilled team available only at a tertiary care center were necessary. The patient was subsequently referred to such a center for further management. The IVC anomaly directly affected the procedural outcome, making pre-procedural imaging important when unexpected difficulties arise during ablation for WPW. This case demonstrates how congenital vascular anomalies may complicate standard electrophysiological procedures, especially in arrhythmia management. Future research should focus on developing alternative ablation techniques, such as the aortic approach, which may offer solutions for patients with vascular anomalies but require specialized facilities. While routine imaging for all WPW patients is not necessary, this case suggests that early imaging should be considered when procedural access is unexpectedly difficult. Establishing protocols and training for these complex scenarios is important for improving outcomes in similar cases.