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Aortosternal Venous Compression in Patients with Aberrant Right Subclavian Arteries

¹ All authors: Department of Radiology, The University of Texas Medical Branch, Children's Hospital, 301 University Blvd., Galveston, TX 77555.

Received June 18, 2004; accepted after revision August 13, 2004.

 
Address correspondence to J. A. Hernandez (jahernan{at}utmb.edu).

Introduction

Top Introduction Case Reports Discussion References

 
The term "innominate vein compression syndrome" was coined by Wurtz et al. in 1989 [1]. We report two cases of left innominate vein compression associated with an aberrant right subclavian artery, the most common aortic arch anomaly after the bovine arch (anomalous origin of the left common carotid artery from the innominate artery). Neither of the two patients had a history of trauma, surgery, or intervention that may have altered the anatomic relationship between the aortic arch and great vessels with the innominate vein.

Case Reports

Top Introduction Case Reports Discussion References

 
The first patient was a 57-year-old woman who presented with a 3-month history of pain and edema in the left supraclavicular region and upper extremity. The edema was intermittent. The pain originated in the left shoulder and radiated down to the lateral aspect of the arm. Medical history was significant for an episode of neck pain and dizziness 5 years previously, for which she underwent CT of the head and neck, which suggested an aberrant right subclavian artery. On physical examination, mild edema in the left shoulder and arm region was noted. Tenderness over the lateral aspect of the left shoulder was also noted. The neurologic examination and brachial and radial pulses were normal. The patient had a left upper extremity venous Doppler study that was suspicious for left subclavian deep vein thrombosis. Left upper extremity venography and chest CT (Fig. 1A, 1B, 1C, 1D) showed extrinsic compression of the left innominate vein between the sternum and left common carotid and innominate arteries. The compression was evident at expiration and relieved during inspiration.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —57-year-old woman with pain and edema in left supraclavicular region and upper extremity. Digital substraction venogram obtained on expiration shows compression of left innominate vein by origins of branches of aortic arch. Notice fingerlike external compression (arrows) of left innominate vein by proximal left common carotid artery and left subclavian artery.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —57-year-old woman with pain and edema in left supraclavicular region and upper extremity. Aortic arch angiogram. Aberrant right subclavian artery (arrow) arises distal to origin of left subclavian artery.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —57-year-old woman with pain and edema in left supraclavicular region and upper extremity. Three-dimensional CT venogram shows meniscus impression (arrows) at left innominate vein near junction with superior vena cava caused by extrinsic compression by proximal left common carotid artery and left subclavian artery.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —57-year-old woman with pain and edema in left supraclavicular region and upper extremity. Three-dimensional CT angio/venography shows impingement (arrows) of proximal left brachiocephalic vein by origins of left common carotid and left subclavian arteries as they originate from aortic arch.

The second patient was a 77-year-old woman who also presented with intermittent left arm swelling. Left upper extremity venography and chest CT (Fig. 2A, 2B, 2C, 2D) showed compression of the left innominate vein by the sternum and abnormal rotation of the aortic arch that shifted clockwise when an aberrant right subclavian artery pinned the descending aorta closer to the spine medially. A left central venogram performed during the peak of inspiration and expiration showed no acute thrombosis but a relative narrowing of the left innominate vein caused by its compression against the anterior sternum by the great arteries posteriorly during peak expiration (Fig. 2A). No significant collateral flow was present and the superior vena cava was normal.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —77-year-old woman with intermittent left arm swelling. Digital substraction venogram obtained on expiration shows compression of left innominate vein (arrow) by origins of branches of aortic arch.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —77-year-old woman with intermittent left arm swelling. Digital substraction venography of left innominate vein obtained on inspiration shows patent and unremarkable left innominate vein (arrow).

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —77-year-old woman with intermittent left arm swelling. CT scans of upper mediastinum obtained during expiration (C) and inspiration (D) shows origin of aberrant right subclavian artery from aortic arch. It crosses mediastinum posterior to trachea and esophagus and suggests compression of left innominate vein by sternum and abnormally anteriorly rotated aortic arch branches.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D. —77-year-old woman with intermittent left arm swelling. CT scans of upper mediastinum obtained during expiration (C) and inspiration (D) shows origin of aberrant right subclavian artery from aortic arch. It crosses mediastinum posterior to trachea and esophagus and suggests compression of left innominate vein by sternum and abnormally anteriorly rotated aortic arch branches.

Discussion

Top Introduction Case Reports Discussion References

 
Symptomatic compression of the innominate veins is rare. The first report was from Wurtz et al. [1] in 1989 in the surgical literature. In 1995, Moes et al. published a case of left innominate vein compression by a leftward origin of the brachiocephalic artery in conjunction with an aberrant right subclavian artery anomaly, resulting in compression of the innominate vein in a localized fashion [2]. The two cases we report on further document this unique group of patients. The aberrant right subclavian artery arises distal to the origin of the left subclavian artery in the descending thoracic aorta, traverses the mediastinum posterior to the esophagus and trachea, and follows the course of a normal subclavian artery into the right upper extremity.

Venous return from the upper extremities can be affected by the position of the arm during contrast media injection, the Valsalva maneuver, mediastinal masses, severe congestive heart failure, and vascular anomalies [3]. Extrinsic compression of the innominate vein is sometimes seen in patients with hemodialysis access fistulas in the left upper extremity and may be hemodynamically significant in this group [4]. The cause is thought to be extrinsic compression on the vein from an ectatic and tortuous left subclavian artery, forming as a response to high flow through a dialysis arteriovenous fistula. Self-expanding stents have been successfully used to treat these symptomatic stenoses, which threaten dialysis access.

An aberrant right subclavian artery is most often asymptomatic but can occasionally cause dysphagia lusoria because of significant esophageal narrowing as the subclavian artery courses behind the esophagus. Fusiform (Kommerell) aneurysms at the origin of the aberrant right subclavian artery likely aggravate pressure symptoms associated with this anomaly [5]. Our two patients presented with mild symptoms and were evaluated for intrinsic narrowing of the central venous system. Both had venographic findings of normal blood flow in the innominate vein at the end of inspiration and extrinsic compression during expiration. Although neither had frank aneurysms of the aberrant subclavian artery origin, both arteries were ectatic at their origins, a common finding in this arch anatomic variant. Large diameter aberrant right subclavian arteries, particularly in patients with a diminished anteroposterior chest diameter, possibly predispose to at least intermittent left innominate vein compression, which may progress to symptoms of left arm swelling that are worse in the morning and sometimes associated with morning headaches [6–9]. It is thought that shallow breathing during sleep and recumbent positioning aggravates the venous compression in these patients. As these stenoses are not fixed and are caused by extrinsic pressure, balloon expandable stents should be avoided since they can be crushed and can migrate. Self-expanding stents are an option but are probably best avoided in the non-dialysis patient, since metal stents in the subclavian vein have limited patency and these patients are relatively young and healthy. We tried conservative methods, such as arm elevation at night and avoidance of the left lateral decubitus position. Neither of our patients returned with upper extremity venous thrombosis during a mean follow-up of over 1 year.

It is important to be aware of left innominate vein compression by aortic arch arteries in patients with an aberrant right subclavian artery. Findings on MRI, CT, or sonography of slow flow or venous collateralization in the left subclavian venous system in patients with an aberrant right subclavian artery should prompt investigation into innominate vein syndrome or aortosternal venous compression. Venographic findings are characteristic tubular (vascular) compressions on the left innominate vein seen only on expiration.

References

Top Introduction Case Reports Discussion References

 

1. Wurtz A, Quandalle P, Lemaitre L, Robert Y. Innominate vein compression syndrome. Br J Surg1989; 76:575 –576[Medline]
2. Moes CA, MacDonald C, Mawson JB. Left innominate vein compression by a brachiocephalic artery anomaly. Pediatr Cardiol1995; 16:291 –293[Medline]
3. Lee Y, Chung T, Joo J, Chien D, Laub G. Suboptimal contrast-enhanced carotid MR angiography from the left brachiocephalic venous stasis. J Magn Reson Imaging1999; 10:503 –509[Medline]
4. Itkin M, Kraus MJ, Trerotola SO. Extrinsic compression of the left innominate vein in hemodialysis patients. J Vasc Interv Radiol 2004;15:51 –56
5. Fujimoto K, Abe T, Kumabe T, Hayabuchi N, Nozaki Y. Anomalous left brachiocephalic (innominate) vein: MR demonstration. AJR 1992;159:479 –480[Free Full Text]
6. el-Shahawy MA, Gadallah MF, Teitelbaum GP, Kaptein E, Akmal M. Compression of the left brachiocephalic vein by the innominate artery resulting in massive arm edema in a hemodialysis patient. Am J Nephrol 1992;12:108 –110[Medline]
7. Tanaka T, Uemura K, Takahashi M, et al. Compression of the left brachiocephalic vein: cause of high signal intensity of the left sigmoid sinus and internal jugular vein on MR images. Radiology1993; 188:355 –361[Abstract/Free Full Text]
8. Forman JW, Unger KM. Unilateral superior vena caval syndrome. Thorax 1980;35:314 –315[Free Full Text]
9. Campbell CB, James GC, Tegtmeyer CJ, Berstein EF. Axillary, subclavian, and brachiocephalic vein obstruction. Surgery 1977;82:816 –826[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hernandez, J. A. Articles by Swischuk, L. E. Search for Related Content PubMed PubMed Citation Articles by Hernandez, J. A. Articles by Swischuk, L. E. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?