Resection and a rare type of reconstruction of the superior vena cava with the left brachiocephalic vein.

Resection and reconstruction of the superior vena cava (SVC) are required in a selected group of patients with anterior mediastinal tumors and lung neoplasms. We present the case of a 63-year-old woman who underwent invasive type B2 thymoma resection and a rare type of reconstruction of the superior vena cava using a patch of the left brachiocephalic vein (LBV). The various types of reconstruction of the superior vena cava are discussed.

Complex aortic-arch pseudoaneurysm with aorto-innominate vein fistula in a case of traumatic chest injury.

A patient in his late 30s presented with issues of retrosternal chest pain and palpitations. He had sustained a splinter injury to the left hemithorax a year ago for which he had been managed with a tube thoracostomy. During subsequent evaluations, he was found to have atrial fibrillations and a CT angiography revealed an arch of the aorta pseudoaneurysm with a fistulous communication with the innominate vein, which being a rare condition has no established treatment protocols. Endovascular salvage of the condition required an aortic Ishimaru zone 2 deployment of the thoracic endovascular aortic repair stent graft to provide an adequate landing zone. The elective left subclavian artery revascularisation was obtained by a left carotid artery to left subclavian artery bypass. Post procedure there was complete exclusion of the pseudoaneurysm sac, and the fistulous aorto-venous communication inflow tract. The patient recuperated well and has returned to full active duties.

Prenatal ultrasound diagnosis of fetal isolated left innominate vein under the aortic arch: A case report.

Abnormalities of the left innominate vein beneath the aortic arch are exceedingly rare. While they may not exhibit overt clinical symptoms, misdiagnosis, or failure to diagnose can significantly complicate and increase the risk associated with cardiac interventional procedures.

Tetralogy of Fallot with an Anomalous Course of the Brachiocephalic Vein.

CLINICAL DATA: Infant, 11-month-old, male, diagnosis of Tetralogy of Fallot with retrotracheoesophageal course of the brachiocephalic vein. Usual findings of Tetralogy of Fallot on physical examination. Technical description: Chest radiography showed slightly reduced pulmonary vascular markings and no cardiomegaly. Normal preoperative electrocardiogram with postoperative right bundle branch block. Usual findings of Tetralogy of Fallot on echocardiogram. Postoperative computed tomography angiography confirmed left brachiocephalic vein with anomalous retrotracheoesophageal course, configuring a U-shaped garland vein, in addition to postoperative findings of total correction of Tetralogy of Fallot. OPERATION: Complete surgical repair was performed with pulmonary valve commissurotomy and placement of bovine pericardial patch to solve right ventricular outflow tract obstruction, pulmonary trunk enlargement, and ventricular septal defect closure. COMMENTS: Systemic venous drainage may show variations in patients with Tetralogy of Fallot. These abnormalities are usually of little clinical relevance, as they are asymptomatic. We presented a rare case of retrotracheoesophageal course of an anomalous left brachiocephalic vein with intraoperative diagnosis, confirmed by imaging during postoperative follow-up, without compromising clinical management or surgical approach.

Central vein stenosis: a rare cause of orbital congestion in a haemodialysis patient.

We report a rare, potentially sight-threatening ocular complication due to central venous stenosis related to a previous site of haemodialysis catheter. A dialysis-dependent woman in her 60s presented with left eye redness for 1 month followed by a remarkably prominent vessel on the left upper eyelid for 2 weeks. Examinations found left eyelid oedema with prominent venous dilatation on the upper eyelid as well as left eye mild proptosis, conjunctiva injection with corkscrew vessels, raised intraocular pressure, and dilated and tortuous retina vessels. Central thoracic venogram showed total occlusion on the left brachiocephalic vein with retrograde reflux to the jugular vein. An endovascular percutaneous transluminal balloon angioplasty was performed for the left brachiocephalic vein stenosis, which resolved the orbital, facial and neck venous congestion. The patient remained asymptomatic after 1 year.

Cadaveric dissection of connection between accessory hemiazygos vein and left brachiocephalic vein.

PURPOSE: The azygos system of veins has many anatomical variations that can impact mediastinal and vascular interventions. While radiological reports on these are of great clinical value, this study is among the first to present a high-quality cadaveric dissection of a rare anatomical variant to supplement previously published radiologic studies. The azygos venous system consists of the azygos vein (AV), hemiazygos vein (HAV), and the accessory hemiazygos vein (AHAV), which develop from the last portion of the posterior cardinal veins. The normal anatomical configuration includes drainage of the posterior intercostal veins, vertebral vein, esophageal veins, HAV, and AHAV to an unpaired right-side AV at the level of the 8th/9th thoracic vertebra. The reported incidence of AHAV draining directly into the left brachiocephalic vein is 1-2%. METHODS: An adult formalin-fixed 70-year-old female cadaver was dissected as part of a medical gross anatomy elective course. RESULTS: Gross documentation of a direct connection of the HAV to the AHAV with the AHAV draining into the left brachiocephalic vein. CONCLUSION: It is important to note the variations of the azygos system to avoid confusion with a potential pathology such as mediastinal masses. Understanding of the rare variant reported here could be useful in the prevention of iatrogenic bleeding from the misplacement of venous catheters and help facilitate radiological diagnosis in the incidence of venous clot formation.

Diagnostic Value of Contrast-Enhanced Ultrasonography for Catheter-Related Right Brachiocephalic Vein and Superior Vena Cava Lesions in Patients Undergoing Hemodialysis-A Pilot Study.

OBJECTIVES: To evaluate the diagnostic efficacy of contrast-enhanced ultrasonography (CEUS) for detecting catheter-related right brachiocephalic vein (RBV) and superior vena cava (SVC) obstructions in patients undergoing hemodialysis (HD). METHODS: From June 1, 2021 to December 31, 2022, we enrolled 80 patients undergoing HD who had used or were using a central venous catheter as vascular access. We evaluated the diagnostic efficacy of conventional ultrasonography and CEUS for identifying RBV and SVC obstructions and compared them with that of digital subtraction angiography (DSA). In the stratified analysis, the SVC was divided into the upper and lower segments. In total, we analyzed 240 central venous segments, including the RBV. RESULTS: Among the RBV and SVC visualized by DSA, conventional ultrasonography and CEUS could visualize 67.92 and 100% of the vein segments, respectively; however, the lengths and diameters of the RBV and SVC were smaller than those recorded with DSA (P < .001). The diagnostic efficacy of CEUS for detecting catheter-related central venous obstruction was better than that of conventional ultrasonography, with a higher sensitivity (83.95 vs 41.98%), specificity (89.94 vs 53.46%), accuracy (87.92 vs 49.58%), and F1 score (82.42 vs 49.64%). CEUS showed good agreement (κ = 0.732) with DSA. In the stratified analyses, CEUS also showed higher sensitivity (83.93, 83.33, and 84.62%, respectively) and better agreement with DSA (κ = 0.635, 0.655, and 0.673, respectively) than conventional ultrasonography for detecting the RBV and the upper and lower segments of the SVC. CONCLUSIONS: CEUS had high sensitivity and specificity in diagnosing catheter-related RBV and SVC obstructions.

Comparison between in-plane and out-of-plane techniques for ultrasound guided cannulation of the left brachiocephalic vein in pediatric population: A randomised controlled trial.

BACKGROUND AND AIMS: Brachiocephalic vein is a novel site for central venous cannulation in infants. It becomes useful in patients where the internal jugular vein lumen is small (e.g., volume deficient patient), patients with a history of multiple cannulations, and in whom subclavian puncture is contraindicated. METHODS: In this randomized double-blinded study, 100 patients, aged between 0 and 1 year scheduled for elective central venous cannulation were recruited. The patients were allocated into two groups (50 patients in each). Group I patients had ultrasound (US) guided cannulation of the left brachiocephalic vein (BCV) by inserting a needle in-plane to the US probe from lateral to the medial direction, whereas Group II patients underwent cannulation of the BCV via an out-of-plane approach. RESULTS: The first-attempt success rate was significantly higher in Group I (74%) than in Group II (36%) (p < 0.001). The total success rate was higher in group I (98%) than in group II (88%) however the difference was statistically insignificant (p > 0.05). The mean BCV cannulation time was significantly shorter in group I (35.46 ± 25.10) than in group II (65.24 ± 40.26) (p < 0.001). The rate of unsuccessful BCV cannulation (12%) and hematoma development (12%) was significantly higher in group II than in group I (2%). CONCLUSION: Compared to the out-of-plane approach of left BCV cannulation, US-guided in-plane cannulation of the left BCV increased the first-attempt success rate, decreased the number of puncture attempts, and decreased the time required for cannulation.

Most complex brachiocephalic vein occlusion in hemodialysis patients can be treated with simple endovascular techniques in an office-based angiosuite.

OBJECTIVE: Brachiocephalic vein (BCV) obstruction can cause dialysis access dysfunction and failure. Central vein stenosis involving the BCV may require advanced endovascular procedures. We report that most BCV occlusions can be treated using simple endovascular techniques on an outpatient basis. METHODS: From January 2009 to January 2022, 115 hemodialysis patients underwent BCV endovascular revascularization. Seventy-three of the initial procedures were performed in an office-based angiosuite. Indications for the procedure were BCV occlusion endangering the performance of a previous arm access or making the creation of a new arm access unadvisable. We recorded and analyzed risk factors and procedural results, patency rates, complications, and mortality. RESULTS: The median age was 62 years (range, 23-91 years); 56% were female. Most prevalent associated conditions were diabetes mellitus (61%) and hypertension (68%). Fifty-six patients (48.7%) presented with severe upper extremity edema ipsilateral to the side of pre-existing functioning access. Obstruction recanalization was effective using standard catheter and wire in 106 cases (92.1%) and transseptal needle in nine cases (7.8%), that included seven using inside-out procedure. Initial management of the BCV stenosis was percutaneous transluminal balloon angioplasty alone in 74 patients (64.3%), stenting in 33 (28.7%), and HeRO conduit in eight cases (7%). Treatment of other central venous lesions included 49 cases (42.6%). The procedure was successful in 99.1% of patients. No intraoperative complications occurred. All 92 patients with previous arm access maintained adequate performance (100%). In 22 of 23 patients (95.6%), new upper extremity access creation was effectively performed after the venous intervention. Overall clinical success rate was 92%. The mean postoperative monitoring was 23 months, the median was 12 months, and the range was 1 to 84 months. During this monitoring period, 266 endovascular procedures, 91% in the office and 9% in the hospital, were required to preserve access performance. Eventually, 49 patients (42.6%) were stented. Eleven patients (9.56%) had infections, and six required complete access removal. Other causes of access failure included two patients with central vein thrombosis and one with massive pulmonary embolus. At the end, nine patients (7.8%) had access failure. Thirty-two patients (27.8%) died of unrelated causes during the follow-up period. Seventy-six patients (66%) have maintained functional access. Kaplan-Meier curves determined median primary patency of 9.6 months, median primary assisted patency of 56.2 months, and secondary patency of 75% at 80 months. CONCLUSIONS: Successful endovascular revascularization of BCV obstruction can be treated safely, with simple endovascular techniques in an office-based context with minor complication rates and durable results.

Prenatal diagnosis of double aortic arch with subaortic left brachiocephalic vein and right-side ductus arteriosus using high-definition flow render mode and spatiotemporal image correlation.

Double aortic arch (DAA) with subaortic left brachiocephalic vein (LBCV) and right-side ductus arteriosus (RDA) was not reported before delivery, only in adults with anatomy course findings. We present a case of fetal DAA with subaortic LBCV and RDA using high-definition (HD) flow render mode and spatiotemporal image correlation (STIC).

Suitability of the left internal jugular vein for CRT-D placement in the setting of extensive venous occlusion: Case report and review of the literature.

Placement of coronary sinus (CS) leads is predominantly accomplished via the left cephalic-axillary-subclavian venous system. However, vein stenosis or occlusion from long-term chronic hemodialysis (HD) in patients with end-stage renal failure can pose a challenge. Cannulation of the CS via the left internal jugular vein (IJV) is technically difficult but often feasible. We report a case in which a patient with end-stage renal disease (ESRD) had extensive left venous system occlusion from prior in dwelling HD catheters, and an AV fistula contralaterally, who underwent biventricular implantable cardioverter defibrillator placement with lead insertion through the left IJV.

Ultrasound-guided supraclavicular cannulation of left brachiocephalic versus right internal jugular vein: Comparative analysis of central venous catheter-associated complications.

AIMS: Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound-guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery. METHODS: Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two-year period receiving central venous catheters for cardiac surgery. PRIMARY ENDPOINT: Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height-based formula without adjustment for side used. RESULTS: Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively. CONCLUSIONS: Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth.

Fetal left brachiocephalic vein diameters in normal and growth restricted fetuses.

OBJECTIVES: To develop a nomogram for fetal left brachiocephalic vein (LBCV) diameters during a healthy pregnancy and to assess LBCV values in fetuses with fetal growth restriction (FGR). METHODS: This prospective observational study included 31 FGR pregnancies and 438 low-risk pregnancies. The low-risk group was used to determine the 5th, mean, and 95th percentiles for the LBCV between 12 and 39 weeks of gestation based on gestational age. On growth charts, LBCV measurements of FGR fetuses were displayed, and those above the gestational age 95th percentile were considered wide vein. Cerebroplacental ratio (CPR) and umbilical artery (UA), middle cerebral artery (MCA), and ductus venosus (DV) Doppler parameters were evaluated in FGR fetuses. RESULTS: LBCV diameter increased significantly with advancing gestational age. The LBCV diameters were above the 95th percentile in 23 of the 31 FGR fetuses (74.2%). All fetuses (15/15, 100%) with early-onset (EO)-FGR and 8 fetuses (8/16, 50%) with the late-onset (LO)-FGR had LBCV values above the 95th percentile (p<0.01). UA-PI was significantly higher and MCA-PI and CPR were significantly lower in LO-FGR fetuses with LBCV diameters above the 95th percentile (p<0.05). CONCLUSIONS: LBCV diameters of fetuses with FGR were significantly wider than the normal population. In the LO-FGR group, there was a good correlation between LBCV diameter and CPR.

Iatrogenic Vertebral Arteriovenous Fistula Involving Brachiocephalic Vein Due to Central Venous Catheterization: A Case Report.

PURPOSE: To report a case of vertebral arteriovenous fistula (VAVF) caused by iatrogenic trauma of central venous catheterization (CVC) involving brachiocephalic vein (BCV). CASE REPORT: A 79-year-old female was referred for assessment of a vertebral artery (VA) aneurysm at the V1 segment. The patient had no signs other than a vascular murmur on the right neck and was diagnosed 20 years after undergoing CVC. Right vertebral angiography revealed a high-flow shunt from the V1 segment of the right VA and draining into the right BCV. The fistula had a single communication between a pseudoaneurysm and large varix. We diagnosed the patient with CVCinduced VAVF (CIVAVF) involving BCV and obliterated the shunt by selective transarterial and transvenous embolization of the pseudoaneurysm under flow control using a balloon catheter with no complications. CONCLUSION: This case highlights the point that CIVAVF involving BCV is rare but possible. In addition, there is a possibility that CIVAVF involving BCV does not demonstrate the findings of arterial steal or retrograde venous drainage and is undiagnosed for a long term due to lack of neurological manifestation and other subjective symptoms. We also showed that endovascular treatment can be feasible and useful for CIVAVF involving BCV.

The different forms of the left brachiocephalic vein visualised during cardiovascular implantable electronic device implantation procedures.

BACKGROUND: Among the factors ensuring successful completion of such minimally invasive procedures as cardiac implantable electronic device (CIED) implantation and central venous catheter (CVC) placement are the morphometry and topography of the vessels used for cardiac lead or catheter advancement. Venous access through the left clavipectoral triangle makes use of the left brachiocephalic vein (BCV). The purpose of this study was to present the radiology images of various individual forms of this vessel observed during CIED implantation procedures. MATERIALS AND METHODS: Our analysis included 100 venography recordings illustrating the left BCV, obtained during de novo CIED implantation procedures. We assessed the mediastinal course of the left BCV, with its natural angles, including angle α (in the middle section of the vessel) and the two angles created by the left BCV and the left subclavian vein (angle ß) and the left BCV and the superior vena cava (angle γ). RESULTS: The mean values of angle α tended to be higher (approximately 141°) than those of the two remaining angles (γ and ß), which were comparable at 123° and 127°, respectively. An increase in mean angle α values were accompanied by increased mean angle γ and ß values (p = 0.05), with only 5% of ß and γ angles, in total, having values close to those of a right angle (90 ± 10º). CONCLUSIONS: Individual variability of left BCV topography and morphology comes from developmental formation of the physiological angle in the middle section of this mediastinal vessel's course. The presence of near-right angles along the course of left BCV may potentially result in injuries to the vessel during intravascular procedures.

Surgical removal of a foreshortened right innominate vein Wallstent causing venous outflow obstruction.

OBJECTIVES: Stenting of central venous stenosis to preserve upper extremity hemodialysis access is well-described, though upper extremity complications secondary to these stents are less frequently discussed. METHODS: We present the case of a 43-year-old male with a right brachiocephalic fistula who developed symptoms of venous hypertension following placement of a Wallstent for central venous stenosis. Workup demonstrated venous outflow obstruction secondary to stent foreshortening into the right subclavian vein. RESULTS: The Wallstent was removed in a piecemeal fashion using an open surgical technique and a HeRO graft was placed for dedicated fistula outflow with complete relief of the patient's symptoms. CONCLUSION: In situations where a stent has migrated and endovascular removal is not possible, individual Wallstent fibers can be removed through a limited venotomy.