Venous chest anatomy: clinical implications

doi:10.1016/S0720-048X(97)00147-2

European Journal of Radiology

Volume 27, Issue 1, March 1998, Pages 2-14

https://doi.org/10.1016/S0720-048X(97)00147-2 Get rights and content

Abstract

This article provides a practical approach to the clinical implications and importance of understanding the collateral venous anatomy of the thorax. Routine radiography, conventional venography, computed tomography (CT), and magnetic resonance (MR) imaging studies provide correlative anatomic models for the demonstration of how interconnecting collateral vascular networks within the thorax maintain venous stability at all times. Five major systems comprise the collateral venous network of the thorax (Fig. 1

). These include the paravertebral, azygos–hemiazygos, internal mammary, lateral thoracic, and anterior jugular venous systems (AJVS). The five systems are presented in the following sequence: (a) a brief introduction to the importance of catheter position and malposition in understanding access to the thoracic venous system, (b) the anatomy of the azygos–hemiazygos systems and their relationship with the paravertebral plexus, (c) the importance of the AJVS, (d) ‘loop’ concepts interconnecting the internal mammary and azygos–hemiazygos systems by means of the lateral thoracic and intercostal veins, and (e) the interconnecting venous networks on the thoracic side of the thoracoabdominal junction. Certain aspects of the venous anatomy of the thorax will not be discussed in this chapter and include (a) the intra-abdominal anastomoses between the superior and inferior vena cavae (IVC) via the internal mammary, lateral thoracic, and azygos–hemiazygos systems (beyond the scope of this article), (b) potential collateral vessels involving vertebral, parascapular, thyroidal, thymic, and other smaller veins that might anastomose with the major systems, and (c) anatomic variants and pitfalls that may mimic pathologic conditions (space limitations).

Section snippets

Definitions and conventions

The following definitions and conventions are provided to present a consistent set of terms that will be used throughout this article.

(1) Antegrade—injection of contrast material in the normal direction of flow in a vessel, or flow in the normal direction within that vessel because of obstruction elsewhere.

(2) Retrograde—injection of contrast material against the normal direction of flow in a vessel, or flow in the opposite direction within that vessel because of obstruction elsewhere.

(3)

Catheter position and malposition

Catheters are inserted into the venous system of patients on a routine basis. Most of these catheters are introduced in a blind fashion (i.e. without fluoroscopic guidance) for specific applications (e.g. central monitoring, hyperalimentation, or chemotherapy). The most common routes of insertion include the subclavian, internal jugular, and basilic veins via a percutaneous approach. The optimal location of these catheters is within the SVC, and most are positioned without incident. Routine

Azygos–hemiazygos systems and the paravertebral plexus

The normal anatomy of the azygos and hemiazygos systems is described in Heitzman's excellent text on the mediastinum [3]. Basically, both systems are thoracic continuations of the ascending lumbar veins and provide venous drainage for intercostal and paravertebral veins within the posterior aspect of the thorax. The two systems are venous analogs, are interconnected at varying levels, and can be venographically demonstrated (Fig. 4Fig. 5).

The azygos vein drains into the posterior aspect of the

Anterior jugular venous system

The anterior jugular venous system (AJVS), with its interconnections to the subclavian and deep jugular veins, provides an important collateral venous network across the midline of the superoanterior aspect of the thorax. The venous components of this system have been illustrated with diagrams and conventional venography in the article by Okay and Bryk [6], demonstrated to some extent in the nuclear medicine literature [7], and occasionally visualized on CT scans [5]. However, it is important

Venous loop concepts

In the previous two sections, we have described the relationship between the azygos–hemiazygos systems and the paravertebral plexus in the posterior aspect of the chest and the role of the AJVS as a superoanterior bridging network between the subclavian and deep jugular veins. It should now be apparent that the arch of the azygos vein and the left superior intercostal vein are bridging vessels that link the posteriorly located azygos–hemiazygos systems with the anteriorly located SVC and left

Conclusion

In the loop concept of venous collateral vessels, the vascular skeleton, in some ways, resembles a bird cage in the shape of a thorax. The basic frame of this cage consists of the interconnecting structures seen in Fig. 15 extending from the level of the innominate veins to the diaphragm. The top of this cage is the thoracic inlet from the lower neck to the level of the innominate veins. Within the cage are the major venous structures that connect to the SVC. This loop concept is actually a

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2020, American Journal of Kidney Diseases
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Due to complex anatomy of the thoracic veins, CVC malposition is common546 (Guideline 9). In the settings of superior vena cava (SVC) stenosis (itself common in HD patients) and venous aberrations that follow, such as dilatation of the azygous vein, the likelihood of incorrect CVC positioning is even higher.547 Even if initially appropriately positioned, CVCs can migrate spontaneously, most commonly in the contralateral innominate vein generating an array of complications.548,549
The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease “Life-Plan” and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
Prevalence and characteristics of intravertebral enhancement on contrast-enhanced CT scans in cancer patients
2017, European Journal of Radiology
This was a single center, retrospective observational study.
to investigate—in a cancer population—the prevalence and hallmarks of intravertebral enhancement (IVE) detected on contrast-enhanced CT.
Intravertebral enhancements secondary to iodinated contrast stagnation have been described. Cancer patients have an increased risk of perivertebral venous thrombosis or stenosis secondary to several risk factors (cancer or drug induced hypercoagulability, deterioration of venous flow linked to catheter insertion, prolonged immobilization). In case of a high density lesion identified on CT, the diagnostic choice between metastasis and contrast media within bone marrow vessels may be an issue, especially as oncologic follow-up CT scans are usually performed with contrast medium injection.
2572 contrast-enhanced body CT scans performed in cancer patients over 3 months in the medical imaging department of a university hospital were retrospectively reviewed. IVE was sought when paravertebral venous collateral circulation was detected and bone metastasis ruled out and classified as linear or nodular. Their locations within vertebra, their relation to the injection side and the predominant collateral venous network side were evaluated.
Sixty-seven (2.8%) patients had a collateral paravertebral venous system and among them 21 had IVE (37%). There were 208 IVE locations involving 75 vertebrae. 199 IVE were linear-shaped (95.7%) and 9 nodular-shaped (4.3%). 80.8% were located between C6 and T4. 88.9% were localized in the vertebral body. 73.1% were located medially or ipsilateral to the injection side.
Intravertebral enhancement is found in 37% of the patients with paraspinal collateral venous circulation when a CT scan is performed for cancer. The ipsilateral or medial position of the IVE relative to the injection side and the side of the dominant perivertebral venous system, and the possibility of connecting the IVE to a paravertebral vein may be in favor of vascular opacification.
Anatomical variation in the anterior jugular veins and its clinical implications - A case report
2015, Journal of the Anatomical Society of India
Citation Excerpt :
The present reported and discussed variations advocated that anatomically AJVs showed high degree of variations. AJV has also been reported as a very important venous channel involved in maintenance of thoracic venous stability as an important collateral channel11 and knowledge of its anatomical variations are essential for surgeons to avoid any complications during neck surgery and catheterization4 because of their attachment to the platysma above and the fascia below the superficial veins (AJV and EJV) do not retract, bleeding from the veins may not cease easily and cause serious impact.12 Prior and sound knowledge of such variations is of utmost important to clinicians, surgeons, anesthetists and radiologists for ease and safe approach during neck surgeries.
Paired anterior jugular veins were present on either side of the midline of the neck, connected by a transverse (jugular) venous arch in the suprasternal space and drains into the external jugular vein (EJV) and subclavian vein (SV).
The current variations were found in approximately 50-year-old female cadaver during routine dissection in the Department of Anatomy.
In present case, the anterior jugular venous system presents a variant formation, course and termination. Anterior jugular veins (AJVs) formed “V1” at the level of third tracheal ring; the major part of the “V1” deviated towards right side and joined with EJV forming “V2”. The “V2” finally drained into the right jugulo subclavian junction. Clinically, the variant arrangement of AJV may involve malposition of the catheter and misinterpretation of the examination of cardiovascular system.
Knowledge of such variations of AJV is important for medical professionals to avoid any clinical mismanagement during cardiac examination, vascular surgeries, anesthetic and radiological procedures.
Pseudopathologic vertebral body enhancement in the presence of superior vena cava obstruction on computed tomography
2015, Spine Journal
Citation Excerpt :
The vertebral venous plexus is one of the four main collateral pathways because of SVC obstruction that contain the lateral thoracic, internal thoracic, and azygos veins. Usual or unusual collaterals related to SVC obstruction have been documented in plenty of literature [1–7]. However, only one case of vertebral body enhancement has been reported in the English literature [8].
Superior vena cava (SVC) obstruction can cause the development of collateral vessels. During contrast-enhanced thoracic computed tomography (CT), contrast material may reflux into the collaterals such as paravertebral venous plexus. However, an unusual pseudopathologic vertebral body enhancement on CT in the presence of SVC obstruction has not been studied previously.
To demonstrate clinical presentation and imaging findings of pseudopathologic vertebral body enhancement in patients with SVC obstruction.
Retrospective study of diagnostic CT images examined at our clinic.
From March, 2009 to September, 2012, a retrospective radiologic database review was performed to identify patients with obstruction of SVC causing contrast reflux into collateral vessels and presented with an unusual vertebral body enhancement on thoracic CT. Thirteen patients (11 men, mean age 51.4 years) with vertebral body enhancement were enrolled.
Enhancement patterns of vertebral bodies were classified as nodular enhancement with round shape occupying less than one-third of vertebral body or polygonal enhancement occupying greater than or equal to one-third of vertebral body on axial image. The locations of enhanced areas within vertebral bodies were described using right lateral/central/left lateral, anterior/posterior, and upper/middle/lower in the x-, y-, or z-axis directions, respectively.
Enhancement patterns, locations, and the presence of a connection between vertebral body enhancement and the paravertebral venous plexus were evaluated.
A total of 39 vertebral body enhancements were found in the 13 patients, involving cervical (n=12), thoracic (n=25), or lumbar (n=2) vertebrae. Vertebral body enhancements showed a nodular (n=19) or a polygonal (n=20) pattern. The central portions of vertebral bodies were more frequently involved. The connection to the paravertebral venous plexus was observed in 34 lesions (87.2%).
Patients with SVC obstruction with extensive collateral vessels might exhibit a pseudopathologic vertebral enhancement. They tended to involve the central portion of the vertebral body, and most of them showed connection to the paravertebral venous plexus.
Review of venous anatomy for venographic interpretation in chronic cerebrospinal venous insufficiency
2011, Journal of Vascular and Interventional Radiology
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The vertebral venous plexus is another major route for intracranial outflow, particularly when the body is in an upright position and when intraabdominal or intrathoracic pressure is increased (42–45). The azygos system of veins provides outflow from the intercostal and paravertebral veins within the posterior aspect of the chest (36). The ascending lumbar veins form the origin of the azygos system.
Chronic cerebrospinal venous insufficiency (CCSVI) represents a recently described condition that may potentially contribute to the symptoms experienced by patients with multiple sclerosis. The evaluation of a prospective patient for CCSVI often involves an invasive evaluation with venography of the internal jugular and azygos veins. The purpose of this article is to review the normal anatomy of the internal jugular, vertebral, and azygos veins, as an understanding of these veins is necessary for appropriate interpretation of the venograms obtained to evaluate patients for CCSVI.
Malposition of central venous catheter in left superior intercostal vein in a patient with superior vena cava syndrome
2007, Radiography
Citation Excerpt :
The LSICV is part of azygos–hemiazygos collateral system. The dilatation of the LSICV beyond 4.5 mm may be due to left brachiocephalic hypoplasia, congestive heart failure, or superior or inferior vena cava obstruction.7,8 We believe that this patient's SVC syndrome as well as the occlusion of her right brachiocephalic vein led to LSICV dilatation and resulted in the malpositioning of catheter tip.

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¹: This article has been extracted from a chapter in: Chasen MH, Charnsangavej C. Venous chest anatomy: clinical implications. In: Greene R, Muhm Jr, eds. Syllabus: a categorical course in diagnostic radiology. Chest Radiology. Oak Brook, Ill: Radiological Society of North America, 1992: 121–134.

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Venous chest anatomy: clinical implications1

Abstract

Section snippets

Definitions and conventions

Catheter position and malposition

Azygos–hemiazygos systems and the paravertebral plexus

Anterior jugular venous system

Venous loop concepts

Conclusion

Impending catheter perforation of superior vena cava: radiographic recognition

Am J Roentgenol

Thoracic venous anatomy

Am J Roentgenol

Venous chest anatomy: clinical implications¹