Venous chest anatomy: clinical implications1
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
References (7)
- et al.
Impending catheter perforation of superior vena cava: radiographic recognition
Am J Roentgenol
(1986) - et al.
Thoracic venous anatomy
Am J Roentgenol
(1986) - Heitzman ER. The mediastinum: radiologic correlations with anatomy and pathology. . 2nd ed. Berlin: Springer-Verlag,...
Cited by (33)
KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update
2020, American Journal of Kidney DiseasesCitation Excerpt :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
Prevalence and characteristics of intravertebral enhancement on contrast-enhanced CT scans in cancer patients
2017, European Journal of RadiologyAnatomical variation in the anterior jugular veins and its clinical implications - A case report
2015, Journal of the Anatomical Society of IndiaCitation 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.
Pseudopathologic vertebral body enhancement in the presence of superior vena cava obstruction on computed tomography
2015, Spine JournalCitation 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].
Review of venous anatomy for venographic interpretation in chronic cerebrospinal venous insufficiency
2011, Journal of Vascular and Interventional RadiologyCitation Excerpt :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.
Malposition of central venous catheter in left superior intercostal vein in a patient with superior vena cava syndrome
2007, RadiographyCitation 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.
- 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.