Amazing anatomy: roadmaps of venous collateral circulation

in patients with SVC obstruction.

Poster No.:

C-1962

Congress:

ECR 2011

Type:

Educational Exhibit

Authors:

G. Staskiewicz , E. Czekajska-Chehab , S. Uhlig , K. Torres , A.

2 1

Torres , R. Maciejewski , A. Drop ; LUBLIN/PL, Lublin/PL

Keywords:

Anatomy, Cardiovascular system, CT-Angiography, Diagnostic

procedure, Education, Obstruction / Occlusion, Embolism /
Thrombosis

DOI:

10.1594/ecr2011/C-1962

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Learning objectives
To review the anatomical background of collateral venous communications in patients
with SVC obstruction. To analyze patterns of MDCT presentation of collateral vessels; to
remember and recall the main anatomical variants of thoracic veins. To provide images
of rare CT presentations of venous collaterals.
Images for this section:

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Fig. 1

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Background
Collateral circulation plays important role in patients with obstruction of SVC, which
may result from multiple benign, malignant or iatrogenic conditions. The purpose of the
presentation is to review the most important pathways of collateral circulation in patients
with obstruction of SVC, as well as to provide tips for easy identification.
Four main systems of collateral venous circulation include: (1) azygos system of veins,
which provides communication between SVC and ascending lumbar vein; (2) subfascial
system of epigastric veins, which provide collateral circulation between brachiocephalic
vein and external femoral vein; (3) subcutaneous system of superficial epigastric vein;
(4) vertebral veins. Less frequent variants include systemic-pulmonary or intramuscular
pathways.
Images for this section:

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Fig. 1

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Imaging findings OR Procedure details

Azygos system of veins provides communication between SVC and ascending lumbar
veins, which receive lumbar veins, forming anastomosis with IVC. Azygos system
consists of veins of posterior wall of the trunk, which receive multiple tributaries,
particularly within their course through the mediastinum (Figure 1 on page
, Figure
2 on page 8). Azygos system forms the best developed anastomosis between
vena cava systems, with its tributaries arising from both parietal, as well as visceral (in
particular mediastinal and bronchial - Figure 3 on page 8) veins.
Subcutaneous veins of the trunk form the anastomosis between axillary vein and
femoral vein (Figure 4 on page 9). Superficial system anastomoses with the
subfascial system by means of perforating veins, which carry blood from medial aspect
of breasts (Figure 5 on page 10) and sternal branches of internal thoracic veins.
Subfascial system of veins connects external iliac vein and subclavian vein by means
of internal thoracic and inferior epigastric veins. Internal thoracic veins (ITV) are
tributaries of brachiocephalic veins. They are formed by junction of musculophrenic
veins (Figure 6 on page 11) and superior epigastric veins. Internal thoracic veins
anastomose at the posterior surface of sternum (Figure 7 on page 12). Parietal
tributaries of ITV are anterior intercostal veins (Figure 8 on page 13), which provide
anastomosis with the azygos sysem, by means of posterior intercostals. Additional
tributaries of brachiocephalic veins, frequently widened in patients with SVC syndrome,
are pericardiophrenic veins (Figure 9 on page 14). Relations of superficial and inferior
epigastric veins and their junctions with femoral and external iliac veins are presented
at Figure 10 on page 15.
Vertebral plexuses form two vascular rings, located outside the vertebrae: anterior and
posterior external vertebral plexus, as well as inner, internal vertebral plexuses located
within the vertebral canal (Figure 11 on page 16, Figure 12 on page 17). In the
cervical region, anterior external plexus anastomoses with vertebral veins, in thoracic
region with posterior intercostal veins, in lumar - lumbar veins. At the anterior aspect
of sacral bone it anastomoses with median and lateral sacral veins. Posterior external
plexus is best developed in the cervical region, anastomosing with occipital, vertebral
and deep cervical veins.
Images for this section:

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Page 7 of 19

Fig. 1: Azygos system of veins. Multiple anastomoses of this system include parietal
veins (lumbar, ascending lumbar, intercostal, @-superior phrenic) as well as visceral (#renal, *- mediastinal, including: bronchial, esopahgeal, pericardiac) veins

Fig. 2: Widening of azygos sytem of veins in a patient with left-sided SVC syndrome.

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Fig. 3: BV - bronchial veins.

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Fig. 4: Superficial (R) and subfascial (L) systems of veins. Superifical veins: Superificial
EV - superficial epifastric vein, TEV - thoracoepigastric veins, CAV - costoaxillary veins,
LTV - lateral thoracic vein, AP - areolar plexus. ST - sternal branches of internal thoracic
vein, Perf - perforating branches.

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Fig. 5: Perforating branch - tributary of internal thoracic vein.

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Fig. 6: MPV - musculophrenic vein.

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Fig. 7: Retrosternal anastomoses of internal thoracic veins.

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Fig. 8: LTV - lateral thoracic vein, AIcV - anterior intercostal vein, ITV - internal thoracic
vein.

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Fig. 9: PCPV - pericadriophrenic vein, MV- mediastinal veins.

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Fig. 10: Veins of anterior abdominal wall.

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Fig. 11: AI - anterior internal plexus, PI - posterior internal plexus. AE - anterior external
plexus, PE - posterior external plexus, BVV - basivertebral vein, VV - vertebral vein, DCV
- deep cervical vein.

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Fig. 12: Vertebral plexus in cervical region.

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Conclusion
MDCT allows detailed visualization of anatomical structures important in patients with
SVC obstruction. Appropriate knowledge of its anatomy and common anatomical variants
is essential for proper identification of abnormal conditions. Postprocessing methods are
extremely useful in explaining the complex anatomy of small thoracic veins, especially
for in-training readers, however, proper training allows quick identification of anatomy on
axial scans.

Personal Information
Grzegorz Staskiewicz, MD, PhD
Medical University of Lublin,
I Department of Radiology
Jaczewskiego 8, 20-079
Lublin, Poland
grzegorz.staskiewicz@gmail.com

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Radiographics. 2010 Jan;30(1):67-78.
Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy, LWW, 2009
Netter FH. Atlas of Human Anatomy, Saunders, 2010.

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