From the Guidelines
Reflux of contrast into the inferior vena cava (IVC) and hepatic vessels is a nonspecific finding that can indicate right-sided cardiac issues, most commonly right ventricular dysfunction, valvular heart disease (particularly tricuspid regurgitation), or cardiac arrhythmias, as noted in the European Heart Journal study 1. This phenomenon occurs when the right heart cannot efficiently pump blood forward, leading to increased pressure in the right atrium and backflow into the venous system. The contrast material follows this retrograde flow pattern, appearing in the IVC and hepatic veins during imaging. Key considerations in evaluating this finding include:
- Assessing for symptoms of right heart failure, such as peripheral edema, ascites, or jugular venous distention, as outlined in the Circulation study 1
- Utilizing echocardiography to determine the exact cause and severity of the cardiac dysfunction, including evaluation of tricuspid annular plane systolic excursion (TAPSE) and systolic myocardial velocities, as recommended in the European Heart Journal study 1
- Considering the potential for right ventricular dysfunction, valvular heart disease, or cardiac arrhythmias, and evaluating for signs such as increased jugular venous pressure, hepatojugular reflux, or pulmonary rales, as discussed in the Circulation study 1
- Evaluating laboratory evidence, such as BNP or NT-proBNP concentrations, and radiological evidence, such as pulmonary congestion on chest X-ray, to support the diagnosis of heart failure, as outlined in the Circulation study 1
- Recognizing that reflux of contrast into the IVC and hepatic vessels is not diagnostic of a specific condition, but rather a radiological clue that warrants further clinical correlation and evaluation, as noted in the European Heart Journal study 1.
From the Research
Reflux of Contrast into the IVC and Hepatic Vascular
- Reflux of contrast into the inferior vena cava (IVC) and hepatic vascular is a finding that can be seen on computerized tomographic pulmonary angiogram (CTPA) and is associated with right heart dysfunction 2, 3, 4.
- This finding is nonspecific but can be seen in the setting of right ventricular dysfunction, valvular disease, or arrhythmia 2, 5, 4.
- The degree of reflux into the IVC and hepatic veins can be graded, with higher grades indicating more severe reflux 2.
- Studies have shown that extensive reflux of contrast medium into the IVC is associated with pulmonary hypertension, history of congestive heart failure, chronic atrial fibrillation, and acute pulmonary embolism 2, 3.
Clinical Relevance
- Reflux of contrast into the IVC or hepatic veins on CT is a specific but insensitive sign of right-sided heart disease at low contrast injection rates, but the usefulness of this classic sign decreases with high injection rates 4.
- High injection rate, tricuspid regurgitation, pulmonary hypertension, and right ventricular systolic dysfunction are independent predictors of retrograde inferior vena cava or hepatic vein opacification 4.
- The reticulated-mosaic pattern of the liver on contrast-enhanced computed tomography, combined with hepatic venous or caval reflux of contrast, indicates the presence of hepatic venous hypertension 6.