Diversion of venous blood flow through transverse sinuses in one-sided innominate vein obstruction.

Abstract

The literature contains many reports of superior vena cava obstruction (1) but few of one-sided innominate vein obstruction with the superior vena cava remaining patent. Such reports of innominate vein obstruction as have appeared deal mainly with the clinical findings, without demonstration by phlebography of all possible routes of blood-flow diversion from the affected area (2, 3). As far as we could ascertain, the case to be reported here is the first in which the transverse sinuses were demonstrated by the injection of contrast medium into the cubital vein. It came to our attention in the course of angiography for the diagnosis of mediastinal lesions. S. K., a 30-year-old male, two years before admission to our hospital noticed swelling of his face and both arms, and a mass above the left clavicle, the size of a hen's egg. A diagnosis of Hodgkin's disease had been made at that time (Fig. 1). After x-ray therapy the supraclavicular mass and the swelling of the face disappeared, and the patient felt well until about six months before admission, when he began to experience a dull ache behind the right sternoclavicular junction, radiating into the right shoulder. At the same time he noticed swelling of the right arm and shoulder, appearing after exercise and disappearing with rest. The face and the left arm remained unaffected. Clinical examination revealed no abnormalities, except for a persistent fullness of the right jugular vein. Venous pressure readings were as follows: in the right arm, 20 cm. H2O; in the left arm, 10 cm. H2O. The circulation time (Decholin), right arm to tongue was 19 seconds; left arm to tongue, 10 seconds. A film on admission showed a normal mediastinal shadow and increased markings of the right upper lung field, due probably to radiation fibrosis. Phlebography (Fig. 2) with 30 c.c. of diodrast (35 per cent) injected into the right cubital vein, with the patient sitting, showed complete obstruction of the right innominate vein with reflux of contrast medium into the jugular vein. No collaterals were visible. Phlebography with injection of the left cubital vein, under same conditions, revealed normal filling of the left innominate vein and superior vena cava. As no collaterals except the cervical veins (thyroid veins) could be demonstrated, the conclusion was reached that the venous blood flow from the right arm, right shoulder, and the right half of the neck must be diverted through the dural sinuses of the skull to the left jugular vein, reaching finally the superior vena cava. To prove this assumption, 60 c.c. of diodrast (35 per cent) was injected into the right cubital vein, and exposure of film made twelve seconds after start of injection (injection time ten seconds). The resulting phlebogram (Fig. 3) shows good filling of the right and left jugular vein, with some contrast medium in the left innominate vein.