Bilateral Brachiocephalic Veins Research Articles

Comparison of Catheter Malposition Between Left and Right Ultrasound-Guided Infraclavicular Subclavian Venous Catheterizations: A Randomized Controlled Trial.

Catheter malposition after subclavian venous catheterization (SVC) is not uncommon and can lead to serious complications. This study hypothesized that the left access is superior to the right access in terms of catheter malposition after ultrasound-guided infraclavicular SVC due to the asymmetry of the bilateral brachiocephalic veins. Parallel-armed randomized controlled trial. A tertiary referral hospital in Korea. Patients 20-79 years old who were scheduled to undergo SVC under general anesthesia. Patients were randomly assigned to either the left ( n = 224) or right ( n = 225) SVC group. The primary outcome measure was the overall catheter malposition rate. The secondary outcome measures included catheter malposition rates into the ipsilateral internal jugular and contralateral brachiocephalic veins, other catheterization-related complications, and catheterization performance. The catheter malposition rate was lower (10 [4.5%] vs. 31 [13.8%], p = 0.001), especially in the ipsilateral internal jugular vein (9 [4.0%] vs. 24 [10.7%], p = 0.007), in the left SVC group than in the right SVC group. In the left SVC group, catheterization success rates on the first pass (88 [39.3%] vs. 65 [28.9%], p = 0.020) and first-catheterization attempt (198 [88.4%] vs. 181 [80.4%], p = 0.020) were higher whereas times for vein visualization (30 s [18-50] vs. 20 s [13-38], p < 0.001) and total catheterization (134 s [113-182] vs. 132 s [103-170], p = 0.034) were longer. There were no significant differences in other catheterization performance and catheterization-related complications between the two groups. These findings strengthen the rationale for choosing the left access over the right access for ultrasound-guided infraclavicular SVC.

Superior Vena Cava Syndrome in a Case of Interstitial Lung Disease

Abstract Superior vena cava (SVC) syndrome is mostly seen secondary to malignancies, while benign causes account for only 30% of cases. This case report is of a 62-year-old obese male diagnosed with interstitial lung disease (ILD) non specific interstitial pneumonia (NSIP) pattern on steroids for 1 year and antifibrotics for 3 months came with exacerbation of dyspnea, orthopnea, and nonproductive cough of 3 months duration. He had a facial plethora, watering of eyes, dilated veins over the chest, striae over the abdomen, and Grade 2 clubbing clinically suggestive of SVC obstruction. Contrast-enhanced computed tomography (CT) thorax revealed mediastinal lipomatosis compressing SVC and bilateral brachiocephalic veins. His steroids were tapered and stopped, and he was initiated on pioglitazone. Serum cortisol level was normal suggestive of exogenous Cushing’s disease. Repeat CT taken after 5 months showed reversal of SVC obstruction with no progression of ILD.

Direct superior vena cava puncture for inferior vena cava filter retrieval.

Most inferior vena cava (IVC) filters are designed for retrieval from a superior approach. Retrieval becomes technically challenging when the central veins in the chest are occluded. In a patient with thrombosis of the bilateral brachiocephalic veins, the authors describe direct puncture of the superior vena cava (SVC) under fluoroscopy, followed by the successful retrieval of a fractured IVC filter using forceps. A snare inserted into the SVC via the common femoral vein was used as a radiopaque target for direct SVC puncture from the lower neck. Cone beam computed tomography and pullback tractography were used to confirm a safe access trajectory. Thus, direct SVC access may be used for filter retrieval in similar clinical scenarios.

Estimating right atrial pressure using upright computed tomography in patients with heart failure

ObjectivesUpright computed tomography (CT) can detect slight changes particularly in the superior vena cava (SVC) volume in healthy volunteers under the influence of gravity. This study aimed to evaluate whether upright CT-based measurements of the SVC area are useful for assessing mean right atrial pressure (mRAP) in patients with heart failure.MethodsWe performed CT in both standing and supine positions to evaluate the SVC (directly below the junction of the bilateral brachiocephalic veins) and inferior vena cava (IVC; at the height of the diaphragm) areas and analyzed their relationship with mRAP, measured by right heart catheterization in 23 patients with heart failure.ResultsThe median age of enrolled patients was 60 (51−72) years, and 69.6% were male. The median mRAP was 3 (1−7) mmHg. The correlations between the standing position SVC and IVC areas and mRAP were stronger than those in the supine position (SVC, ρ = 0.68, p < 0.001 and ρ = 0.43, p = 0.040; IVC, ρ = 0.57, p = 0.005 and ρ = 0.46, p = 0.026; respectively). Furthermore, the SVC area in the standing position was most accurate in identifying patients with higher mRAP (> 5 mmHg) (SVC standing, area under the receiver operating characteristic curve [AUC] = 0.91, 95% confidence interval [CI], 0.77–1.00; SVC supine, AUC = 0.78, 95% CI, 0.59–0.98; IVC standing, AUC = 0.77, 95% CI, 0.55–0.98; IVC supine, AUC = 0.72, 95% CI, 0.49–0.94). The inter- and intraobserver agreements (evaluated by intraclass correlation coefficients) for all CT measurements were 0.962–0.991.ConclusionsUpright CT-based measurement of the SVC area can be useful for non-invasive estimation of mRAP under the influence of gravity in patients with heart failure.Key Points• This study showed that the superior vena cava (SVC) area in the standing position was most accurate in identifying patients with heart failure with higher mean right atrial pressure.• Upright computed tomography-based measurements of the SVC area can be a promising non-invasive method for estimating mean right atrial pressure under the influence of gravity in patients with heart failure.• Clinical management of patients with heart failure based on this non-invasive modality may lead to early assessment of conditional changes and reduced hospitalization for exacerbation of heart failure.

Giant Ascending Aortic Aneurysm Causing Central Venous Occlusion.

HomeRadiologyVol. 305, No. 1 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyGiant Ascending Aortic Aneurysm Causing Central Venous OcclusionPedro V. Staziaki , Sandeep S. HedgirePedro V. Staziaki , Sandeep S. HedgireAuthor AffiliationsFrom the Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114.Address correspondence to P.V.S. (email: [email protected]).Pedro V. Staziaki Sandeep S. HedgirePublished Online:Jul 19 2022https://doi.org/10.1148/radiol.220414MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In An 82-year-old woman with hypertension presented with epistaxis and hemoptysis. Physical examination revealed distended veins in the chest and abdominal wall, which prompted chest radiography followed by a CT angiography (CTA) of the chest, abdomen, and pelvis. CTA showed a giant ascending thoracic aortic aneurysm (TAA) measuring 10.5 × 10 cm at its largest dimension, with normal-sized sinuses of Valsalva (Fig 1). The aneurysm was notably compressing the superior vena cava, bilateral brachiocephalic vein, and right internal thoracic (internal mammary) vein, resulting in multiple superficial collateral veins in the thoracic and abdominal wall. The patient was referred to cardiothoracic surgery for repair but declined surgical intervention, and a decision was made to continue medical therapy with antihypertensives.Figure 1: (A) CT angiogram in the axial plane in an 82-year-old woman shows a large saccular ascending thoracic aortic aneurysm with wall calcifications and a partially thrombosed lumen (*). The right internal thoracic vein, superior vena cava, and azygos arch are not visualized due to extrinsic compression, whereas the left internal thoracic vein can still be seen (arrow). Notice a right lateral thoracic vein (white arrowhead) and large bilateral superficial venous tributaries (black arrowheads) coursing in the subcutaneous tissue. (B) CT angiogram in the coronal plane depicts the large size of the thoracic aortic aneurysm and the eccentric thrombus (*).Figure 1:Download as PowerPointOpen in Image Viewer Giant ascending TAAs are defined as aneurysms greater than 10 cm in size (1,2). Here, we show an example of a giant ascending TAA resulting in central venous occlusion and development of multiple collateral vessels throughout the chest and abdominal walls. Venous collateral pathways include deep or superficial venous pathways (3–5). In this case, the predominant collateral pathway was by means of superficial veins (Fig 2).Figure 2: Cinematic rendering of the same CT angiogram in Figure 1 of the chest, abdomen, and pelvis reveals the extent of superficial collateral veins throughout the torso. Because the bilateral brachiocephalic veins, superior vena cava, and right internal thoracic vein were extrinsically compressed by the ascending thoracic aortic aneurysm, the collateral venous pathway on the right is superficial, with enlargement of multiple superficial venous tributaries in the upper chest, right lateral thoracic and thoracoepigastric veins (arrowheads), and right superficial epigastric vein (white arrow). Because the left internal thoracic vein (black arrow) is still present, the superficial pathway on the left is from the left internal thoracic vein to the multiple superficial tributaries to the left superficial epigastric vein (white arrow). The azygos system was not available as a collateral option because the azygos arch was also compressed by the large thoracic aortic aneurysm.Figure 2:Download as PowerPointOpen in Image Viewer Disclosures of conflicts of interest: P.V.S. Member of the Radiology: Artificial Intelligence Trainee Editorial Board. S.S.H. Member of the RadioGraphics Social Media and Digital Innovation Team.AcknowledgmentCinematic rendering access was provided in cooperation with Siemens Healthineers.

A case of thymic carcinoma resected by preserving collateral circulation tract via azygos vein with combined resection of superior vena cava and bilateral brachiocephalic vein

A case of thymic carcinoma resected by preserving collateral circulation tract via azygos vein with combined resection of superior vena cava and bilateral brachiocephalic vein

Endovascular treatment of superior vena cava syndrome does not preclude continued use of indwelling hemodialysis and chemotherapy lines

Obstruction of the Super Vena Cava (SVC) can result in symptoms, such as facial plethora and swelling, and be due to a variety of underlying causes besides lung malignancies, the rates of which have changed over time; the underlying etiology is used to determine the best management strategy. This case report aims to discuss the role of etiology in determining the best initial treatment for SVC syndrome (SVCS) and outlines the unique management for a patient that represents the changing demographics of SVCS causes. A 73-year-old male with end-stage renal disease and metastatic carcinoma of the colon presented with swelling of the jaw, neck, and tongue. Computed tomography (CT) scan showed chronic thrombosis of the SVC and bilateral brachiocephalic veins. He had been receiving hemodialysis and chemotherapy through central venous catheters (CVCs) that traversed the SVC and terminated in the right atrium. Treatment involved double-barrel stent reconstruction of the SVC with a snare technique to temporarily reposition the chemotherapy port catheter and exchange of the hemodialysis catheter. After this single procedure, he experienced relief of symptoms without disrupting the use of his CVCs for further hemodialysis or chemotherapy appointments. For cases of SVCS due to underlying lung malignancies, which has been and remains the most common cause, endovascular stenting is reserved as a palliative measure when treatment of a refractory malignancy fails to resolve the obstruction and for when symptoms are severe because most cases are not life-threatening. However, increased use of CVCs has caused a rise in SVCS due to thrombosis, for which stenting is the first-line treatment. Of the few previously published case reports that depict using a snare technique to temporarily reposition a CVC, they all describe cases due to lung malignancies. Outlining this case presentation can increase awareness of thrombotic stenosis as an increasingly common cause of SVCS, which may occur in patients with a broader range of underlying conditions, ages, and life expectancies and require a wider array of physicians to be knowledgeable of management strategies. Furthermore, detailing this unique technique can provide therapeutic alternatives that show how endovascular interventions do not disrupt interdisciplinary treatment plans or preclude continued use of CVCs. While stenting technology has improved dramatically since its inception, follow-up on stent patency will help determine if expanding treatment for lower acuity cases is beneficial. Endovascular stenting is the treatment of choice for thrombotic causes of SVCS, which is becoming more common due to the increased use of CVCs. Techniques to temporarily reposition CVCs intra-procedurally allow for limited disruption in multidisciplinary treatment plans for patients with complex underlying conditions.

The left brachiocephalic vein 'spur': A cadaveric and contrast computed tomography study.

Objectives This study investigated the presence of the ‘spur’ which separates the lumen in the left brachiocephalic vein (LBV). Method We macroscopically observed the lumen of the bilateral brachiocephalic veins and the superior vena cava in 56 cadavers. The samples were treated with haematoxylin and eosin staining and immunostaining using an α-smooth muscle action antibody. Contrast-enhanced computed tomography images from 170 subjects were analysed. Results The septal structure was found in only 7% of LBVs included in the cadaveric study and 1.2% of LBVs included in the contrast-enhanced computed tomography image analysis. In the cadaveric study, the septal structure was identified as a ‘spur’ using histopathology. In both studies, a non-septal structure was found in the right brachiocephalic vein. Conclusions This is the first report indicating the existence of an LBV ‘spur’.

Complete nasal obstruction secondary to pacemaker insertion

We present the case of a 71-year-old man who presented to the ear, nose and throat department with complete nasal obstruction and facial plethora on bending forward. Clinical examination was positive for Pemberton's sign. Computed tomography and ultrasonography demonstrated bilateral brachiocephalic vein thrombosis secondary to pacemaker insertion. This case highlights a novel complication of pacemaker insertion.

Middle mediastinal thymic carcinoma with cystic findings in radiologic images: a case report.

BackgroundThymic carcinomas are usually detected in the anterior mediastinum. Thymic carcinoma occurring in the middle mediastinum and showing an image of a cyst is extremely rare.Case presentationA 64-year-old man with a middle mediastinal tumor detected incidentally by a CT scan was referred. Chest CT showed an entirely cystic mass in the middle mediastinum between the bilateral brachiocephalic vein and trachea. We resected the tumor completely in the right recurrent nerve because it had invaded the nerve. Immunohistochemical features showed a thymic carcinoma pattern. The final diagnosis was thymic squamous cell carcinoma occurring in the middle mediastinum.ConclusionTo our best knowledge, this is the first report of a thymic carcinoma occurring in the middle mediastinum, as demonstrated by histopathological findings with immunohistochemical features.

Anatomical variation of thyroid veins on contrast-enhanced multi-detector row computed tomography

ObjectiveThe objective of this study was to clarify the anatomical variation of thyroid veins into the systemic vein using contrast-enhanced multi-detector row computed tomography (MDCT). Design and methods: The subjects were 80 patients (34 males and 46 females; mean age, 50.1 years; age range, 15–92 years) with neck diseases who underwent MDCT. The number and location of inflow points of the thyroid veins into the systemic vein, and the length from the junction of bilateral brachiocephalic veins to the orifice of inferior thyroid vein were investigated by reviewing the axial and coronal images. ResultsAll superior thyroid veins were detected. Right and left middle thyroid veins were identified in 39 and 29 patients, respectively. Right inferior thyroid veins, left inferior thyroid veins, and common trunks were detected in 43, 46, and 39 patients, respectively; in five patients, two left thyroid veins were identified. All left inferior thyroid veins and 34 common trunks flowed into the innominate vein, while right ones had some variations in inflow sites. Mean lengths were 3.01±1.30cm (range, 0.5–6.19) and 2.04±0.91cm (0.5–4.4) in the left inferior thyroid vein and common trunk, and 1.96±1.05cm (0.81–4.8) and 1.65±0.69cm (0.63–2.94) in the right one flowing into the right internal jugular vein and the innominate vein, respectively. ConclusionsThe numbers and orifices of thyroid veins were identified at high rates on contrast-enhanced MDCT. This strategy can provide anatomical information before selective venous sampling for measurements of parathyroid hormone.

Surgical treatment of an invasive thymoma extending into the superior vena cava and right atrium

Although invasive thymoma commonly infiltrates neighbouring mediastinal structures, its extension into the superior vena cava (SVC) and consequent SVC occlusion are rare. In such cases, the urgent removal of the thymoma and radical resection of the infiltrated SVC representreasonable options, since induction therapy is time-consuming and useless for symptom resolution. A case of invasive thymoma extending into the SVC and right atrium (RA) with SVC syndrome is reported. The patient underwent a combined resection of the invasive tumor and SVC under cardiopulmonary bypass (CPB), and the SVC and bilateral brachiocephalic vein (BCV) were reconstructed with an autologous pericardial ‘Y’ conduit. After 40 months of follow-up, the patient showed a patent graft and no tumor recurrence.

Reconstruction of the Superior Vena Cava and the Bilateral Brachiocephalic Veins for Invasive Thymoma Under Monitoring of Regional Cerebral Saturation of Oxygen

Reconstruction of the Superior Vena Cava and the Bilateral Brachiocephalic Veins for Invasive Thymoma Under Monitoring of Regional Cerebral Saturation of Oxygen

Partial absence of superior vena cava in an adult patient

Absence of the superior vena cava (SVC) is a rare variety of vascular anomaly. The purpose of this report is to describe the computed tomography (CT) findings of the partial absence of the SVC without persistent left SVC in a patient with no evidence of congenital cardiovascular disease and no prior history of central venous instrumentation. A 77-year-old woman with a history of colon cancer underwent thoracoabdominal CT imaging because of abdominal pain of uncertain cause. No tumor recurrence was observed. A complicated"investigation" confirmed a thymoid cancer surgery back in 1976, which was accompanied by resection of the SVC and the left brachiocephalic vein because of their invasion. Owing to the absence of the SVC and bilateral brachiocephalic veins, caval hypertension developed in the patient, resulting in the dilation of cavo-caval anastomoses. In addition, new anastomoses were opened. The clinical significance and possible embryogenesis of this anomaly are discussed. The extremely rare condition of the partial absence of the SVC appeared with subcutaneous dilated, tortuous collaterals in an asymptomatic adult patient. This anomaly is becoming clinically more relevant with the increasing use of minimally invasive vascular surgery.

Intracaval and intracardiac extension of invasive thymoma complicated by superior and inferior vena cava syndrome

We present a case of an aged male with invasive thymoma that extended into the right atrium and led to superior and inferior vena cava syndrome. The patient initially presented with edema of the face and bilateral lower extremities. Echocardiography revealed a mass within the right atrium. Imaging studies demonstrated an anterior mediastinal tumor that continuously occupied the bilateral brachiocephalic veins, superior vena cava, and right atrium. Pathological diagnosis of the tumor biopsy was highly suspicious of thymoma. Due to the high risk of wide spread of the tumor, treatments including resection of the tumor were impossible. Several days later he died, and an autopsy was performed. The tumor was type B2 thymoma invading bilateral brachiocephalic veins, superior vena cava and right atrium. Multiple tumor emboli within the pulmonary arteries were identified. Direct cause of death was deemed to be tumor strangulation at the tricuspid orifice. In addition to the superior vena cava syndrome, inferior vena cava syndrome including ectasia of the intrahepatic vessels was confirmed along with pericarditis. To our knowledge, this is the first English report of an autopsy case of intracardiac thymoma extension, and a detailed literature review of similar cases is also presented.

Follicular carcinoma of the thyroid with massive invasion into the cervical and mediastinum great veins: Our own experience and literature review

Thyroid carcinomas with massive intralumen invasion of the great veins are extremely rare and reported to have poor prognosis. We report a case of a poorly differentiated follicular carcinoma of the thyroid with extensive invasion into the bilateral internal jugular veins, brachiocephalic vein, and superior vena cava. All of the seven major drainage veins from the thyroid were involved by tumor thrombus. The patient was successfully treated by surgical resection including removal of the tumor thrombus and repair of the great veins. The importance of preoperative radiological findings, treatment, and outcome are discussed along with a literature review.

Giant aneurysm of the proximal left subclavian artery

Figure 1: Volume-rendered image of CT (computed tomographic) angiography shows a huge saccular aneurysm measuring 11 × 9 × 8.5 cm located at the origin of the left subclavian artery from the aortic arch. Such a huge aneurysm of the intrathoracic subclavian artery is rare. It also demonstrates the occlusion of the left common carotid artery and the left internal carotid artery. There is 75% stenosis of the left subclavian artery after the branching of the left vertebral artery and 50% stenosis of the right subclavian artery after the branching of the right vertebral artery. After the occurrence of left arteria cerebri media infarction 8 years before the operation, the patient had dysarthria and sensorimotor paralysis, which remained at the time of operation. Furthermore, the patient had progressive stridor due to the compression of the trachea by the aneurysm. In view of severe impairment of venous return due to the compression of the bilateral brachiocephalic veins, collateral venous pathways were identified in the chest wall. The aneurysm had enlarged progressively compared with its size 3 years before the operation (5.5 × 5.4 cm). An: aneurysm; BCA: brachiocephalic artery; LSCA: left subclavian artery.

Evaluation of the function of autotransplanted parathyroid tissues

To evaluate the function autotransplanted parathyroid tissues in thyroid surgery. The control group comprised 120 volunteers with normal parathyroid glands in whom serum parathyroid hormone (PTH) levels in blood samples taken from the bilateral elbow head veins. The experimental group comprised 34 patients in whom the parathyroid glands, which were mistakenly cut or could not be preserved during thyroid surgery because of ischemia, were fragmented and autografted into the brachioradialis muscle of the nondominant forearm. On the day of surgery and at 3 days, 7 days, and 2 months postoperatively, contrast imaging and detection of serum PTH levels were performed to evaluate the function of the transplanted parathyroid tissues. In the control group, the mean value of the difference between the bilateral brachiocephalic vein PTH levels was (1.19 ± 0.98) ng/L (maximum 4.52 ng/L). In this study, twice the maximum value (9.04 ng/L) was taken as the effective standard. Based on the 9.04 ng/L effective value, the effective number was 26 patients and the effective rate was 76.5% at 2 months postoperatively in the 34 patients of the experimental group. The autotransplanted parathyroid tissues showed their functions in most patients, therefore, parathyroid gland autotransplantation is an effective method of preserving function of parathyroid glands that are free or severely ischemic in thyroid surgery.

Percutaneous transluminal angioplasty in the treatment of bilateral brachiocephalic vein stenosis in hemodialysis patient

Percutaneous transluminal angioplasty in the treatment of bilateral brachiocephalic vein stenosis in hemodialysis patient

Use of PTFE Stent Grafts for Hemodialysis-related Central Venous Occlusions: Intermediate-Term Results

To assess the safety and effectiveness of a polytetrafluoroethylene (PTFE) encapsulated nitinol stents (Bard Peripheral Vascular, Tempe, AZ) for treatment of hemodialysis-related central venous occlusions. Study design was a single-center nonrandomized retrospective cohort of patients from May 2004 to August 2009 for a total of 64 months. There were 14 patients (mean age 60 years, range 50-83 years; 13 male, 1 female). All patients had autogenous fistulas. All 14 patients had central venous occlusions and presented with clinical symptoms of the following: extremity swelling (14%, 2 of 14), extremity and face swelling (72%, 10 of 14), and face swelling/edema (14%, 2 of 14). There was evidence of access dysfunction with decreased access flow in 36% (5 of 14) patients. There were prior interventions or previous line placement at the site of the central venous lesion in all 14 patients. Results were assessed by recurrence of clinical symptoms and function of the access circuit (National Kidney Foundation recommended criteria). Sixteen consecutive straight stent grafts were implanted in 14 patients. Average treated lesion length was 5.0cm (range, 0.9-7cm). All 14 patients had complete central venous occlusion (100% stenosis). The central venous occlusions were located as follows: right subclavian and brachiocephalic vein (21%, 3 of 14), right brachiocephalic vein (36%, 5 of 14), left brachiocephalic vein (36%, 5 of 14), and bilateral brachiocephalic vein (7%, 1 of 14). A total of 16 PTFE stent grafts were placed. Ten- or 12-mm-diameter PTFE stent grafts were placed. The average stent length was 6.1cm (range, 4-8cm). Technical (deployment), anatomic (<30% residual stenosis), clinical (resolution of symptoms), and hemodynamic (resolution of access dysfunction) success were 100%. At 3, 6, and 9months, primary patency of the treated area and access circuit were 100% (14 of 14). This PTFE encapsulated stent graft demonstrates encouraging intermediate-term patency results for central vein occlusions. Further prospective studies with long-term assessment and larger patient populations will be required.