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

An unusual case of duplicated left brachiocephalic vein with right sided aortic arch and aberrant origin of LSCA in a patient undergoing implantable cardioverter defibrillator (ICD) implantation

BACKGROUND

Anomalous left brachiocephalic vein (ALBCV) is a rare venous anomaly. Double Left brachiocephalic vein is the rarest type of ALBCV anomaly.

CASE REPORT

Here we report a case of gentleman with post myocardial infarction ventricular tachycardia who underwent ICD implantation, where we could not place the lead initially through left side. CT angiography revealed presence of a duplicated circumaortic left BCV. It's cranial limb coursing normally anterior to arch and compressed at its confluence with RBCV and the caudal limb with a subaortic course draining into the RSVC. We report this first case of double LBCV along with right sided aortic arch and aberrant origin of LSCA arising from Kommerel's diverticulum.

CONCLUSION

This case highlights that interventional cardiologists should be aware of these venous anomalies for proper planning and implantation of CIED successfully via transvenous approach.

Accidental Diagnosis of Isolated Persistent Left Superior Vena Cava After an Elective Central Venous Access Procedure for Chronic Hemodialysis: Clinical Implications and Precautions From a Case Report

Persistent left superior vena cava (PLSVC) is the most frequent thoracic venous anatomical variant in the general population. Isolated PLSVC, without formation of the right superior vena cava, is described in 10% of cases of PLSVC only. While it can be associated with congenital heart disease, arrhythmias, and premature death, adult patients with PLSVC are mostly asymptomatic, and the diagnosis is usually accidental. We present the case of a 72-year-old male with end-stage renal disease who was started on urgent hemodialysis through a temporary non-tunneled femoral central venous catheter (CVC) in the SLED (slow low-efficiency dialysis) modality and later remained dependent on hemodialysis. At this stage, placement of a tunneled CVC in the right internal jugular vein was necessary and fluoroscopy guidance was not available. There were no complications during the procedure, but postoperative conventional chest radiography revealed an inadequate positioning of the CVC tip in the left hemithorax, crossing the midline. Subsequently, the diagnosis of PLSVC was obtained by performing a thoracic angio-CT scan, confirming CVC tip positioning inside the PLSVC, and also excluded the presence of cardiac defects or additional anatomical variations of the great vessels of the thorax. Early evaluation for the creation of autologous vascular access was started under our care, and there were no mechanical or other complications associated with hemodialysis sessions during early follow-up after discharge.

Congenital Anomalous Azygos Vein Drainage Causing Pulmonary Embolus in a 91-Year-Old Patient

Background

Retroaortic course and azygos continuation of aberrant left brachiocephalic vein is a rare venous anomaly, which is usually associated with congenital heart disease and pulmonary artery anomalies. Venous stasis is a cause of pulmonary arterial thromboembolism, which can result from venous anomalies.

Case presentation

We describe the case of a 91-year-old female admitted to our hospital with shortness of breath diagnosed with pulmonary embolism and infarctions by a CT pulmonary angiogram. CT also showed aberrant left brachiocephalic vein with vascular webs at its retroaortic course and azygos continuation, suggesting chronic venous thrombosis, which was considered to be the suspected source of emboli.

Conclusion

To our knowledge, this is the first report presenting this vascular anomaly manifesting with chronic venous thrombosis and pulmonary embolism. Although rare, awareness and identification of this entity is important, especially in the absence of obvious embolic sources or in patients with recurrent embolus/consolidation.

LEARNING POINTS