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• W2009443064 abstract "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. 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. This case presents an exceedingly rare anomalous central vein, defined as an “aortic collar of the left brachiocephalic vein” (LBV). This was incidentally identified in an abnormal computed tomographic pulmonary arteriogram of a 46-year-old patient with no history of congenital or ischemic heart disease. Surveying the central vasculature in the thorax prompted a detailed cross-sectional assessment of the enhancing veins encircling the arch of the aorta. As depicted, this case demonstrates an unreported variant of the LBV (supraaortic and subaortic patent courses) in a healthy adult, along with a suggested list of clinical implications to highlight its importance.A previously healthy 46-year-old man was admitted to the medical ward with acute dyspnea and pleuritic chest pain. The preliminary clinical assessment included a normal chest roentgenogram and unremarkable biochemical test results (including cardiac enzyme determinations). Based on an abnormal echocardiogram (sinus tachycardia) and a raised D-dimer level, the pulmonary embolism pathway was followed. Urgent computed tomographic pulmonary angiography was performed to reveal the culprit pathologic process of a massive central pulmonary embolism. The patient was treated with long-term anticoagulation and discharged with regular follow-up.CommentPrognostic reporting practice in abnormal tomographic pulmonary angiograms prompts radiologists to further evaluate the scan for signs indicative of right ventricular dysfunction, such as that of the azygos vein and inferior vena cava. By doing so in our patient, an unusual contrast-filled vessel resulting from venous congestion revealed an occult anomaly of the LBV. Normally, the LBV is formed through the confluence of the left internal jugular and subclavian veins. With a usual course anterior and superior to the aortic arch, it will invariably cross from left to right to join the contralateral right brachiocephalic vein, forming the superior vena cava (SVC).Although the persistent left-sided SVC is the most common thoracic vascular anomaly, with a prevalence of 0.3% to 1% in the normal population, anomalies of the LBV are considered to be exceedingly rare, with a 0.5% to 1% incidence in patients with congenital cardiac defects, in whom such anomalies are generally more prevalent [1Chen S.J. Liu K.L. Chen H.Y. et al.Anomalous brachiocephalic vein: CT, embryology, and clinical implications.AJR Am J Roentgenol. 2005; 184: 1235-1240Crossref PubMed Scopus (69) Google Scholar, 2Kulkarni S. Jain S. Kasar P. Garekar S. Joshi S. Retroaortic left innominate vein—incidence, association with congenital heart defects, embryology, and clinical significance.Ann Pediatr Cardiol. 2008; 1: 139-141Crossref PubMed Google Scholar, 3Nakamura R. Yoshihisa I. Iwasaki K. Yumoto T. Yuzawa K. Ueki H. Left anomalous brachiocephalic vein in a patient with right lung cancer.Ann Thorac Surg. 2013; 96: 307-309Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Srinivasan S. Kannivelu A. Ali S.Z. See P.L. Isolated retroaortic left innominate vein in an adult without cardiac or aortic anomalies.Indian J Radiol Imaging. 2013; 23: 308-309Crossref PubMed Scopus (12) Google Scholar].Embryologically, the LBV develops from the anastomosis between the paired anterior cardinal veins carrying the venous return from head and upper limbs to the fetal heart [5Nagashima M. Shikata F. Okamura T. et al.Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.Clin Anat. 2010; 23: 950-955Crossref PubMed Scopus (29) Google Scholar]. In the literature, the most commonly reported course of an anomalous LBV is the subaortic type with right SVC drainage below the azygous orifice [6Hellinger J.C. Daubert M. Lee E.Y. Epelman M. Congenital thoracic vascular anomalies: evaluation with state-of-the-art MR imaging and MDCT.Radiol Clin North Am. 2011; 49: 969-996Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. There are 3 recognized variants in a LBV course (supraaortic, subaortic and preaortic), divided by the aortic ligament and its relation to the pulmonary artery [2Kulkarni S. Jain S. Kasar P. Garekar S. Joshi S. Retroaortic left innominate vein—incidence, association with congenital heart defects, embryology, and clinical significance.Ann Pediatr Cardiol. 2008; 1: 139-141Crossref PubMed Google Scholar, 3Nakamura R. Yoshihisa I. Iwasaki K. Yumoto T. Yuzawa K. Ueki H. Left anomalous brachiocephalic vein in a patient with right lung cancer.Ann Thorac Surg. 2013; 96: 307-309Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Srinivasan S. Kannivelu A. Ali S.Z. See P.L. Isolated retroaortic left innominate vein in an adult without cardiac or aortic anomalies.Indian J Radiol Imaging. 2013; 23: 308-309Crossref PubMed Scopus (12) Google Scholar, 5Nagashima M. Shikata F. Okamura T. et al.Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.Clin Anat. 2010; 23: 950-955Crossref PubMed Scopus (29) Google Scholar].This case demonstrates a fourth previously unreported variant. In this patient, the LBV is noted to divide before the aortic arch and follows both a supraaortic (normal) and subaortic (anomalous) course before both divisions join the right brachiocephalic vein above the azygos orifice to form the SVC proper (Figs 1A-1C). This therefore constitutes a circumferential LBV around the aortic arch (collar type) in a healthy adult without cardiac defects. This anomaly has only been described in a relevant postmortem report showing pre- and subaortic LBVs without any corresponding imaging [7Ohsawa R. Kyuno T. Ohtani Y. Ohtani O. A case of double aortic arch accompanied by sub-aortic and pre-aortic left brachiocephalic veins and anomalous origin and course of left vertebral artery.Anat Sci Int. 2011; 86: 164-166Crossref PubMed Scopus (5) Google Scholar].A similar anatomic analogy is more frequently encountered in the abdomen with a circumferential left renal vein through the persistence of both ventral and dorsal venous plexuses draining the left kidney [8Nam J.K. Park S.W. Lee S.D. Chung M.K. The clinical significance of a retroaortic left renal vein.Korean J Urol. 2010; 51: 276-280Crossref PubMed Scopus (37) Google Scholar]. Once identified, it is duly noted and reported as a renal aortic collar for its serious implications in retroperitoneal vascular and urologic operations.It is also important to distinguish this anomaly as a separate entity from persistent left-sided SVC because the drainage point of the latter is mainly into the coronary sinus, whereas a subaortic LBV drains into the SVC below the level of the azygous orifice. The LBV aortic collar described here has a subaortic confluence joining the SVC above the azygous orifice (Figs 2A-2B). In addition to the need for careful radiologic assessment to rule out undiagnosed cardiac defects, a number of important clinical implications are envisaged by an LBV aortic collar.1.At times of thoracic surgery or interventions, or both, potential complications may arise in aortic ductal ligation unless the subaortic portion is identified to avoid potential injury during the paraaortic surgical dissection.2.Several cardiovascular interventions ranging from central venous access/line insertion (eg, peripherally inserted central catheter or Hickman’s catheter) to the transvenous cardiac implantation (eg, defibrillator or pacemaker [usually left sided]) could prove problematic. During these procedures, a catheter or guidewire path will appear on fluoroscopy as nonanatomic, especially if placed in the subaortic division. This may incorrectly alter line length measurements and position.3.In a left-sided dual-chamber pacemaker, the possibility of an apparent gap (aortic arch) between the wires may confuse the operating physician and prolong the procedure, specifically if either lead runs a separate course in an LBV division around the aorta. However, this gap is unlikely to trigger electrical induction should a third wire be inserted in the aorta during vascular interventions, because of the fact that pacemakers operate on a direct current and not an alternate current.Fig 2Three-dimensional reconstruction with vascular segmentation of the central vasculature demonstrating the anomalous relationship of the vein and the aortic arch and pulmonary artery (PA). (A) Anterior view and (B) posterior view. (A = aorta; Aa = ascending aorta; B = brachiocephalic vein; B1 = supraaortic branch; B2 = subaortic branch; Da = descending aorta; PA = pulmonary artery; SVC = superior vena cava.)View Large Image Figure ViewerDownload (PPT) This case presents an exceedingly rare anomalous central vein, defined as an “aortic collar of the left brachiocephalic vein” (LBV). This was incidentally identified in an abnormal computed tomographic pulmonary arteriogram of a 46-year-old patient with no history of congenital or ischemic heart disease. Surveying the central vasculature in the thorax prompted a detailed cross-sectional assessment of the enhancing veins encircling the arch of the aorta. As depicted, this case demonstrates an unreported variant of the LBV (supraaortic and subaortic patent courses) in a healthy adult, along with a suggested list of clinical implications to highlight its importance. A previously healthy 46-year-old man was admitted to the medical ward with acute dyspnea and pleuritic chest pain. The preliminary clinical assessment included a normal chest roentgenogram and unremarkable biochemical test results (including cardiac enzyme determinations). Based on an abnormal echocardiogram (sinus tachycardia) and a raised D-dimer level, the pulmonary embolism pathway was followed. Urgent computed tomographic pulmonary angiography was performed to reveal the culprit pathologic process of a massive central pulmonary embolism. The patient was treated with long-term anticoagulation and discharged with regular follow-up. CommentPrognostic reporting practice in abnormal tomographic pulmonary angiograms prompts radiologists to further evaluate the scan for signs indicative of right ventricular dysfunction, such as that of the azygos vein and inferior vena cava. By doing so in our patient, an unusual contrast-filled vessel resulting from venous congestion revealed an occult anomaly of the LBV. Normally, the LBV is formed through the confluence of the left internal jugular and subclavian veins. With a usual course anterior and superior to the aortic arch, it will invariably cross from left to right to join the contralateral right brachiocephalic vein, forming the superior vena cava (SVC).Although the persistent left-sided SVC is the most common thoracic vascular anomaly, with a prevalence of 0.3% to 1% in the normal population, anomalies of the LBV are considered to be exceedingly rare, with a 0.5% to 1% incidence in patients with congenital cardiac defects, in whom such anomalies are generally more prevalent [1Chen S.J. Liu K.L. Chen H.Y. et al.Anomalous brachiocephalic vein: CT, embryology, and clinical implications.AJR Am J Roentgenol. 2005; 184: 1235-1240Crossref PubMed Scopus (69) Google Scholar, 2Kulkarni S. Jain S. Kasar P. Garekar S. Joshi S. Retroaortic left innominate vein—incidence, association with congenital heart defects, embryology, and clinical significance.Ann Pediatr Cardiol. 2008; 1: 139-141Crossref PubMed Google Scholar, 3Nakamura R. Yoshihisa I. Iwasaki K. Yumoto T. Yuzawa K. Ueki H. Left anomalous brachiocephalic vein in a patient with right lung cancer.Ann Thorac Surg. 2013; 96: 307-309Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Srinivasan S. Kannivelu A. Ali S.Z. See P.L. Isolated retroaortic left innominate vein in an adult without cardiac or aortic anomalies.Indian J Radiol Imaging. 2013; 23: 308-309Crossref PubMed Scopus (12) Google Scholar].Embryologically, the LBV develops from the anastomosis between the paired anterior cardinal veins carrying the venous return from head and upper limbs to the fetal heart [5Nagashima M. Shikata F. Okamura T. et al.Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.Clin Anat. 2010; 23: 950-955Crossref PubMed Scopus (29) Google Scholar]. In the literature, the most commonly reported course of an anomalous LBV is the subaortic type with right SVC drainage below the azygous orifice [6Hellinger J.C. Daubert M. Lee E.Y. Epelman M. Congenital thoracic vascular anomalies: evaluation with state-of-the-art MR imaging and MDCT.Radiol Clin North Am. 2011; 49: 969-996Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. There are 3 recognized variants in a LBV course (supraaortic, subaortic and preaortic), divided by the aortic ligament and its relation to the pulmonary artery [2Kulkarni S. Jain S. Kasar P. Garekar S. Joshi S. Retroaortic left innominate vein—incidence, association with congenital heart defects, embryology, and clinical significance.Ann Pediatr Cardiol. 2008; 1: 139-141Crossref PubMed Google Scholar, 3Nakamura R. Yoshihisa I. Iwasaki K. Yumoto T. Yuzawa K. Ueki H. Left anomalous brachiocephalic vein in a patient with right lung cancer.Ann Thorac Surg. 2013; 96: 307-309Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Srinivasan S. Kannivelu A. Ali S.Z. See P.L. Isolated retroaortic left innominate vein in an adult without cardiac or aortic anomalies.Indian J Radiol Imaging. 2013; 23: 308-309Crossref PubMed Scopus (12) Google Scholar, 5Nagashima M. Shikata F. Okamura T. et al.Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.Clin Anat. 2010; 23: 950-955Crossref PubMed Scopus (29) Google Scholar].This case demonstrates a fourth previously unreported variant. In this patient, the LBV is noted to divide before the aortic arch and follows both a supraaortic (normal) and subaortic (anomalous) course before both divisions join the right brachiocephalic vein above the azygos orifice to form the SVC proper (Figs 1A-1C). This therefore constitutes a circumferential LBV around the aortic arch (collar type) in a healthy adult without cardiac defects. This anomaly has only been described in a relevant postmortem report showing pre- and subaortic LBVs without any corresponding imaging [7Ohsawa R. Kyuno T. Ohtani Y. Ohtani O. A case of double aortic arch accompanied by sub-aortic and pre-aortic left brachiocephalic veins and anomalous origin and course of left vertebral artery.Anat Sci Int. 2011; 86: 164-166Crossref PubMed Scopus (5) Google Scholar].A similar anatomic analogy is more frequently encountered in the abdomen with a circumferential left renal vein through the persistence of both ventral and dorsal venous plexuses draining the left kidney [8Nam J.K. Park S.W. Lee S.D. Chung M.K. The clinical significance of a retroaortic left renal vein.Korean J Urol. 2010; 51: 276-280Crossref PubMed Scopus (37) Google Scholar]. Once identified, it is duly noted and reported as a renal aortic collar for its serious implications in retroperitoneal vascular and urologic operations.It is also important to distinguish this anomaly as a separate entity from persistent left-sided SVC because the drainage point of the latter is mainly into the coronary sinus, whereas a subaortic LBV drains into the SVC below the level of the azygous orifice. The LBV aortic collar described here has a subaortic confluence joining the SVC above the azygous orifice (Figs 2A-2B). In addition to the need for careful radiologic assessment to rule out undiagnosed cardiac defects, a number of important clinical implications are envisaged by an LBV aortic collar.1.At times of thoracic surgery or interventions, or both, potential complications may arise in aortic ductal ligation unless the subaortic portion is identified to avoid potential injury during the paraaortic surgical dissection.2.Several cardiovascular interventions ranging from central venous access/line insertion (eg, peripherally inserted central catheter or Hickman’s catheter) to the transvenous cardiac implantation (eg, defibrillator or pacemaker [usually left sided]) could prove problematic. During these procedures, a catheter or guidewire path will appear on fluoroscopy as nonanatomic, especially if placed in the subaortic division. This may incorrectly alter line length measurements and position.3.In a left-sided dual-chamber pacemaker, the possibility of an apparent gap (aortic arch) between the wires may confuse the operating physician and prolong the procedure, specifically if either lead runs a separate course in an LBV division around the aorta. However, this gap is unlikely to trigger electrical induction should a third wire be inserted in the aorta during vascular interventions, because of the fact that pacemakers operate on a direct current and not an alternate current. Prognostic reporting practice in abnormal tomographic pulmonary angiograms prompts radiologists to further evaluate the scan for signs indicative of right ventricular dysfunction, such as that of the azygos vein and inferior vena cava. By doing so in our patient, an unusual contrast-filled vessel resulting from venous congestion revealed an occult anomaly of the LBV. Normally, the LBV is formed through the confluence of the left internal jugular and subclavian veins. With a usual course anterior and superior to the aortic arch, it will invariably cross from left to right to join the contralateral right brachiocephalic vein, forming the superior vena cava (SVC). Although the persistent left-sided SVC is the most common thoracic vascular anomaly, with a prevalence of 0.3% to 1% in the normal population, anomalies of the LBV are considered to be exceedingly rare, with a 0.5% to 1% incidence in patients with congenital cardiac defects, in whom such anomalies are generally more prevalent [1Chen S.J. Liu K.L. Chen H.Y. et al.Anomalous brachiocephalic vein: CT, embryology, and clinical implications.AJR Am J Roentgenol. 2005; 184: 1235-1240Crossref PubMed Scopus (69) Google Scholar, 2Kulkarni S. Jain S. Kasar P. Garekar S. Joshi S. Retroaortic left innominate vein—incidence, association with congenital heart defects, embryology, and clinical significance.Ann Pediatr Cardiol. 2008; 1: 139-141Crossref PubMed Google Scholar, 3Nakamura R. Yoshihisa I. Iwasaki K. Yumoto T. Yuzawa K. Ueki H. Left anomalous brachiocephalic vein in a patient with right lung cancer.Ann Thorac Surg. 2013; 96: 307-309Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Srinivasan S. Kannivelu A. Ali S.Z. See P.L. Isolated retroaortic left innominate vein in an adult without cardiac or aortic anomalies.Indian J Radiol Imaging. 2013; 23: 308-309Crossref PubMed Scopus (12) Google Scholar]. Embryologically, the LBV develops from the anastomosis between the paired anterior cardinal veins carrying the venous return from head and upper limbs to the fetal heart [5Nagashima M. Shikata F. Okamura T. et al.Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.Clin Anat. 2010; 23: 950-955Crossref PubMed Scopus (29) Google Scholar]. In the literature, the most commonly reported course of an anomalous LBV is the subaortic type with right SVC drainage below the azygous orifice [6Hellinger J.C. Daubert M. Lee E.Y. Epelman M. Congenital thoracic vascular anomalies: evaluation with state-of-the-art MR imaging and MDCT.Radiol Clin North Am. 2011; 49: 969-996Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. There are 3 recognized variants in a LBV course (supraaortic, subaortic and preaortic), divided by the aortic ligament and its relation to the pulmonary artery [2Kulkarni S. Jain S. Kasar P. Garekar S. Joshi S. Retroaortic left innominate vein—incidence, association with congenital heart defects, embryology, and clinical significance.Ann Pediatr Cardiol. 2008; 1: 139-141Crossref PubMed Google Scholar, 3Nakamura R. Yoshihisa I. Iwasaki K. Yumoto T. Yuzawa K. Ueki H. Left anomalous brachiocephalic vein in a patient with right lung cancer.Ann Thorac Surg. 2013; 96: 307-309Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Srinivasan S. Kannivelu A. Ali S.Z. See P.L. Isolated retroaortic left innominate vein in an adult without cardiac or aortic anomalies.Indian J Radiol Imaging. 2013; 23: 308-309Crossref PubMed Scopus (12) Google Scholar, 5Nagashima M. Shikata F. Okamura T. et al.Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.Clin Anat. 2010; 23: 950-955Crossref PubMed Scopus (29) Google Scholar]. This case demonstrates a fourth previously unreported variant. In this patient, the LBV is noted to divide before the aortic arch and follows both a supraaortic (normal) and subaortic (anomalous) course before both divisions join the right brachiocephalic vein above the azygos orifice to form the SVC proper (Figs 1A-1C). This therefore constitutes a circumferential LBV around the aortic arch (collar type) in a healthy adult without cardiac defects. This anomaly has only been described in a relevant postmortem report showing pre- and subaortic LBVs without any corresponding imaging [7Ohsawa R. Kyuno T. Ohtani Y. Ohtani O. A case of double aortic arch accompanied by sub-aortic and pre-aortic left brachiocephalic veins and anomalous origin and course of left vertebral artery.Anat Sci Int. 2011; 86: 164-166Crossref PubMed Scopus (5) Google Scholar]. A similar anatomic analogy is more frequently encountered in the abdomen with a circumferential left renal vein through the persistence of both ventral and dorsal venous plexuses draining the left kidney [8Nam J.K. Park S.W. Lee S.D. Chung M.K. The clinical significance of a retroaortic left renal vein.Korean J Urol. 2010; 51: 276-280Crossref PubMed Scopus (37) Google Scholar]. Once identified, it is duly noted and reported as a renal aortic collar for its serious implications in retroperitoneal vascular and urologic operations. It is also important to distinguish this anomaly as a separate entity from persistent left-sided SVC because the drainage point of the latter is mainly into the coronary sinus, whereas a subaortic LBV drains into the SVC below the level of the azygous orifice. The LBV aortic collar described here has a subaortic confluence joining the SVC above the azygous orifice (Figs 2A-2B). In addition to the need for careful radiologic assessment to rule out undiagnosed cardiac defects, a number of important clinical implications are envisaged by an LBV aortic collar.1.At times of thoracic surgery or interventions, or both, potential complications may arise in aortic ductal ligation unless the subaortic portion is identified to avoid potential injury during the paraaortic surgical dissection.2.Several cardiovascular interventions ranging from central venous access/line insertion (eg, peripherally inserted central catheter or Hickman’s catheter) to the transvenous cardiac implantation (eg, defibrillator or pacemaker [usually left sided]) could prove problematic. During these procedures, a catheter or guidewire path will appear on fluoroscopy as nonanatomic, especially if placed in the subaortic division. This may incorrectly alter line length measurements and position.3.In a left-sided dual-chamber pacemaker, the possibility of an apparent gap (aortic arch) between the wires may confuse the operating physician and prolong the procedure, specifically if either lead runs a separate course in an LBV division around the aorta. However, this gap is unlikely to trigger electrical induction should a third wire be inserted in the aorta during vascular interventions, because of the fact that pacemakers operate on a direct current and not an alternate current." @default.
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• W2009443064 title "Potential Clinical Implications of the “Aortic Collar” Configuration of an Anomalous Left Brachiocephalic Vein" @default.
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