Cover Image: Superior caval vein thrombosis with unusual collateral flow
Borja Ibanez, Felipe Navarro, Manuel Cordoba, Andres Iniguez, and Jeronimo Farre
Servicio de Cardiología, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
An 80-year-old male patient, with a dual-chamber pacemaker (PM) implanted 2 years earlier, was admitted to hospital with a swelling of his face and neck that had persisted for 8 months. No arm oedema was present. An axillary venous Doppler study was informed as normal, with no evidence of venous thrombosis. However, a phlebography showed evidence of thrombosis involving the left innominate vein. Panel A shows the study performed from the right brachial venous approach. The venogram was performed with the catheter located in the superior caval vein (SCV) and shows a severe stenosis on SCV at innominate vein drainage level (arrow), which is totally occluded. Note the development of collateral flow (*) arising from the SCV. Panel B shows the location of the obstruction more closely. Panel C shows the venogram performed from the left brachial approach. The left innominate vein is totally occluded (arrow) just distally to the subclavian (Sub) and jugular veins, which are patent. Venous drainage is performed by collateral flow through the left internal mammary vein (†), which continues in the coronary vein tree through the middle cardiac vein, which ends in the coronary sinus (CS). Additional collateral flow drainage is established throughout the dilated azygos vein (**), which ends in the SCV just before entering the right atrium. Several SCV thromboses secondary to PM have been documented. Azygos hypertrophied vein is a common collateral pathway; however collateral flow through coronary vein circulation has yet to be documented. The connection between the left internal mammary vein (thoracic vessel) and the middle cardiac vein (intra-pericardial vessel) is most probably carried out by a hypertrophied pericardial vein. Drainage of cardiac veins into thoracic vessels through a collateral circuit crossing the pericardium has been documented in cases of coronary sinus obstruction, which is the same circuit as in our patient but in the opposite direction.
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