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Introduction. Intravascular procedures, including central venous catheterization and placement of cardiac implantable electronic device (CIED) leads, present an opportunity for radiological assessment of the relevant vessels. Obtaining vascular access via left clavipectoral triangle veins may lead to an unintentional catheter/lead insertion into a left brachiocephalic vein (BCV) tributary. This article presents the left-BCV tributaries encountered during CIED implantation procedures and discusses the potential impact of vessel topography on the course of such procedures. Material and methods. Venography records of de novo CIED implantation procedures conducted between 2014 and 2018 were analyzed retrospectively. The indication for these venographies had been the need to determine the cause of difficulties in threading a lead through the venous system. As the title suggests, this paper focuses only on the records illustrating the presence and course of left-BCV tributaries. Results. Out of a total of 315 venographies, we found 12 cases of left-BCV tributaries, including nine left superior intercostal veins (SICVs), two left internal thoracic (mammary) veins (IMVs), and one inferior thyroid vein. Other veins had not been visualized. Conclusions. The left SICV and, less commonly, left IMV were the most commonly visualized left-BCV tributaries in the analyzed imaging records of de novo CIED placement procedures. The anatomical variants of those vessels that drain into the left BCV from below, at the outer or convex wall of the bend in the left BCV, increase the risk of unintentional CIED lead or central venous catheter insertion.

Knowledge of variations of azygos and hemiazygos veins is of importance to cardiothoracic surgeons and radiologists during various surgical, radiological, and echography techniques. We report some unique variations of azygos system of veins observed during dissection classes for undergraduate medical students. The azygos vein was formed as usual by the union of right subcostal and ascending lumbar veins. The vein ascended upward and to the left to reach the midline at the level of the 9th thoracic vertebra. After ascending till 5th thoracic vertebra, it gradually inclined to the right of midline and terminated by opening into the superior vena cava at the level of the 3rd thoracic vertebra. There was no major variation in the tributaries of the azygos vein on the right side, except that the right superior intercostal vein crossed behind the azygos vein from right to left and opened into the left side of the azygos vein. Further, two anastomotic veins connected the 10th, 11th and 12th posterior intercostal veins with each other to form two anastomotic circles on the right side of 10th to 12th thoracic vertebrae. The hemiazygos vein bifurcated on the left side of the 10th thoracic vertebra and the two ends opened into the azygos vein at the level of 9th and 10th thoracic vertebrae forming a venous circle in front of the 10th thoracic vertebra. The course of accessory hemiazygos vein was noteworthy. Instead of its classic descending course, the vein ascended upward from the left side of the 8th thoracic vertebra till the 6th thoracic vertebra before opening into the azygos vein.

Azygos venous system drains the venous blood from thoracic wall. Knowledge of variations of its course and tributaries is important to cardiothoracic surgeons, radiologists and orthopedic surgeons. We observed the following variations in the azygos veins. Both azygos and hemiazygos veins were formed by union of lumbar azygos and subcostal veins of corresponding sides. The ascending lumbar vein did not drain into the azygos system. The hemiazygos vein had a larger diameter than the lower part of azygos vein and it joined azygos vein at the level of seventh thoracic vertebra. Accessory hemiazygos vein was totally absent. The azygos vein received 4th to 11th right posterior intercostal veins and also received 3rd to 6th left posterior intercostal veins. Hemiazygos vein received 7th to 11th left posterior intercostal veins.

Atypical anatomy may be encountered unexpectedly and undiagnosed in clinical practice, and this is especially important during the performance of interventional procedures such as transvenous implantation of cardiac electronic devices. The body of the first rib can be absent. If this not noticed, pneumo-/haemothroax may be induced during subclavian vein puncture as the needle may enter the first intercostal space rather than the costo-clavicular angle. The cephalic vein may pursue a supraclavicular course, the axillary vein may drain into an intercostal vein rather than the axillary vein, and the entire length of the axillary-subclavian-brachio-cephalic vein may be absent. Device implanters should be vigilant about the possibility of these anatomical variations, and be equipped with the knowledge and spectrum of alternative techniques needed to deal with them.

Objective: The purpose of our investigation was to determine the safety and usefulness of embolisation procedures in balloon occluded retrograde transvenous obliteration (BRTO) as treatment of gastric varices after portal hypertension. Materials and Methods: Between June 2004 and August 2009, 40 patients underwent BRTO for gastric varices that occurred after portal hypertension in our institution. When large collateral vessels of gastric varices had developed as drainage veins other than the gastro-renal shunt, these collateral vessels were embolised prior to BRTO. Results: Embolisation was performed for 18 collateral vessels in 16 cases before BRTO. Embolised collateral vessels were the left inferior phrenic vein (n = 14), intercostal vein (n = 3), and ascending lumbar vein communicating with the gastro-renal shunt (n = 1). Mean number of micro-coils used was 5.7 in left inferior phrenic veins, 4.7 in intercostal veins and 4 in the ascending lumbar vein. In 36 (90%) patients, contrast-enhanced abdominal CT after BRTO showed that the gastric varices were well obliterated. The rate of occurrence of cases in which the remnant of the enhanced area in the gastric varices was seen even after BRTO was statistically higher in cases requiring embolisation of collateral vessels than in those who did not (4/16 versus 0/24, P = 0.0199 according to Fisher's exact probability test). Recurrence of gastric varices was determined by endoscopy in 1 (2.5%) case necessitating embolisation of collateral vessels. There were no serious complications. Conclusion: Embolisation of collateral vessels before BRTO is a safe and useful procedure. However, especially in cases having collaterals sufficiently large to require embolisation, careful follow-up for recurrence of gastric varices is necessary.

Chylothorax is a rare clinical condition characterized by high triglyceride and low cholesterol levels in milky pleural aspirate. Generally, it occurs through leakage of chyle as result of trauma or malignancy. Chylothorax due to tuberculous lymphadenitis is very rare clinical condition that has only been documented in a few cases. Although precise pathogenesis is not known, enlarged mediastinal and hilar lymph nodes are thought to be associated with opening of collateral anastomosis between thoracic duct and the azygos and intercostal veins by creating pressure on thoracic duct and cisterna chyli. Presently described is case of chylothorax thought to be due to compression from mediastinal tuberculous lymphadenitis, and which had complete remission after antituberculosis treatment.

A n asymptomatic intercostal arteriovenous fistula was suspected because of a faint midthoracic intercostal bruit detected during auscultation in a 3-year-old girl with common cold. There was no history of trauma, iatrogenic therapeutic procedures, or congenital abnormality. Multislice contrast-enhanced computed tomography of the thorax revealed an engorged T8 intercostal artery arising from the thoracic aorta, engorged intercostal vein, and engorged intervertebral vein (Figures 1-3; Figures 1 and 3 available at www.jpeds.com). A three dimensional volume-rendered lateral oblique image confirmed the engorgement of the T8 intercostal artery arising from the thoracic aorta and the engorgement of the intercostal vein (Figure 4; available at www.jpeds.com). Based on the imaging and clinical findings, the diagnosis of congenital intercostal arteriovenous fistula was made. The patient underwent uneventful coil embolization. Intercostal arteriovenous fistulas and malformations are rare lesions, and only a few cases have been published. Most of them occur secondary to trauma or iatrogenic therapeutic procedures and in association with neurofibromatosis type 1, although a congenital origin is suggested in extremely rare cases. Clinical manifestations vary according

Objective The superior vena cava (SVC) obstruction by malignant diseases is either by direct invasion and compression or by tumour thrombus of the SVC. Whatever is its cause, obstruction of the SVC causes elevated pressure in the veins draining into the SVC and increased or reversed blood flow through collateral vessels. Severity of the syndrome depends on the collateral vascular system development. Therefore, imaging of the collateral veins with variable location and connection is important in determining the extension and management of the disease. Our aims are to describe collateral vessels of the superior vena cava syndrome (SVCS) related with the malignant diseases and to assess the ability of multi-detector row CT with multiplanar and 3D volume rendering techniques in determining and describing collateral circulations. Materials and methods We present CT angiography findings of seven patients with small cell carcinoma of the lung (n = 2), squamous cell carcinoma of the lung (n = 3), Hodgkin disease of the thorax (n = 1), and squamous cell carcinoma of the oesophagus (n = 1). The patients received contrast-enhanced CT scans of the chest and abdomen on a multi-detector row CT during breath holding at suspended inspiration. Results CT images revealed the cause and level of the SVC obstruction in all patients with axial and multiplanar reconstructed images. The SVC showed total obstruction in five patients and partial obstruction in two patients. The most common experienced collateral vessels were azygos vein (6), intercostal veins (6), mediastinal veins (6), paravertebral veins (5), hemiazygos vein (5), thoracoepigastric vein (5), internal mammary vein (5), thoracoacromioclavicular venous plexus (5), and anterior chest wall veins (5). While one case showed the portal-systemic shunt, V. cordis media and sinus coronarius with phrenic veins were enlarged in two cases, and the left adrenal vein was enlarged in a patient. In one case, the azygos vein with reversed blood flow was drained into both inferior vena cava and hemiazygos vein with the left renal vein. Conclusion Multi-detector row CT with multiplanar and 3D imaging is an effective tool in evaluation of the SVCS and has a greater advantage than the other imaging techniques. 3D volume rendering is a useful technique in determining and describing collateral circulations in addition to the primary disease process.

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).

A 28-year-old man with a persistent cough and a mild fever was transferred to our institution. Computed tomography angiography showed a giant azygos venous aneurysm associated with the dilation of lumbar veins, azygos veins, hemiazygos veins, and intercostal veins (A-D). At the ages of 3 and 18 years, the man had undergone resection of angiomas in the chest wall (approximately 8 8 7 cm) and on the back (approximately 10 8 8.5 cm), respectively. The pathologic diagnosis showed cavernous hemangioma and lymphangioma. After the second operation, he was subsequently injected with ureaphil every 3 months for 18 times in total. However, the computed tomography scan at that time did not show the visible dilation of azygos veins and fertile varicose veins including intercostal veins, lumbar veins, and partial visceral veins, which was significantly different from that of 10 years later. Azygos venous aneurysms are extremely rare. Nakamura et al reported three main types of azygos venous aneurysms caused by different factors. One of them was dilation of the azygos vein induced by increased venous pressure and volume load, as in the cases of heart failure, portal hypertension, right atrial mural thrombosis, and inferior vena caval occlusion. In this case, we believe it was induced by resection of hemangioma, which increased pressure and volume load. To the best of our knowledge, the giant azygos venous aneurysm caused by resection and embolization of cavernous hemangioma in the chest wall and back has never been reported. Azygos venous aneurysms may also be related to traumatic pseudoaneurysm and idiopathic saccular aneurysm. Its differential diagnosis should include other posterior mediastinal masses. However, Gomez et al reported that if it is thrombosed, surgical therapy is necessary to prevent pulmonary embolism. A video-assisted thoracoscopic excision is recommended as the best technique.

Multiple variations of the azygos venous system were detected during routine dissection. The hemiazygos vein was underdeveloped. On the left side of the thorax, posterior intercostal veins between the 8th and 11th intercostal spaces and the subcostal vein drained into the azygos vein independently. In addition, the posterior 4th, 5th, 6th and 7th intercostal veins united and formed two superior and inferior trunks. The superior common trunk, at the level of the T4 vertebra, crossed the vertebral column obliquely, lying anterior to the aorta and posterior to the esophagus, opening into the azygos vein at the level of the T4 vertebra. The other structures in this part were normal. There were different courses of the azygos vein system. This variation is important in mediastinal surgery and also in the interpretation of radiographs.

The uppermost portion or arch of the azygos vein is frequently ligated and divided in thoracic surgery. The hemodynamic effects arising from this proce dure have not, however, been described previously. The authors assessed such effects by using transesophageal real-time two-dimensional Doppler echography (TE2DD). Nine patients, whose azygos arch had been ligated and divided in the course of surgery for lung cancer, were examined. The intervals between the prior operation and the examination with TE2DD ranged from one to fifty months. By use of a convex array transducer with a frequency of 7.5 MHz, the hemodynamics of both the azygos vein and the intercostal veins, which join the former, were assessed. The esophagopetal portion of the azygos vein could be visualized in color in 6 of 9 cases. In all these 6 cases, the flow direction of the azygos vein was reversed and directed caudally. Blood flow in both the azygos vein and the intercostal veins is normally pulsatile. After ligation, however, it had become constant in 3 of 5 cases analyzed by pulsed Doppler spectrum. The value of mean flow velocity in the azygos vein (9 ± 5 cm/sec) was significantly (p < 0.05) smaller than that of the control group (15 ±5 cm/sec).

innominate and intercostal veins. PTH gradients assist in localization of parathyroid adenomas. A correlation between surgical pathology and parathyroid venous sampling is made. Conclusion and/or Teaching Points: Parathyroid venous sampling is an effective tool in the evaluation of parathyroid adenoma, particularly in the setting of hyperparathyroidism and negative non-invasive imaging. Interventional radiologists should become familiar with this procedure as it may be a last resort imaging modality.

A case of posterior mediastinal panniculitis is reported. CT and MRI showed a paraspinal mass containing a small amount of fat. The intercostal veins were found to run through the mass without being distorted, mimicking lymphoma. The diagnosis of panniculitis was made by CT-guided biopsy and open biopsy.

We illustrate the spectrum of venous collateral pathways caused by the thoracic central venous obstruction with direct spiral computed tomography (CT) venography and 3-dimensional reconstruction images. Venous structures that can be demonstrated with CT venography include the jugular veins; the subclavian and brachiocephalic (innominate) veins; the internal and lateral thoracic veins; the superior and inferior venae cavae; the pericardiophrenic veins; the azygos, hemiazygos, and accessory hemiazygos veins; and the intercostal veins.

Multi-detector row computed tomography (CT) and volume rendering can be used as an interpretive aid to present the systemic and pulmonary venous anatomy of the thorax. Both of these venous systems are routinely imaged in clinical practice and are important in interpretation of diagnostic images in health and disease. Multi-detector row CT and three-dimensional volume rendering provide high-quality near-isotropic data (ie, the longitudinal resolution approximates the in-plane resolution). The data sets allow tailored postprocessing to produce images optimized for these vessels, which are often not fully appreciated at planar axial imaging alone. Venous structures of the thorax that can be demonstrated with multi-detector row CT and volume rendering include the jugular veins; the subclavian and brachiocephalic veins; the internal and lateral thoracic veins; the superior and inferior venae cavae; the coronary sinus, the cardiac and pericardiophrenic veins, and vein grafts; the azygos, hemiazygos, and accessory hemiazygos veins; the intercostal veins; the pulmonary veins; and other thoracic veins.

A 28-year-old woman suffered severe back pain and headache during exercising on three occasions during the prior two-month period. On admission, the physical examination revealed symptoms of meningeal irritation, nuchal rigidity, severe headache, continuous nausea, and vomiting. Cerebral computed tomography of the intracranial subarachnoidal space revealed no subarachnoid hemorrhage. Her cerebrospinal fluid was bloody. Spinal magnetic resonance imaging identified a posterior mediastinal tumor adherent to the left side of the 5th thoracic vertebra and an abnormally expanded blood vessel near the mediastinal tumor. In addition, a high signal intensity lesion appeared to be present on the surface of the spinal cord. A mediastinal neoplasm was removed through standard thoracotomy. During surgery, marked enlargement was noted in some veins (hemiazygos and 5th intercostal veins) which apparently had been constricted by the mediastinal tumor. Surgical and radiological findings suggested a relationship between the constricted venous return due to the tumor and the patient’s spinal subarachnoid hemorrhage.

Lung perfusion imaging with Tc-99m MAA was performed in a patient thought to have pulmonary embolism. The dynamic flow images obtained before static lung perfusion imaging showed delayed drainage of the tracer into the right brachiocephalic vein and superior vena cava, and unusual demonstration of the right lateral thoracic and intercostal veins as collateral pathways. It was thought that coughing at the time of bolus injection of the tracer into a right antecubital vein caused an increase of intrathoracic pressure and consequently disturbed the venous return to the thorax.

Dear Editor, With great interest we read the article by Schroder et al. to be published in a forthcoming issue of the Journal of Gastrointestinal Surgery in which they investigated the potential value of resecting the azygos vein in transthoracic esophagectomy for esophageal cancer. During (robot-assisted) thoracoscopic esophagectomy, the trunk of the azygos vein is often preserved as the scopic ligation of the numerous intercostal veins is technically difficult and time-consuming. One may postulate that this may negatively affect the extent of lymph node harvesting or the circumferential radical (R0) resection rate. Schroder et al. have, therefore, performed a prospective evaluation on the amount of lymph nodes surrounding the azygos vein in 92 patients with esophageal cancer having undergone open transthoracic esophagectomy with two-field lymphadenectomy. Lymph nodes near the azygos vein were identified in 65% of patients and metastases in these lymph nodes were found in 8%. They, therefore, conclude that the dissection of the azygos vein should not be abandoned, irrespective of the surgical approach. A comment should be made on the design of the study. As clearly shown in Figure 2 of their article, they dissected the azygos vein with the surrounding tissues sharply from the esophagus, which is not representative for (robot-assisted) thoracoscopic esophagectomy. In (robot-assisted) thoracoscopic esophagectomy, subsequent to the ligation of the azygos arch, the mediastinal dissection of the esophagus and surrounding tissues is performed sharply along the azygos trunk. In this way, the fatty tissue in between the esophagus and the azygos vein (including the lymph nodes of stations 108 and 110) as well as the thoracic duct are included in the esophageal resected specimen and are not left in situ when the trunk of the azygos vein is preserved. The number of lymph nodes that will be left in situ with (robot-assisted) thoracoscopic esophagectomy will, therefore, be much less than stated in this article. Indeed, in our recently published cadaveric study in which we investigated an identical research question, a mean amount of only 0.67 lymph nodes were identified around the azygos vein using the thoracoscopic dissection method. Using this approach, in 60% of cadavers, no lymph nodes near the azygos vein were detected at all. With regard to the possible effect of azygos vein preservation on the radical resection rate, we can refer to our first report on 21 esophageal cancer patients having undergone robot-assisted thoracoscopic esophagectomy. The R0 resection rate of 76% in that series is similar to that of open transthoracic esophagectomy. In our opinion, it is, therefore, justified to preserve the azygos trunk during (minimally invasive) transthoracic esophagectomy.

Learning Objectives To facilitate widespread utilization of the parathyroid venous sampling, this pictorial assay reviews normal anatomy and its variants of considerable clinical importance. We will also present the problems and challenges they pose for the interventional radiologist. Background Parathyroid venous sampling for para-thyroid hormone (PTH) is a highly promising method for localization and diagnosis of parathyroid tumors. Sampling of small veins is the goal. The reported sensitivity of parathyroid venous sampling is 70-80%. However, patients with congenital variation in anatomy and also those with distorted anatomy due to previous surgery can sometime present significant challenge to successful completion of bilateral parathyroid venous sampling resulting in false negative test. Clinical Findings/Procedure Details Technical Details : This pictoral review presents parathyroid venous anatomy along with the details of catheterization and retrograde venography of the parathyroid venous bed wherever necessary. In the entire series of no significant complication has occurred. Normal Anatomy and Variants : The thyroid venous bed is composed of: (a) a diffusely anastomosing, valveless plexus of veins arising from and investing the thyroid gland; and (b) paired, draining superior, middle and inferior thyroid veins. - Superior thyroid veins - Middle thyroid veins - Inferior thyroid veins - most common patterns - Thymic mediastinal veins - Azygos vein and left superior intercostal veins - Few confusing veins such as anterior jugular and the vertebral veins as well as mediastinal veins. - Interesting cases Conclusion and/or Teaching Points The roentgenographic anatomy of parathyroid veins is presented. As usual with venous anatomy, variations from the preceding standard description are common. Parathyroid drainage occurs predominantly via the inferior thyroid vein. Although inferior thyroid drainage is variable, bilateral samples could be obtained in a high percentage of cases. Probably least important for parathyroid drainage, the superior thyroid was the most constant and predictable of the thyroid veins.

In the cadaver of an 86 year old man the inferior segment of the azygos vein could not be found. Furthermore, a normally developed hemiazygos vein drained the right and left intercostal veins from T 10 to T 6. This vessel finally curved towards the right to reach the superior vena cava after having drained the right superior intercostal veins. The left superior intercostal vein ended in a short vessel draining into the left brachiocephalic vein. This condition may be represented in a standard chest radiograph by the so-called "aortic nipple". Agenesis of the azygos vein, suspected because of the presence of this radiological sign, should be confirmed in the living by means of computerized tomography. This can clarify the anatomy of the mediastinal vessels precisely. Embryological pattern of the azygos system accounting for its possible defects is discussed.

Pulmonary vein thrombosis is a rare but potentially life threatening complication following lobectomy or bilobectomy. We present a case of right upper pulmonary vein thrombosis after a middle and lower lobectomy diagnosed at transoesophageal echocardiography. The patient was treated with antibiotics and anticoagulation with good recovery. Pulmonary angiography was performed 35 days after surgery and revealed the venous return of the right lung through the intercostal veins. Despite double venous drainage of the lungs consisting of bronchial and pulmonary veins, pulmonary to systemic collaterals following pulmonary vein thrombosis have not previously been reported. The development of this shunt can prevent gangrene, and surgical resection of the lung segment involved can be avoided.

Gastric varices are usually associated with a gastro-renal (G-R) shunt. However, the gastric varices described in this case report were not associated with a G-R shunt. The inflow vessel was the posterior gastric vein and the outflow vessels were the narrow inferior phrenic vein and the dilated cardio-phrenic vein. First, percutaneous transhepatic obliteration of the posterior gastric vein was performed, but the gastric varices remained patent. Then, micro-balloon catheterization of the subphrenic vein was carried out via the jugular vein, pericardial vein and cardio-phrenic vein, however, micro-balloon-occluded inferior phrenic venography followed by micro-coil embolization of the cardio-phrenic vein revealed no delineation of gastric varices resulting in no further treatment. Thereafter, as a gastro-subphrenic-intercostal vein shunt developed, a micro-balloon catheter was advanced to the gastric varices via the intercostal vein and balloon-occluded retrograde transvenous obliteration (BRTO) was performed resulting in the eradication of gastric varices. BRTO for gastric varices via the intercostal vein has not previously been documented.

Sir, Gasparetto et al. [1] present an interesting case report of a rare anomaly—asymptomatic unilateral pulmonary vein atresia that was confirmed by magnetic resonance angiography. Unlike the case reported at our institution [2], the girl had no symptoms and on follow-up after 5 years she remained asymptomatic. An asymptomatic or mildly symptomatic course of this anomaly could be explained by complexity and pliability of the bronchopulmonary circulation. Liebow [3] showed a double venous drainage in normal human lungs consisting of pulmonary and bronchial veins that intercommunicate between each other. Proximal bronchial veins drain into the azygos, hemiazygos and intercostal veins and pulmonary veins drain into the left atrium. Presumably connections between the pulmonary veins and the caval system via azygos veins are capable of expansion or proliferation in various congenital or acquired pathological conditions. Definitive diagnosis and functional parameters of this anomaly require invasive angiography, but because the girl is asymptomatic, postponement of this procedure could be justifiable. We suggest that increasing availability of cross-sectional techniques (CT, MR) with comprehensive three-dimensional visualization will be used more frequently as a first-line modality to clarify incidental findings. Therefore it is possible that this cardiovascular defect will appear to be not so infrequent.

Long-term central venous access usually is achieved by placing a catheter into the superior vena cava through the upper extremity orjugular veins [1 , 2]. Alternative percutaneous approaches to the central veins are required when the subclavian and brachiocephalic veins no longer are available due to thrombosis related to instrumentation and hypercoagulable states [1]. These alternative approaches include translumbar puncture of the infrarenal inferior vena cava (IVC), transhepatic cannulation of the hepatic veins or intrahepatic IVC, and femoral venous catheterization [1-3]. The use of intercostal veins as alternative conduits for placing central venous catheters previously has required a surgical procedure [4-7]. In this article,we describe the cannulation of an intercostal vein via the basilic vein for placement of a long-term central venous access catheten in a patient with occlusion of the subclavian veins, brachiocephalic veins, and proximal superior vena cava.

The superior intercostal veins define the pleural reflections of the caudad extent of the posterior junction line. They are paired structures which drain the first three intercostal spaces and join the azygous on the right and the accessory hemiazygous on the left. Because of their location posterior and lateral to the esophagus and trachea, their pleural reflections may be altered early in the course of a focal nodal disease of the posterior mediastinum.

A widened mediastinum was found on chest radiography following blunt chest trauma. Aortography alone could not adequately determine the etiology of the radiographic findings; on computed tomography (CT) benign mediastinal widening was confirmed owing to accessory hemiazygous continuation of a left inferior vena cava (IVC), with communication to the left brachiocephalic vein through an enlarged left superior (highest) intercostal vein. This unusual anatomic variant and its radiographic findings are reviewed, as well as the complementary role of CT in the evaluation of the traumatized thoracic aorta and mediastinum.

The right superior intercostal vein is visualised on CT examination as a circular opacity laterally at the right aspect of the vertebral body at the T4-T5 level. In venographic examination the RSIV appears to be formed by the confluence of the venous channels, the right second, third and fourth intercostal veins. In superior vena cava obstruction the RSIV is an important collateral pathway: the flow through the vein depends on the site of the obstruction, anterograde if the obstruction is superior or parallel to the level of the vena azygos, and retrograde if the obstruction is below the vena azygos.

Using a convex array transducer, the advantages and shortcomings of transesophageal real-time two-dimensional Doppler echography (TE2DD) were assessed in a study of the vessels around the esophagus and the stomach in 67 adult patients with (n = 56) or without (n = 11) liver cirrhosis. In most cases, all but the upper- and lowermost margins of the azygos vein could be visualized. The more caudally the portion located, the smaller its diameter and flow velocity became. The average number of intercostal veins visualized by TE2DD was 4 per person. The observable esophagogastric varices seemed to be limited to deeply located ones around the esophagogastric junction. In five patients who had undergone distal splenorenal shunt, splenic venous flow, or shunt flow could be seen from the stomach over a length of about 5 cm. The azygos venous flow in cirrhotic patients was significantly greater than that of patients without cirrhosis. TE2DD appears to be very useful for evaluating flow in the cephalad collateral veins and other vessels around the esophagus and the stomach.

Early and accurate diagnosis of disease—both of malignant and of non-malignant character—involving the bones and blood vessels of the skull, spine and pelvis is of the utmost importance. However, the angiographic visualisation of various pathological conditions within the spine is particularly difficult and on occasion impossible. This is primarily due to the peculiar anatomical and physiological nature of the meningo-rachnoidian venous system (MRVS) (Batson, 1940; Borak, 1942; Bachman and Sproul, 1955; Abrams, 1961). We have developed a new technique for the introduction of a radio-opaque medium intravenously directly into the MRVS through the intercostal veins (Setala, Tarkiainen and Nyyssonen, 1966; Tarkiainen, 1966). The purpose of this paper is to demonstrate the accuracy of the technique in the light of one case randomly selected from our files of about 250 examinations. All surgical and radiographic measures were performed by the authors.

In a dissection performed in our department, we observed multiple variations of the azygos venous system. The hemiazygos vein was absent. The posterior 8th, 9th, and 10th intercostal veins united and their common trunk crossed the vertebral column obliquely lying anterior to the aorta and posterior to the esophagus and opening into the azygos vein at the level of T7-T8 vertebrae. The 7th left posterior intercostal vein also crossed the column anteriorly and joined the common trunk. The present report identifies the variable positions and courses of the veins related to the azygos system. It is important to keep in mind that different courses of the azygos system do exist, so that extra caution is required during surgery of the mediastinum and also in appropriately interpreting the radiographs.

Background The azygos venous system consists of the azygos vein on the right side and the hemiazygos and accessory hemiazygos on the left side. The azygos vein runs through the abdominal cavity along the right side of the vertebral bodies, in a cranial direction, passes through the diaphragm and reaches the mediastinum, where it forms the arch of the azygos which flows into the superior vena cava. Along its course, the azygos vein communicates with the intercostal veins on the right, the hemiazygos vein that collects blood from the left lower intercostal veins, and accessory hemiazygos vein that drains into the left upper intercostal veins. The last two, at the level of the seventh thoracic vertebra, unite and end in the azygos vein. The accessory hemiazygos vein is normally included in the length between T4 and T8. The embryological origin of the accessory hemiazygos vein is the result of an expansion in the direction of the cranial hemiazygos vein, which comes from the left upper sovracardinale vein (Dudiak et al. in Semin Roentgenol 24(1):47–55, 1989; Radiographics 11(2):233–246, 1991; Webb et al. in Am J Roentgenol 139(1):157–161, 1982). Findings This case report describes a rare variant of azygos vein system identified in prenatal diagnosis and confirmed by postnatal ultrasonography. Conclusions The observation of the patient has excluded hemodynamic alterations associated with vascular anomaly.