DOI:10.2214/AJR.07.3552
AJR 2008; 191:897-907
© American Roentgen Ray Society
Imaging of the Brachiocephalic Vein
Sheung-Fat Ko1,
Chung-Cheng Huang1,
Shu-Hang Ng1,
Ming-Jeng Hsieh2,
Chi-Chia Lee1,
Yung-Liang Wan1 and
Chi-Di Liang3
1 Department of Radiology, Division of General Radiology, Chang Gung Memorial
Hospital–Kaohsiung Medical Center, Chang Gung University, College of
Medicine, 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung, 833, Taiwan.
2 Department of Cardiovascular and Thoracic Surgery, College of Medicine, Chang
Gung University, Chang Gung Memorial Hospital–Kaohsiung Medical Center,
Kaohsiung, Taiwan.
3 Department of Pediatric Cardiology, College of Medicine, Chang Gung
University, Chang Gung Memorial Hospital–Kaohsiung Medical Center,
Kaohsiung, Taiwan.
Received December 16, 2007;
accepted after revision March 5, 2008.
Address correspondence to S. F. Ko
(sfatko{at}adm.cgmh.org.tw).
Presented at the 2008 annual meeting of the American Roentgen Ray Society,
Washington, DC.
Abstract
OBJECTIVE. The purpose of this study was to review the imaging
features of congenital variants of and pathologic conditions affecting the
brachiocephalic vein.
CONCLUSION. CT and MRI are excellent for visualizing developmental
anomalies and mediastinal tumors that involve the brachiocephalic vein.
Although they affect this vein less commonly than do developmental anomalies
and tumors, trauma, aneurysm formation, stenosis related to dialysis or other
conditions, and various complications related to central venous catheters do
occur, and familiarity with the imaging findings is helpful for diagnosis.
Keywords: brachiocephalic vein • chest radiography • CT • interventional radiology • MRI
Introduction
The brachiocephalic vein is form ed by the junction of the sub clavian and
jugular veins in the superior mediastinum. It receives venous return from the
head and neck and both upper extremities. The right brachiocephalic vein is
shorter and vertically oriented, and the left brachiocephalic vein is longer
and horizontally or transversely oriented. Although the anatomic configuration
of the brachiocephalic vein seems simple, this article highlights the
appearance of congenital variants and reviews the radiographic, CT, MRI, and
venographic features of the perplexing pathologic conditions affecting this
vessel.
Congenital Anomalies
Anomalous brachiocephalic vein is uncommon, accounting for approximately
0.2–1% of congenital cardiovascular anomalies
[1,
2]. Normal development of the
brachiocephalic vein encompasses persistence of the right common cardinal vein
and precardinal anastomosis and regression of the middle and lower portions of
the left common cardinal vein (Fig.
1A,
1B,
1C,
1D). The cause of an anomalous
brachiocephalic vein remains controversial. Abnormal regression of the
precardinal anastomosis or development of the precardinal anastomosis in any
pathway where there is the available space have been proposed
[1,
2]. Chen et al.
[2] proposed the presence of
double transverse precardinal anastomoses to explain three patterns of
anomalous brachiocephalic vein development: anomalous subaortic left
brachiocephalic vein (Fig. 2A,
2B), persistent left superior
vena cava (SVC) with a hypoplastic left brachiocephalic vein connecting to the
right SVC (Fig. 3), and double
SVC with agenesis of the left brachiocephalic vein (Fig.
4A,
4B). Recognition of these
anomalies of the brachiocephalic vein is important for avoiding
misinterpretation of the anomaly as an enlarged lymph node and for insertion
of a central venous catheter (Fig.
5), cardiovascular intervention, and surgical plan ning,
especially in establishment of a systemic-to-pulmonary venous anastomosis.
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Fig. 1A —Sketches show four stages of embryologic development of
brachiocephalic and internal jugular veins and superior vena cava (SVC).
Starting with 4-mm embryo, bilateral precardinal (PCV) and postcardinal (PoCV)
veins join to form common cardinal veins (CCV).
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Fig. 1B —Sketches show four stages of embryologic development of
brachiocephalic and internal jugular veins and superior vena cava (SVC). In
10-mm embryo, precardinal anastomosis (PCA) has developed between bilateral
PCV.
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Fig. 1C —Sketches show four stages of embryologic development of
brachiocephalic and internal jugular veins and superior vena cava (SVC). In
17-mm embryo, normal left brachiocephalic vein (LBCV) has developed from
persistence of right CCV and PCA and regression of middle and lower portions
of left CCV. Internal jugular veins (IJV) have developed from upper parts of
PCV. Subclavian veins (SV) have developed as tributaries of CCV.
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Fig. 1D —Sketches show four stages of embryologic development of
brachiocephalic and internal jugular veins and superior vena cava (SVC). In
24-mm embryo, SVC has developed from right CCV joining heart and hepatocardiac
vein, which eventually develop as hepatic segment of inferior vena cava. BCVs
= brachiocephalic veins.
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Fig. 2A — 74-year-old man with asymptomatic anomalous subaortic left
brachiocephalic vein. Subvolume oblique axial reconstruction (A) and
curved planar reconstruction (B) chest CT scans show anomalous
subaortic course of left brachiocephalic vein (arrows) joining lower
third of superior vena cava, which is formed when there is abnormal regression
of superior precardinal anastomosis and preservation of distal part of left
common cardinal vein and lower precardinal anastomosis.
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Fig. 2B — 74-year-old man with asymptomatic anomalous subaortic left
brachiocephalic vein. Subvolume oblique axial reconstruction (A) and
curved planar reconstruction (B) chest CT scans show anomalous
subaortic course of left brachiocephalic vein (arrows) joining lower
third of superior vena cava, which is formed when there is abnormal regression
of superior precardinal anastomosis and preservation of distal part of left
common cardinal vein and lower precardinal anastomosis.
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Fig. 3 —23-year-old man with situs ambiguus, transposition of great
arteries, common atrium and single ventricle, pulmonary atresia and right
patent ductus arteriosus, and functional left Blalock-Taussig shunt, double
superior vena cava, and hypoplastic left brachiocephalic vein. Coronal
reconstruction chest CT scan shows double superior vena cava (open
arrows) and hypoplastic left brachiocephalic vein (solid
arrows), which is formed by regression of lower precardinal anastomosis
with total preservation of left common cardinal vein and superior precardinal
anastomosis.
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Fig. 4A —11-year-old boy with coarctation of aorta, bicuspid aortic
valve, double superior vena cava, and agenesis of left brachiocephalic vein.
Axial T1-weighted (A) and collapsed gadolinium-enhanced (B) MR
angiograms show presence of double superior vena cava (arrows) and
agenesis of left brachiocephalic vein, which is formed by preservation of left
common cardinal vein with obliteration of whole precardinal anastomosis.
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Fig. 4B —11-year-old boy with coarctation of aorta, bicuspid aortic
valve, double superior vena cava, and agenesis of left brachiocephalic vein.
Axial T1-weighted (A) and collapsed gadolinium-enhanced (B) MR
angiograms show presence of double superior vena cava (arrows) and
agenesis of left brachiocephalic vein, which is formed by preservation of left
common cardinal vein with obliteration of whole precardinal anastomosis.
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Fig. 5 —66-year-old woman with colon cancer and insertion of totally
implantable venous device. Supine chest radiograph shows venous device
catheter (arrows) placed along left side of mediastinum indicating
insertion to left superior vena cava with distal part through coronary sinus
to right atrium.
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Effect of Tumors
Obstruction of the brachiocephalic vein is most frequently caused by
primary mediastinal tumors, including lymphoma, thymoma, and seminoma, and by
metastatic disease, especially breast cancer
[3]. Mediastinal tumors with
invasion of and intravascular extension into the brachiocephalic vein can be
directly visualized with CT and MRI (Fig.
6A,
6B). The brachiocephalic vein
can also act as a pathway for tumor spread with an intraluminal tumor thrombus
extending far beyond the primary tumor site
(Fig. 7). Although
bronchogenic carcinoma usually affects the SVC
[3], in rare instances, an
anomalous subaortic left brachiocephalic vein also is affected, mimicking an
enlarged lymph node (Fig. 8A,
8B).
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Fig. 6A —17-year-old boy with chest tightness due to anterior
mediastinal seminoma. Axial (A) and coronal (B) enhanced
T1-weighted MR images show inhomogeneously enhanced anterior mediastinal tumor
(solid arrows) with invasion of left brachiocephalic vein and
intraluminal spread of tumor to superior vena cava (open arrows).
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Fig. 6B —17-year-old boy with chest tightness due to anterior
mediastinal seminoma. Axial (A) and coronal (B) enhanced
T1-weighted MR images show inhomogeneously enhanced anterior mediastinal tumor
(solid arrows) with invasion of left brachiocephalic vein and
intraluminal spread of tumor to superior vena cava (open arrows).
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Fig. 7 —58-year-old man with rapidly growing right axillary
rhabdomyosarcoma. Coronal T1-weighted MR image shows large right axillary mass
and central tumor extension (arrows) through right subclavian vein
and brachiocephalic vein to superior vena cava.
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Fig. 8A —50-year-old man with right upper lobe squamous cell
carcinoma. Axial (A) and coronal (B) CT scans show right upper
lobe lung tumor (open arrows) with obstructive atelectasis and
invasion of adjacent mediastinum with encasement of superior vena cava.
Anomalous subaortic left brachiocephalic vein (solid arrow) mimics
enlarged lymph node in A.
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Fig. 8B —50-year-old man with right upper lobe squamous cell
carcinoma. Axial (A) and coronal (B) CT scans show right upper
lobe lung tumor (open arrows) with obstructive atelectasis and
invasion of adjacent mediastinum with encasement of superior vena cava.
Anomalous subaortic left brachiocephalic vein (solid arrow) mimics
enlarged lymph node in A.
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Trauma
Blunt chest trauma can injure intrathoracic vessels, usually affecting the
aorta and arch vessels, with resultant mediastinal hematoma, which is best
evaluated with CT [4]. However,
nonaortic sources, such as the mediastinal small veins and fractures of the
sternum, ribs, and spine, are possible
[4,
5]. In rare instances,
traumatic impingement on the sharp angulation of the left brachiocephalic vein
in the left parasternal region leads to vascular insult and a perivenous
hematoma extending along the course of the left brachiocephalic vein
[5] (Fig.
9A,
9B,
9C). Traumatic posterior
sternoclavicular joint dislocation with complete obstruction of the
brachiocephalic vein also has been described
[6].
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Fig. 9A —57-year-old man with chest pain 1 hour after blunt chest
trauma in motor vehicle crash. Unenhanced axial CT scan shows cordlike
hyperdense hematoma along course of left brachiocephalic vein
(arrows).
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Fig. 9B —57-year-old man with chest pain 1 hour after blunt chest
trauma in motor vehicle crash. Contrast-enhanced axial CT scan shows
encasement of left brachiocephalic vein (open arrow) by cordlike
perivenous hematoma (solid arrows).
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Fig. 9C —57-year-old man with chest pain 1 hour after blunt chest
trauma in motor vehicle crash. Follow-up CT scan 3 months after conservative
treatment shows marked regression of perivenous hematoma
(arrows).
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Aneurysms
Aneurysms of the brachiocephalic vein are rare. Potential causes include
congenital malformation, trauma, inflammation, and degenerative changes in the
vessel wall [7,
8]. Most aneurysms are
asymptomatic and usually manifest incidentally as mediastinal widening on
chest radiographs. A brachiocephalic vein aneurysm, however, can be
complicated by a pulmonary embolus, rupture, and venous obstruction,
necessitating surgical repair
[8]. There may be a marked
difference in the appearance of the aneurysm depending on the patient's
posture [8]. A brachiocephalic
vein aneurysm can manifest as a mediastinal mass on a supine radiograph but
can be barely seen with the patient in the erect position (Fig.
10A,
10B), reflecting the
distensibility of the lesion and the importance of radiographic technique in
depicting the lesion.
Stenosis and Thrombosis
Establishment of an arteriovenous fistula (AVF) is an important procedure
for facilitating long-term hemodialysis for patients with chronic renal
failure. However, repeated AVF punctures can cause complications such as
stenosis and thrombosis [9].
Although two thirds of AVF-related complications are located at or near AVF
anastomosis sites, central venous lesions occur in 10–16% of
hemodialysis patients, especially in patients with a proximal AVF with a high
flow rate [9,
10]. MDCT has been reported to
be a useful tool with a high accuracy (98%) in evaluation of the complete
vascular tree of a failing AVF. MDCT is especially useful in revealing occult
brachiocephalic vein stenosis
[9]
(Fig. 11). Idiopathic central
venous stenosis is rare in patients not undergoing dialysis but can be present
and asymptomatic. It can result in edema of the ipsilateral face, neck, and
extremity [11] (Fig.
12A,
12B). Balloon angioplasty with
or without stent placement is associated with good secondary patency rates in
the midterm, but frequent or multiple interventions usually are needed. In
recalcitrant cases, surgical bypass of the obstruction is an option
[10,
11].
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Fig. 11 —69-year-old woman with end-stage renal disease and swelling
of left upper extremity 11 months after establishment of left brachiocephalic
dialysis fistula. Oblique axial CT scan shows dilated left brachiocephalic
vein with thrombus (solid arrows) due to severe brachiocephalic vein
stenosis (open arrow) immediately proximal to superior vena cava.
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Fig. 12A —75-year-old man admitted because of progressive right facial
and right upper extremity swelling. Surface-shaded display of chest CT
angiogram shows multiple engorged superficial veins (arrows) in right
side of face, upper part of chest, and upper extremity.
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Fig. 12B —75-year-old man admitted because of progressive right facial
and right upper extremity swelling. Oblique coronal reconstruction CT scan
shows severe stenosis of right brachiocephalic vein (arrow).
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Complications of Central Catheters
Percutaneous central venous catheter placement for administration of drugs
or parenteral nutrition, monitoring of central venous or pulmonary arterial
pressure, and short-term dialysis has become increasingly common in medical
practice [11,
12]. In the emergency
department or ICU, most venous approaches are performed in a blind manner and
then followed up with a chest radiograph. Although uncommon, life-threatening
vascular complications occur in 0.3% of cases. Patients with a body mass index
greater than 30 are especially at risk
[12]. From an anatomic
viewpoint, because of sharp angulations, the junction of the right
brachiocephalic vein and the internal jugular vein is at risk of perforation
when central catheters are placed through the right subclavian vein, and the
inferior wall of the left brachiocephalic vein is at risk of perforation when
central catheters are placed through the left internal jugular vein
[13].
CT findings lead to a definitive diagnosis when the distal tip of a central
venous catheter has coursed outside the vascular structures. CT also depicts
evidence of associated complications such as pneumothorax, hemothorax, and
arterial injury [12] (Fig.
13A,
13B). Repeated placement and
long duration of catheter use can induce endothelial injury, thrombosis,
smooth-muscle proliferation, and central venous stenosis with an incidence of
approximately 7% [11,
14] (Fig.
14A,
14B). Totally implantable
venous devices with a catheter inserted into the SVC or brachiocephalic vein
are widely used in the care of oncology patients who need prolonged
chemotherapy. However, the catheter can become pinched-off with resultant
fracture and embolization, possibly complicated by ventricular tachycardia,
atrial thrombosis, and even perforation. Fortunately, most fractured catheters
can safely be retrieved percutaneously
[15]. In rare instances, chyle
can be withdrawn from an implantable device when there is simultaneous severe
stenosis of the left brachiocephalic and subclavian veins (Fig.
15A,
15B).
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Fig. 13A —87-year-old woman with shock after placement of central
venous catheter. Chest radiograph shows abnormal loop of central venous
catheter (arrows) in right upper part of chest and adjacent massive
accumulation of pleural fluid.
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Fig. 13B —87-year-old woman with shock after placement of central
venous catheter. Enhanced axial CT scan shows penetration of catheter
(arrow) through right brachiocephalic vein and massive right
hemothorax.
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Fig. 14A —80-year-old woman with progressive right upper extremity
swelling 21 weeks after insertion of dialysis double catheter through right
internal jugular vein. Oblique axial (A) and coronal (B) CT
scans show site of insertion of dialysis double catheter (solid
arrows) to right brachiocephalic vein with thrombosis (open
arrows) of right subclavian vein.
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Fig. 14B —80-year-old woman with progressive right upper extremity
swelling 21 weeks after insertion of dialysis double catheter through right
internal jugular vein. Oblique axial (A) and coronal (B) CT
scans show site of insertion of dialysis double catheter (solid
arrows) to right brachiocephalic vein with thrombosis (open
arrows) of right subclavian vein.
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Fig. 15B —60-year-old man with rectal cancer and implanted venous
device for chemotherapy. Venogram with contrast injection through implanted
port shows marked stenosis (arrows) of central part of left
brachiocephalic vein.
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Conclusion
CT and MRI are excellent for visualizing developmental anomalies and
mediastinal tumors that involve the brachiocephalic vein. Although trauma,
aneurysm formation, stenosis related to dialysis and other conditions, and
various central catheter-related complications are less common than
developmental anomalies and tumors, familiarity with the imaging features of
the brachiocephalic vein is helpful in the diagnosis of these lesions.
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Fig. 10C —70-year-old woman with asymptomatic mediastinal mass
incidentally found on chest radiograph. Volume-rendered display of chest CT
angiogram shows large saccular aneurysm (open arrow) originating from
left brachiocephalic vein (solid arrow).
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Fig. 15C —60-year-old man with rectal cancer and implanted venous
device for chemotherapy. Left upper extremity venogram shows simultaneous
occlusion of left subclavian vein and prominent collateral veins in left
shoulder and left neck regions (arrows).
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Abstract
Introduction
