Correct answer is:

Left portal vein -> umbilical vein/paraumbilical vein -> superior epigastric vein -> internal thoracic vein -> brachiocephalic vein -> superior vena cava

Explanation:

In the context of portal hypertension, the umbilical vein undergoes recanalization and, as well as the paraumbilical veins that run with it in the falciform and round ligaments, have their flow inverted, from the peripheral portal branches of the left hepatic lobe towards the epigastric veins. From there the blood goes in cranial direction (superior epigastric vein – internal thoracic vein – brachiocephalic vein – superior vena cava) or caudal (inferior epigastric vein – external iliac vein – common iliac vein – inferior vena cava) to achieve the ultimate goal which is the arrival of blood to the heart, deviating from the liver.

Discussion of the image interpretation leading to the diagnosis compared to the alternative answers

Doppler demonstration of hepatofugal flow in the umbilical veins is pathognomonic for portal hypertension. Paraumbilical vein dilation has been observed in about 34% of cirrhotic patients, while in groups with greater impairment of the liver function (Child C patients) this percentage may be even higher, with reported rates as high as 57%.

Portosystemic communication can lead to vascular dilation in these pathways, that may lead to a peculiar aspect in the periumbilical region often compared to Medusa’s head (origin of the latin term caput medusae).

Take Home Message

As important as detecting collateral circulation in cases of portal hypertension, as important it is to know its possible paths.

References

1. Melo-Leite AF, Mota Jr. A, Chagas-Neto FA, Teixeira SR, Elias Junior J, Muglia VF. Acquired portosystemic collaterals: anatomy and imaging. Radiol Bras.2016 Jul/Ago;49(4):251–256.
2. MARTINELLI ALC. Hipertensão portal. Medicina, Ribeirão Preto, jul./dez. 2004; 37: 253-261.
3. Machado MM, CRF Ana, Barros N, Azeredo LM, Rosa JBF, Cerro LMO, Chammas MC, Daher MT, Daher RT, Saad WA, Cerri GG. Estudo Dopper na hipertensão portal. Radiol Bras 2004; 37 (1):35-39.