AJR 2000; 175:869-870
© American Roentgen Ray Society
Case 2
Vertical Vein (Partial Anomalous Pulmonary Venous Drainage)
Rosemary J. Klecker,
A. J. Christoforidis and
Daniel S. Sinclair
A central venous catheter is seen in the expected location of the left
internal jugular vein with the tip extending into the middle of the left lung
(Fig. 2A). The subsequent
lateral image obtained under fluoroscopy better localizes the catheter tip
within the left upper lobe (Fig.
2B). Contrast material injection into the catheter shows it to be
within a vessel that ascends superiorly and drains into the left innominate
vein and subsequently into the superior vena cava. It shows no direct
connection to the heart (Fig.
2C).
View larger version (195K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —50-year-old woman after intraoperative placement of central venous
line. Contrast material injection through left-sided central venous catheter
shows opacification of left upper lobe vessel (vertical vein) that drains left
upper lobe (solid arrowhead) into left innominate vein (open
arrowhead).
|
|
The vertical vein is a variety of partial anomalous pulmonary venous
drainage (APVD). Partial APVD is more common than total APVD and may occur in
either lung [1]. The anomalous
pulmonary vein may connect with a variety of structures, including the
superior vena cava, right atrium, vertical vein, inferior vena cava, azygous
vein, or pericardial veins.
The most common variety of partial APVD is drainage of the right upper
pulmonary vein into the superior vena cava. Although this type is usually
clinically inconsequential, it may be associated with an atrial septal defect
(sinus venosus) [2]. Probably
the next most common variety is drainage of the right pulmonary vein into the
right atrium or inferior vena cava. When this type is accompanied by a
dysplastic right lung, hypoplastic right pulmonary artery, or other
developmental anomalies of the right lung, it has been called congenital
venolobar syndrome or scimitar syndrome
[2]. On conventional
radiographs, the anomalous pulmonary vein may appear as a curved density
simulating a scimitar.
In this patient, a more unusual variety of partial APVD is seen with the
anomalous pulmonary vein (vertical vein) ascending into the left innominate
vein. The position of the catheter and the history of oxygenated blood with
pulmonary venous pressure confirms the diagnosis of vertical vein. A left
superior vena cava would not have an arterial oxygen partial pressure and
should drain into the coronary sinus. A left superior intercostal vein and
left internal mammary vein would not have arterial oxygen partial pressure.
The remaining choice of left internal mammary artery would not have pulmonary
venous pressures. Partial APVD physiologically creates a left-to-right shunt.
Symptoms usually do not occur unless 50% or more of the pulmonary flow is
shifted from left to right
[1].
The vertical vein may be recognized on conventional radiographs. Partial
APVD may also manifest itself radiographically as enlargement of the right
atrium and ventricle as a result of the left-to-right shunt. CT and MR imaging
may directly depict the abnormal pulmonary vein. Alternatively, it may be
discovered by an abnormal catheter position, as in this patient.
References
-
Budorick NE, McDonald V, Flisak ME, Moncada R. The pulmonary veins.
Semin Roentgenol 1989;24
: 127-140[Medline]
-
White CS, Baffa JM, Haney PJ, Pace ME, Campbell AB. MR imaging of
congenital anomalies of the thoracic veins.
RadioGraphics
1997;17:595
-608[Abstract]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
