Right heart catheterization via hemiazygos-azygos collaterals in the setting of inferior vena cava stenosis

BACKGROUND: In cases of inferior vena cava (IVC) obstruction, venous collaterals involving the hemiazygos and azygos veins can provide venous return to the right atrium. This can lead to procedural challenges in right heart catheterization (RHC). CASE PRESENTATION: A 54-year-old male with end stage renal disease and severe aortic regurgitation underwent RHC for valve replacement planning. Swan Ganz catheter, via left femoral vein, would not advance beyond the distal IVC despite an inflated balloon. It was advanced over a V18 wire, taking a tortuous path to the right ventricle. Imaging revealed infrarenal IVC stenosis due to a dialysis catheter, with venous return through a dilated lumbar vein and hemiazygos and azygos collaterals. CONCLUSION: When catheter advancement fails, IVC stenosis and collateral pathways should be considered. Wire-guided navigation allows completion of RHC in these settings. Familiarity with venous anatomy enables successful RHC despite IVC obstruction. Early recognition and guidewire use can prevent procedural delays.