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Some patients with intestinal failure, who are dependent on total parenteral nutrition for long periods, suffer from a lack of suitable conventional venous access points, including axillary, external jugular, internal jugular, subclavian, saphenous, and the brachio-cephalic and femoral veins, due to their occlusion. Furthermore, extensive central venous stenosis and/or thrombosis of the superior and inferior vena cava may preclude further catheterization, so uncommon routes must be used, which can be challenging. In such patients, the azygos vein via the intercostal vein is a viable candidate. Thoracotomy-assisted, thoracoscopy-assisted, and cut-down procedures are currently suggested such access. We found that ultrasound-guided percutaneous puncture method was a safe and minimally invasive approach and successfully placed two central venous lines in preparation for small bowel transplantation via two different intercostal veins (ninth and tenth). Although the lung was actually located just below the target veins, an ultrasound provided augmented and clear vision, which contributed to the safe performance of the procedure without the need for invasive surgical intervention, such as thoracotomy, thoracoscopy, or rib resection using the cut-down technique. Furthermore, constant positive-pressure ventilation during vein puncture under general anesthesia also helps avoid venous collapse. Despite carrying a slight risk of light injury to the lung, artery, and nerve along with the vein compared to other procedures, we believe that ultrasound-guided puncture under general anesthesia is feasible as a minimally invasive method.

Azygos system of veins is the main source of venous drainage from the thoracic wall. Knowledge of azygos vein anomalies could be of importance to cardiothoracic surgeons and radiologists. We report a rare variation of azygos vein as seen in an adult male cadaver aged 65 years approximately. The azygos vein was formed by the union of left ascending lumbar and subcostal veins. It coursed upwards on the left side of descending thoracic aorta and crossed the left subclavian artery and the left vagus to terminate into the left brachiocephalic vein. It received left superior intercostal vein and left fifth to eleventh posterior intercostal veins. The hemiazygos and accessory hemiazygos veins were situated on the right side of the vertebral column. They received the right posterior intercostal veins and terminated into the azygos vein at the level of eighth thoracic vertebra.

Background: Sympathetic chain interruption is the gold standard treatment for essential hyperhidrosis. Postoperative compensatory hyperhidrosis, the main reason for patients' dissatisfaction, is reduced by selectively lesioning white and grey rami communicantes (ramicotomy).Objective: To develop an endoscopic surgical technique that interrupts only T3 and T4 grey rami communicantes to minimize compensatory hyperhidrosis.Material and Methods: T3 and T4 grey rami communicantes ramicotomy in fifteen cold-preserved cadavers through a uniportal axillary endoscopic approach. The sympathetic chain, its ganglia, and white rami communicantes were left intact. On opening the chest, the sympathetic chain, rami communicantes and ganglia were dissected, photographed, measured and excised for histological examination.Results: Dissecting the grey rami communicantes is feasible as they consistently lie between the intercostal nerve and the homonymous sympathetic ganglion. At some levels, Kuntz nerves, as well as more than one grey ramus communicans, can be found. White rami communicantes are more medial, therefore damaging them can be avoided. Intercostal veins can be obstructive, but these can be controlled via coagulation or clipping if necessary.Conclusion: Uniportal endoscopic selective excision of the T3 and T4 grey rami communicantes is feasible without damaging the white rami communicantes, the sympathetic chain or its ganglia. Clipping the grey rami communicantes is technically possible but not reliable due to their thin diameter. This study confirms that T3 and T4 grey rami sympathetic block is technically feasible. Its application might reduce compensatory hyperhidrosis, but clinical studies are needed.

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.

Background/Purpose Some children dependent on total parenteral nutrition for long periods have no more axillary, internal jugular, external jugular, saphenous, and femoral veins available for cannulation. In such patients, the central venous system can still be accessed via the azygos vein by placing an implantable port catheter through one of the right posterior intercostal veins. This is the first known description of such procedure. Methods We report the use of the second and third right intercostal veins for placement of the catheter by right intrapleural thoracotomy in 2 pediatric patients with short gut syndrome. Results Recovery from the thoracotomy was uncomplicated, and the patients could receive complete intravenous nutritive mixtures immediately after the insertion of the catheter. Both patients remain dependent on total parenteral nutrition and are awaiting an intestinal transplantation. Conclusion The knowledge of alternate routes to obtain central venous access for prolonged parenteral nutrition is critically important, and the azygos system can be used when more accessible veins are unavailable.

Background: This study compared porcine and human thoracic spine anatomies for a better understanding of how structures encountered during thoracoscopy differ between training with a porcine model and actual surgery in humans. Methods: Parameters were measured including vertebral body height, width, and depth; disc height; rib spacing; spinal canal depth and width; and pedicle height and width. Results: Although most porcine vertebral structures were smaller, porcine pedicle height was significantly greater than that of humans because the porcine pedicle houses a unique transverse foramen. The longus colli and psoas attach, respectively, to T5 and T13 in swine and to T3 and T12 in humans. In swine, the azygos vein generally was absent. The intercostal veins drained into the hemiazygos vein. Conclusions: Several thoracoscopically relevant anatomic differences between human and porcine spinal anatomies were identified. A thoracoscopic approach in a porcine model probably is best performed from the right side. The best general working area is between T6 and T10.

The arteries and veins of the left vagus (VN) and left recurrent laryngeal (RLN) nerves from the thoracic inlet to the subaortic region are described following vascular casting with red colored latex in 6 adult fresh non-embalmed cadavers. In all specimens the anterior bronchoesophageal artery supplied at least one vessel to the VN and RLN in the subaortic region. For the RLN other arterial sources were arteries arising from the aortic arch in 1 specimen, the subclavian artery in 3 specimens, the first intercostal artery in 1 specimen, and the inferior thyroid artery in all specimens. For the VN other arterial sources were arteries arising from the aortic arch in 2 specimens and the inferior thyroid artery in 1 specimen. For both the VN and RLN the veins were located under the pleura and directed towards the internal thoracic vein anteriorly and the thoracic intercostal veins posteriorly. In conclusion, the inferior thyroid artery at the thoracic inlet for the RLN and the anterior bronchoesophageal artery are the more consistent vessels supplying the VN and RLN. Vascular damage occurring during mediastinal lymph node excision to the VN and RLN, especially in the subaortic region, may explain postoperative vocal fold paralysis.

Toracoscopia é o método de visibilização da cavidade torácica através de endoscópio rígido ou flexível, indicado como exame auxiliar para diagnóstico das diversas afecções do tórax. Pode ser realizada com o animal sob anestesia geral ou em posição quadrupedal através de anestesia local associada ou não a sedativos. Neste trabalho, foram utilizados seis eqüinos hígidos, que foram submetidos a toracoscopia, em posição quadrupedal, nos dois hemitórax, com intervalo de 15 dias entre cada procedimento. Durante o exame, pôde-se observar as diversas estruturas da cavidade torácica, tais como: músculo diafragma (porção muscular e tendínea), hiato esofágico, mediastino, aorta, troncos dorsal e ventral do nervo vago, ducto torácico, veia ázigos, veias intercostais, músculos intercostais, costelas, tronco nervoso simpático, tronco vascular toracocervical, traquéia, pulmão (lobo cranial e caudal), esôfago, pericárdio, veia cava caudal, nervo frênico e linfonodos aórticos. Discretas alterações foram observadas ao exame físico, laboratorial e ultra-sonográfico no período pós-operatório, sem que trouxessem prejuízos ao desenvolvimento do experimento e recuperação do animal. A toracoscopia mostrou ser exame de auxílio importante, pela facilidade, rapidez de execução, ampla visibilização da cavidade pleural e trauma mínimo ao paciente. Thoracoscopy is the technique based upon the thoracic cavity visualization by means of rigid or flexible endoscope. It is indicated as an additional diagnostic aid to better define thoracic diseases. It can be performed either in an animal subjected to general anesthesia or in a horse standing on stocks with local anesthesia with or without sedative. Six healthy horses were used in this study they were subjected to thoracoscopy in both hemithorax, standing on stocks, with a 15-day interval between each procedure. It was possible to visualize several thoracic structures through the 13th intercostal space aproach, such as: diaphargma (muscular and tendineous portions), esophageus hiatus, mediastinum, aorta, vagus nerve dorsal and ventral trunk, thoracic ductus, azigus vein, intercostal veins and muscles, ribs, sympathetic nervous trunk, thoracocervical vascular trunk, trachea, lungs (cranial and caudal lobes), esophagus, pericardium, caudal cava vein, phrenicus nerve and aortic linphonodes. Slight alterations were observed in physical, laboratorial and ultra-sonographic exams during pos operative period those alterations did not compromise either this experiment development or the animals well being. By being an easy and fast procedure wich allows pleural cavity broad visualization and pacient minimal trauma, thoracoscopy makes itself a great diagnostic aid exam.

Spontaneous hemothorax in the left pleural space occurred suddenly in a patient with thrombotic thrombocytopenic purpura (TTP). In spite of massive blood transfusion, the hemorrhage could not be stopped. The patient suffered shock due to tension hemothorax and hypovolemia, resulting in cardiac arrest. After successful cardiopulmonary resuscitation, surgical hemostasis was performed. The main cause of the bleeding was rupture of the left intercostal vein. TTP is a severe microvascular occlusive thrombotic microangiopathy that can induce congestion, vasculitis, and ischemia. This mechanism is thought to have been involved in the rupture of the intercostal vein in the present patient.

We report the case of a neonate born at 384/7 weeks of gestation with median birth weight and size and in the 75th percentile for head circumference. Routine pregnancy follow up allowed the antenatal discovery of azygos continuation with absence of the inferior vena cava.

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.

Some children requiring chemotherapy, total parenteral nutrition, or repeated blood sampling for long periods have no more axillary, internal jugular, external jugular, saphenous, or femoral veins available for cannulation. In such patients, the central venous system can still be accessed via alternate routes e.g. the azygos vein, the gonadal vein or the inferior epigastric vein.We report the use of: 1) The inferior epigastric vein for placement of the catheter into the IVC in 20 patients. 2) The right gonadal vein for placement of the catheter using a retroperitoneal approach in five pediatric patients. 3) The second and third right intercostal veins for placement of the catheter by right intrapleural thoracotomy in five pediatric patients. Pre-procedural assessment of the patency of these veins was done using colour Doppler ultrasonography and confirmation of occlusion of common sites used for central venous access.A total of 38 implantable venous access devices (IVAD) were inserted in 30 patients. The average age at operation was 1.4 years (range 1 month to 12 years). Infection was seen in two patients, venous thrombosis in two. The average longevity of IVAD is 6.5 months. Recovery from the procedure was uncomplicated and the patients were able to receive complete intravenous medication or nutritive mixtures after the insertion of the catheter.The knowledge of alternate routes to obtain central venous access for children requiring chemotherapy, total parenteral nutrition, or repeated blood sampling for long periods is critically important, and the azygos system, right gonadal vein or the inferior epigastric vein can be used when standard accessible veins are unavailable.

Spontaneous massive haemothorax is rare. We describe a healthy 44 year old woman who experience sudden onset chest pain while sleeping. Chest radiograph revealed massive right pleural effusion. Progressive dyspnoea, cold sweating, and tachycardia developed later. A tube thoracostomy was performed immediately and massive haemothorax was noted. An emergency thoracotomy was performed because of unstable vital signs. Disruption of the right third intercostal vein with continuous bleeding was observed, and suture ligation of the vein was performed. The total blood loss was about 4000 ml. The patient recovered uneventfully, and her condition at follow up visits to the outpatient department was satisfactory.

Central venous lines are of particular importance in seriously ill children that require parenteral nutrition, chemotherapy, or other medications. The jugular or subclavian veins are ordinarily used for primary access. Alternatives include the femoral veins, the intercostal veins, and transhepatic approaches. If the use of these standard sites of placement is made impossible, due, for example, to chronic thrombosis, an alternative approach has to be found. The following report presents the case of an 11-year-old girl with short-bowel syndrome and a desperate need for parenteral nutrition. Over the course of her treatment, she developed chronic thrombosis of the jugular, subclavian, and femoral veins, as well as thrombosis of the inferior vena cava. As an alternative route for central venous access, we describe a successful direct placement of a tunnelled catheter into the right atrium via a right anterolateral thoracotomy.

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.

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.

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.

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.

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.

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.

During the course of parenteral nutrition in infants, access to the central venous system may become limited due to thrombotic occlusion of the superior and inferior caval venous systems. When this problem arises, central venous access via the intercostal vein into the azygos system can provide a safe, relatively easy solution. A new technique utilizing this approach has been developed at our institution using silicone elastomer tubing joined with a Broviac catheter for long-term use. Thus far, six catheters have successfully been inserted with a mean duration of 52 days; one catheter was in place for as long as 110 days.