Cardiac and

Radiology conferenceDr. Jayanth H. Keshavamurthy M.D.3/23/2017.

Gateways to the heart – incidental CT findings of

anomalous systemic venous connections and the clinical

challenges they present

Authors

• Hanzhou Li, BA, Augusta, GA, No conflict of interest to disclose;

• Matthew Brown, BS, Augusta, GA, No conflict of interest to

disclose;

• Christopher Williamson, MS, Augusta, GA, No conflict of interest

to disclose;

• William B. Bates, MD, Augusta, GA, No conflict of interest to

disclose;

• Jayanth H. Keshavamurthy, MD, Augusta, GA, No conflict of

interest to disclose

Teaching Points

• The purpose of this exhibit is to:

• Discuss the anatomy of various anomalous systemic venous connections.

• Illustrate cases of anomalous systemic venous connections in patients with clinical and radiologic correlation.

• Discuss the importance of examining the venous architecture on CT and the clinical challenges they present for cardiothoracic surgery, pacemaker insertion, implantable cardioverter defibrillator insertion, and other procedures.

• Highlight the importance of documenting anomalous systemic venous connections on radiographic impressions.

Patient 1: 41 year old female undergoing a chest CT for suspected pulmonary embolism.

As seen in the anterior-posterior volume rendered (VR), coronal CT, and left anterior oblique VR imaging (Fig. 1A, 1B, 1D), the left innominate vein splits into a superior portion (black arrow) coursing anterior to the arch as well as an inferior portion (red arrow) traveling posterior to the arch. The axial CT (Fig. 1C) depicts contrast flowing through both branches of the anomalous left innominate, encircling the aorta before forming the superior vena cava.

Circumaortic Left Innominate Vein

Patient 2: 43 year old male with a chest CT.Various computerized tomographic views of the aberrant retroaortic left innominate vein. Volume-rendered image (A) demonstrating the retroaorticcourse. Panel B demonstrates axial imaging of the variant joining with right innominate.

Panels C and D demonstrate the full course in coronal view (panel D depicts its origin and continuation under the aortic arch to join, in panel C, the right innominate vein forming the SVC and draining into the right atrium). The white arrows point to the retroaortic left innominate vein. The black arrows point to the right innominate vein. AA –ascending aorta; DA – descending aorta; Z – azygous vein; S – superior vena cava.

Retroaortic Left Innominate Vein

Patient 3: 39 year-old female presented with chest pain, palpitations, and syncope. She received a coronary CTA.

Axial (A) and coronal (B) demonstrate the levoatrial cardinal vein in the interatrial space (arrows).

Panel C demonstrates the full course of the levoatrial cardinal vein in axial views (Upper left is the origin of the vein, branching from the left atrium, upper right and bottom left demonstrate the course in the interatrial space and the bottom right demonstrates the drainage into the distal superior vena cava).

Panel D is a volume-rendered image. The arrow points to the levocardinal cardinal vein.

Persistence of Levoatrial Cardinal Vein With An Interatrial Course

Patient 4: 79 year old male underwent a chest CTA for investigating his shortness of breath.

Axial (A, B) demonstrate the persistent left SVC (PLSVC) lateral to the aortic arch (arrows). The PLSVC curves posteriorly as it descends and eventually drains into the right atrium.

Panels C and D demonstrate the right SVC (RSVC) draining into the left atrium in axial and coronal views (arrows showing the junction of the RSVC and left atrium).

Panel E is a volume-rendered image where the arrow points to the RSVC.

Panel F is an oblique view of the CTA showing the RSVC draining into the left atrium as it curves posteriorly.

Persistent Left Superior Vena Cava Into Right atrium +Right Superior Vena Cava into Left Atrium

A B

C D

E F

Patient 5: 70-year-old female presented with shortness of breath. She had an elevated d-dimer and had contrast injected on the left cephalic vein for a chest CTA.

Axial (A) demonstrate the course of the persistent left SVC (PLSVC) as it continues superior to inferior (arrows). There is no bridging innominate vein that connects the PLSVC to the RSVC throughout the downward course.

Panel B is a coronal view of the PLSVC as it drains into the coronary sinus and eventually the right atrium (arrow).

Panel C is a sagittal view of the descending course of the PLSVC. There is a moderate dilatation of the coronary sinus due to the additional drainage from the PLSVC.

Persistent Left Superior Vena Cava Without a Bridging Innominate Vein

A

B C

Accessory hemiazygous vein draining into coronary sinus

Case