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Anomalous Brachiocephalic Vein: CT, Embryology, and Clinical Implications

Shyh-Jye Chen1, Kao-Lang Liu1, Hsu-Yi Chen2, Ing-Sh Chiu3, Wen-Jeng Lee1, Mei-Hwan Wu4, Yiu-Wah Li1 and Hung-Chi Lue4

1 Department of Medical Imaging and General Examination, National Taiwan University Hospital, Taipei, Taiwan.
2 Department of Diagnostic Radiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, and Fu Jen Catholic University School of Medicine, Taipei, Taiwan.
3 Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
4 Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.



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  		Fig.1. —Patterns of anomalous brachiocephalic veins. Four major patterns (a, a + b, b, and c) are depicted, with similar patterns in each row. Pattern a describes anomalous brachiocephalic veins crossing midline above aortic arch and behind its major cephalic branch. Pattern b defines anomalous brachiocephalic vein crossing midline beneath aortic arch, above pulmonary artery, and in front of patent ductal arteriosus. Pattern a + b is a hybrid of patterns a and b, partially sharing characteristics of both. Pattern c is anomalous brachiocephalic vein crossing midline beneath aortic arch, above pulmonary artery, and behind patent ductal arteriosus. Patterns to left of central perpendicular line are those associated with left-sided aortic arch (first subscript L). Subscript R indicates right-sided aortic arch; these patterns are shown right of central perpendicular line. Second and third subscripts are abbreviations for other coexisting great-vessel anomalies. Asc = aberrant left subclavian artery, bsvc = bilateral superior vena cava, d = double aortic arch, i = behind innominate artery, lsvc = left superior vena cava, retro = retroesophageal segment of proximal descending thoracic aorta. Numbers in brackets indicate number of such cases in this study.

 


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  		Fig.2. —Sequential CT images of 5-year-3-month-old girl with unusual course of anomalous brachiocephalic vein (pattern a + b) (pound sign). Particular features include tetralogy of Fallot with atretic pulmonary trunk, hypoplastic right pulmonary artery, right-sided aortic arch, and aberrant left subclavian artery (arrowheads). Anomalous brachiocephalic vein is located on left, lateral and anterior to left common carotid artery (asterisk) at thoracic inlet. Before crossing beneath aortic arch, this vein passes in front of left common carotid artery. Entry of azygos arch (arrow) into superior vena cava (S) is lower than that of anomalous brachiocephalic vein. Several major aortopulmonary collateral arteries are evident around carina (C) and in subcarinal region. T = trachea, L = left pulmonary artery.

 


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  		Fig. 3A. —Pattern c: Anomalous brachiocephalic vein in 1-year-5-month-old boy with tetralogy of Fallot and right aortic arch. Ao = aorta, S = superior vena cava. Sequential CT images reveal anomalous brachiocephalic vein (pound sign) located behind pulmonary stump of patent ductus arteriosus (asterisk) as it crosses midline, passing below aortic arch with drainage into superior vena cava at level slightly lower than entry of azygos arch (arrows). T = trachea, L = left pulmonary artery, R = right pulmonary artery.

 


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  		Fig.3B. —Pattern c: Anomalous brachiocephalic vein in 1-year-5-month-old boy with tetralogy of Fallot and right aortic arch. Ao = aorta, S = superior vena cava. Surgical finding shows anomalous brachiocephalic vein (pound sign) behind aorta. I = innominate artery.

 


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  		Fig.4. —Proposed embryogenesis of four passages draining venous blood from left upper body to heart.

A, Four-millimeter embryo: Left anterior and posterior cardinal veins join to form left common cardinal vein (black), entering left sinus horn and then primitive sinus venosus, eventually becoming coronary sinus.

B, Ten-millimeter embryo: Development of intersubcardinal anastomosis is illustrated. Analogously, we postulate formation of intersupracardinal anastomosis (gray) around this period. This anastomosis should have vertical connections oriented along cephalocaudal axis and different ventral-dorsal planes. Large defect in illustrated intersupracardinal anastomosis leaves space for development of primitive aortopulmonary system (not shown).

C, Seventeen-millimeter embryos: These diagrams show regression of different parts of previous intersupracardinal anastomosis as result of failure to successfully compete for available space taken by growth of truncoaortic sac and primitive aortic arch system (not shown).

D, Twenty-four-millimeter embryos: Primitive models of major venous channels between bilateral cardinal veins are illustrated. Vessel shown in D1 will become left brachiocephalic vein. Figure reveals nearly total regression of middle and distal portions of left common cardinal vein to become fibrous ligament. Vessel in D2 will become anomalous brachiocephalic vein. Greater preservation of distal portion of left common cardinal vein is constituted as forming proximal part of this vessel. Middle portion of left common cardinal vein is totally obliterated and becomes a fibrous ligament. This ligament is shorter in D2 than in D1. Total preservation of left common cardinal vein results in a persistent left superior vena cava with either presence (D3) or absence (D4) of normal left brachiocephalic vein.

 

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