Anomalous subaortic left brachiocephalic vein in surgical cases and literature review

An unusual case of prenatal diagnosis of isolated subaortic left brachiocephalic vein with HDlive flow and spatiotemporal image correlation(STIC)

Subaortic left brachiocephalic vein (LBCV) is rare in prenatal diagnosis. Reported herein is a case of subaortic a LBCV diagnosed using the HDlive flow and spatiotemporal image correlation with postnatal outcomes evaluation in our hospital.

Anomalous subaortic course of brachiocephalic vein: Evaluation on multidetector computed tomography angiography

AIM

To evaluate the morphology and associated cardiovascular abnormalities in patients with an anomalous subaortic course of brachiocephalic vein on multidetector computed tomography (CT) angiography.

MATERIAL AND METHODS

A retrospective study was performed at a tertiary referral institute to identify patients with subaortic brachiocephalic vein on multidetector CT (MDCT) angiography using dual source CT scanner between January 2014 and July 2021. The morphology of the subaortic brachiocephalic vein along with the cardiovascular anatomy and associated anomalies were evaluated.

RESULTS

Out of 4349 patients who had undergone MDCT angiography for evaluation of congenital heart diseases, we identified 126 (2.9%) patients with subaortic brachiocephalic vein. The subaortic brachiocephalic vein was left-sided in 125 patients while a right-sided subaortic brachiocephalic vein was identified in a patient with left isomerism. Common cardiovascular associations included tetralogy of Fallot (109/126; 88.1%), double outlet right ventricle (8/126; 6.3%) and common arterial trunk (5/126; 3.9%). The presence of a right aortic arch was seen in 78/126 (62%) patients. Some degree of right ventricular outflow obstruction was present in 119/126 (94.4%) patients; pulmonary stenosis was seen in 78 (62%) patients while pulmonary atresia was seen in 41 (32.5%) patients.

CONCLUSION

A subaortic brachiocephalic vein can coexist with various complex congenital heart diseases, most commonly tetralogy of Fallot and commonly associated with right aortic arch and pulmonary stenosis/atresia. It is important to identify this anomalous course of brachiocephalic vein before performing surgical procedures or venous catheterization to avoid potential complications.

Fetal echocardiographic diagnosis of a triad with common embryological origins: Cervical aortic arch, retro-aortic left innominate vein and coarctation of the aorta

Cervical aortic arch (CAA) and retro-aortic innominate vein (RAIV) are rare entities which can be associated with one another in a structurally normal heart. Less well recognized is the fact, that a third entity may often be present as well, since aortic arch abnormalities are common in a CAA. Hence, these three entities (CAA, RAIV, and an arch anomaly - in this case a post-ductal coarctation) may present as a triad. We present the first prenatal diagnosis of this rare triad which can be explained by common embryological origins which are discussed along with instructive aspects in diagnosis and management.

Double left brachiocephalic vein in an adult patient who underwent cardiac surgery: a case report

Background

A double left brachiocephalic vein is an extremely rare venous anomaly.

Case presentation

Herein, we present the case of a 79-year-old woman with a double left brachiocephalic vein who underwent cardiac surgical procedures. The normal left brachiocephalic vein was patent, and the accessory left brachiocephalic vein passed across the heart and aorta in front of the pericardium and drained into the superior vena cava. She underwent surgical ligation of the accessory left brachiocephalic vein, followed by an aortic valve replacement and coronary artery bypass grafting. Her postoperative recovery was uneventful, without any venous complications from the ligation of the accessory vein. The patient is doing well one year after the surgery.

Conclusions

The presence of double left brachiocephalic veins should be recognized before cardiac surgery in order for us to avoid intraoperative technical issues concerning this venous anomaly and unpredictable intraoperative bleeding due to injury of the accessory left brachiocephalic vein.

Surgical management of lesions encountered in the setting of the retroaortic left brachiocephalic vein

BACKGROUND AND AIM

Although the retroaortic left brachiocephalic vein in isolation is of no clinical importance, its recognition in the setting of associated lesions is important. We sought to address issues concerning the influence of isomerism, the establishment of diagnosis, and its importance in various surgical and interventional procedures.

METHODS

A total of 80 published clinical and necropsy studies in the setting of a retroaortic left brachiocephalic vein described 250 patients. Clinical presentation, radiographic, ultrasonographic findings, contrast echocardiography, computed-tomographic angiocardiography, magnetic resonance imaging, and angiocardiography provided the diagnostic information prior to considering the surgical approach to the associated cardiac anomalies.

RESULTS

Among 250 reported cases, three-quarters had associated congenitally malformed hearts. Of these 189 patients, all but seven had usual atrial arrangement. Right isomerism was reported in five patients and two patients having left isomerism. Almost two-thirds had tetralogy of Fallot or its variants, over four-fifths had malformations involving the outflow tract, two-thirds had a right aortic arch with two patients having a cervical aortic arch, and onepatient had double aortic arch. Various innovative individualized surgical procedures were employed with an overall perioperative mortality of 3.4%.

CONCLUSIONS

Although the retroaortic left brachiocephalic vein is asymptomatic, its recognition during clinical investigation should raise the possibility of an association with other malformations, especially right aortic arch, ventricular septal defect, and anomalies of the outflow tracts. We submit that an increased appreciation of this venous anomaly may facilitate surgical planning, endovascular procedures, placement of central venous lines, and transvenous pacemakers.

Intraoperative diagnosis of retroaortic left innominate vein in a patient with congenital heart disease

Diagnosis of retroaortic left innominate vein is usually made by echocardiography, computed tomography, and magnetic resonance imaging, but in several cases, diagnosis is made in the theater.

Developmental anomalies of the superior vena cava and its tributaries: What the radiologist needs to know?

Deviations from the normal process of embryogenesis can result in various developmental anomalies of the superior vena cava (SVC). While these anomalies are often asymptomatic, they assume clinical importance during interventions such as central venous catheterisations and pacemaker implantations and during cardiothoracic surgeries while instituting cardiopulmonary bypass and for creation of cavo-pulmonary connections. Role of imaging in identifying these anomalies is indispensable. Cross-sectional imaging techniques like CT venography and magnetic resonance (MR) venography allow direct visualisation and consequently increased detection of anomalies. CT venography plays an important role in detection of SVC anomalies as it is readily available, has excellent spatial resolution, short acquisition times and potential for reconstruction of images in multiple planes. This pictorial review focuses on the developmental anomalies of the SVC and its tributaries highlighting their embryological basis, imaging appearances on CT venography and potential clinical implications, where relevant.

Case Report: Retroaortic Innominate Vein With Supracardiac Total Anomalous Pulmonary Venous Connection

A retroaortic innominate vein (RAIV) is a rare anomaly that passes posterior to the ascending aorta to join the superior vena cava and is associated with congenital heart disease (CHD). The RAIV and normal left innominate vein (LIV) rarely duplicate. The etiology of the RAIV and its relationship with CHD remains unknown. We report a case involving a 1-month-old baby girl with RAIV and supracardiac total anomalous pulmonary venous connection (TAPVC). Transthoracic echocardiogram demonstrated a pulmonary venous confluence (CPV) posterior to the left atrium, an abnormal vertical vein (VV) that originated from the CPV, and a normally positioned LIV. Three-dimensional cardiac computed tomography revealed the VV and RAIV to which it merged. This is the first reported case of a combination of RAIV and isolated TAPVC. We speculate that the VV is connected to the CPV during fetal life, thus leaving the RAIV behind. The RAIV may be detected in various forms with the development of new diagnostic imaging methods. Although a RAIV itself does not require treatment, establishing a correct diagnosis before invasive tests and procedures are performed can help prevent unexpected complications.

Incidental retroaortic innominate vein in a patient with acute aortic dissection

Background

Retroaortic innominate vein is a rare anomaly. It has been reported in patients with congenital anomalies such as Tetralogy of Fallot or right aortic arch. However, isolated retroaortic innominate vein is quite rare.

Case presentation

A 63-year-old man was transferred to our institution because of Stanford type A acute aortic dissection. Incidentally, we noticed that the left innominate vein coursed under the aortic arch and was directed into the superior vena cava on computed tomography. We performed emergent hemiarch replacement.

Conclusions

Attention must be paid to the cannulation site for venous uptake and the method of myocardial protection.

Isolated retroaortic innominate vein and right aortic arch: a case report and review of literature

Retroaortic course of left innominate vein is a rare venous anomaly which is usually associated with CHD. Isolated retroaortic innominate vein is exceedingly rare with only a handful of reported cases. We report an otherwise healthy newborn with isolated retroaortic innominate vein and right aortic arch, a combination which has previously not been reported.

Tetralogy of Fallot With Right Aortic Arch and Retro-Aortic Innominate Vein

Right aortic arch (RAA) and retro-aortic innominate vein are rare vascular anomalies. Diagnosis of these anatomical variations can be achieved using fetal echocardiography, post-natal echocardiography, and computed tomography scan. RAA can form a vascular ring when associated with other vascular anomalies which may compress the trachea and/or esophagus. On the other hand, the existence of retro-aortic innominate vein can influence the clinical decision-making and surgical strategy. We report a rare occurrence of both RAA and retro-aortic innominate vein in a 3 months old girl with a prenatal diagnosis of tetralogy of Fallot and include details of her presentation and successful management.

Incidental retroaortic left innominate vein in adult patient

Retro-aortic left innominate vein is a rare vascular abnormality, usually associated with congenital heart disease. Here we report a case of isolated retro-aortic left innominate vein in an adult female.

Case report. Retroesophageal Left Brachiocephalic Vein in an Infant Without Cardiac Anomalies

Retroesophageal course of the left brachiocephalic vein is a rare variant seen in patients with congenital heart disease. However, this anomaly without associated cardiac or aortic abnormalities is nearly unheard of, with only one prior case described in the literature. We present an infant with anomalous retroesophageal left brachiocephalic vein that was an incidental finding on computed tomography (CT). We also briefly discuss its embryologic and clinical significance.

An Adult Case of Chromosome 22q11.2 Deletion Syndrome Associated with a High-positioned Right Aortic Arch

Chromosome 22q11.2 deletion syndrome (22q11.2 DS) has a very wide phenotypic spectrum that includes dysmorphic features, cardiac anomalies, and hypocalcemia arising from hypoparathyroidism. We herein describe an adult case of 22q11.2 DS with associated hypoparathyroidism and anomalies of the aortic arch. Because the patient had been diagnosed with primary hypoparathyroidism at another hospital, a diagnosis of 22q11.2 DS had been overlooked. A chest X-ray examination revealed widening of the mediastinum caused by a high-positioned right aortic arch, and we subsequently confirmed a diagnosis of 22q11.2 DS using fluorescence in situ hybridization. Because primary hypoparathyroidism is a rare disorder, physicians should be aware of the variable phenotypic features of 22q11.2 DS.

A case of pacemaker implantation in the patient with duplication of the left innominate vein: a case report

INTRODUCTION

Duplication of the left innominate vein is a rare systemic venous anomaly defined as the coexistence of a retroaortic innominate vein and a normally positioned left innominate vein. We describe a successful case of pacemaker implantation in a patient with duplication of the left innominate vein via a retroaortic innominate vein.

CASE DESCRIPTION

A 70-year-old mentally challenged man was admitted to our hospital because of bradycardia and an altered state of consciousness. Electrocardiogram indicated sinus arrest and junctional escape rhythm with a heart rate of 40 beats/min; hence, a pacemaker was implanted. Left subclavian venography showed two vessels that were connected to the superior vena cava: a narrow, normal positioned left innominate vein and a tortuous vein. The normally positioned left innominate vein was too narrow to pass through with a guide wire. Therefore, we chose the tortuous vein for implantation. However, the procedure was difficult because of the vein's tortuosity. Finally, leads at the right atrium and ventricle were successfully implanted using a steerable stylet. After the procedure, computed tomography showed two innominate veins: a retroaortic innominate vein and narrow left innominate vein that was a duplication of the left innominate vein.

DISCUSSION AND EVALUATION

The exact embryogenesis of retroaortic innominate vein remains unknown and incidence of retroaortic innominate vein is very rare. But for cardiologists performing transvenous pacemaker insertion, the anomalous brachiocephalic vein may cause technical difficulty during a left arm approach.

CONCLUSIONS

In cases in which subclavian venography shows a tortuous vein, cardiologists should consider the presence of a retroaortic innominate vein.

Potential clinical implications of the "aortic collar" configuration of an anomalous left brachiocephalic vein

We present a case report of an extremely rare congenital anomaly of the brachiocephalic vein in a previously healthy patient presenting with acute central pulmonary embolism. Clinical and imaging findings are discussed in the report along with several potential complications envisaged by the authors to inform clinicians about the importance of reporting this particular thoracic vascular variant.

Isolated retroaortic left innominate vein in an adult without cardiac or aortic anomalies

Retroaortic innominate vein is an uncommon variant reported in patients with congenital heart disease. However, isolated retroaortic innominate vein without associated cardiac or arch anomalies is extremely rare. We present a case of a 68-year-old man who was found to have this anomalous variant incidentally on computed tomography (CT) of the thorax. We also briefly discuss its associations, embryology, and clinical significance.

Anatomical study of the coexistence of the postaortic left brachiocephalic vein with the postaortic left renal vein with a review of the literature

In a student course of gross anatomy dissection at Kanagawa Dental University in 2009, we found an extremely rare case of the coexistence of the postaortic left brachiocephalic vein with the postaortic left renal vein of a 73-year-old Japanese male cadaver. The left brachiocephalic vein passes behind the ascending aorta and connects with the right brachiocephalic vein, and the left renal vein passes behind the abdominal aorta. These two anomalous cases mentioned above have been reported respectively. There have been few reports discussing coexistence of the postaortic left brachiocephalic vein with the postaortic left renal vein. We discuss the anatomical and embryological aspect of this anomaly with reference in the literature.

Left anomalous brachiocephalic vein in a patient with right lung cancer

The left anomalous brachiocephalic vein is a rare anomaly without congenital heart disease. It is important to recognize this anomalous vein especially in patients with lung cancer because misinterpretation as a superior mediastinal lymph node enlargement may cause serious complications. We report a case of a 62-year-old lung cancer patient with left anomalous brachiocephalic vein, who underwent surgical treatment safely under video-assisted thoracoscopic surgery after confirmation of this anomaly on contrast-enhanced computed tomographic scan.

Fetal left brachiocephalic vein in normal and abnormal conditions

OBJECTIVES

To establish values of fetal left brachiocephalic vein (LBCV) dimensions during normal pregnancy and determine whether routine assessment of the LBCV may help in identifying fetuses with congenital abnormalities of this vessel.

METHODS

Fetal LBCV was assessed prospectively during ultrasound examinations in 431 normal singleton pregnancies. The visualization rate of the transverse view of the upper fetal chest at the level of drainage of the LBCV into the superior vena cava (SVC) by two-dimensional (2D) and 2D plus color Doppler ultrasound was evaluated. Reference ranges of LBCV diameter during non-complicated pregnancies were established. Interobserver and intraobserver measurement variability was analyzed. In addition, a retrospective review of the hospital medical records of 91 pregnancies with fetuses diagnosed with LBCV abnormalities was performed.

RESULTS

Sonographic assessment of the fetal LBCV was consistently achieved in the second and third trimesters and in some fetuses in the first trimester of pregnancy. In normal fetuses LBCV diameter increased significantly throughout pregnancy, with a mean value of 0.7 mm at 11 weeks and 4.9 mm at term. Dilation of the fetal LBCV was noted in five cases of intracranial arteriovenous malformation and six cases of supracardiac type total anomalous pulmonary venous connection. Abnormal course of the LBCV was noted in 12 fetuses. In 63 fetuses with a persistent left SVC and a right SVC the LBCV was absent.

CONCLUSION

This is the first study describing an effective sonographic approach for the assessment of fetal LBCV dimensions during pregnancy. The normative data may provide an additional means of detecting rare anomalies of systemic and pulmonary veins during pregnancy.