PMC9556204_01
(a) Axial contrast-enhanced CT images (CTA neck) demonstrate the anatomical variation of an aberrant right subclavian artery (yellow arrow) with its course posterior to the esophagus, resulting in an impression along the dorsal aspect of the esophagus. The left brachiocephalic vein (purple arrow) demonstrates no evidence of stenosis, with the examination performed in the inspiratory phase. No evidence of diverticulum of Kommerell. Anteroposterior (AP) diameter of 8 cm on inspiratory phase. (b) Axial contrast-enhanced CT images (CTA neck): retrospective analysis demonstrates an anteroposterior (AP) diameter of 6.4 cm in the expiratory phase. (c) Volume rendered 3D reconstruction demonstrates an aberrant right subclavian artery (arrow) arising distal to the origin of the left subclavian artery and traverses the mediastinum posterior to the esophagus and the trachea.
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fig1
Initial imaging revealed an aberrant right subclavian artery with a course dorsal to the esophagus and an anteroposterior (AP) chest diameter of 6.4 cm (Figure 1).
(a) Proximal segment of the left IJV demonstrates patency. (b) Diffuse slow flow of the compressible left IJV with the near stagnant flow in the proximal left IJV. (c) Comparison between the right IJV (A) and left IJV (B), with the left IJV demonstrating increased echogenicity of the blood suggesting underlying aggregation with near stagnant to and fro flow of blood. This layered appearance could be seen in the setting of underlying proximal compression/obstruction. Right IJV (A) was observed to be patent with the nonsluggish flow.
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fig2
An ultrasound of the neck was ordered as part of the workup (Figure 2) which demonstrated no thrombus within either internal jugular vein (IJV) but did show the diffuse slow flow of the left IJV, with the near stagnant flow in the proximal left IJV.
(a) Axial noncontrast CT obtained in full inspiration demonstrates patent left brachiocephalic vein (purple arrow). AP chest diameter: 8 cm. (b) Axial noncontrast CT obtained in full expiration demonstrates stenosis of the left brachiocephalic vein (purple arrow) as a result of compression between the left common carotid artery/left brachiocephalic artery and the manubrium. AP chest diameter: 5.6 cm.
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fig3
CT (with inspiration and expiration) revealed the left brachiocephalic vein to become severely stenotic on expiration with an AP chest diameter of 5.6 cm. Comparatively, during inspiration, the chest CT revelated a patent left brachiocephalic vein with an AP chest diameter of 8 cm (Figure 3).
(a) Left basilic vein was cannulated and a venogram was performed (in expiration) via a 4F Omni flush catheter in the left axillary vein, which demonstrated severe stenosis of the left brachiocephalic vein (purple arrow). (b) Using a combination of KMP catheter and angled Glidewire, the left IJV was cannulated, with the KMP catheter subsequently exchanged for a 4F Omni flush catheter and a venogram was performed in inspiration demonstrating the prompt flow of contrast from the left IJV into the left brachiocephalic vein and subsequently into the SVC without significant stenosis. No filling defect to suggest thrombus. (c) Venogram within the left IJV (in full expiration) demonstrated contrast within the left IJV to become stagnant with multiple venous collaterals draining the left IJV via contralateral brachiocephalic and jugular veins.
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fig4
The venogram demonstrated severe stenosis of the left brachiocephalic vein during expiration with multiple venous collaterals around the site of obstruction (Figure 4).
PMC9556204_02
(a) Axial contrast-enhanced CT images (CTA neck) demonstrate the anatomical variation of an aberrant right subclavian artery (yellow arrow) with its course posterior to the esophagus. (b) Volume rendered 3D reconstruction demonstrates an aberrant right subclavian artery (arrow) arising distal to the origin of the left subclavian artery and traverses the mediastinum posterior to the esophagus. (c) Axial contrast-enhanced CT images (CTA chest) examination performed in the inspiratory phase demonstrates mild compression of the brachiocephalic vein (yellow arrow), however, patency is maintained. Anteroposterior (AP) diameter of 7.4 cm on inspiratory phase.
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fig5
CTA chest (inspiratory phase) was conducted to rule out a mediastinal mass resulting in venous compression. CTA chest demonstrated no evidence of a mediastinal mass; however, incidentally, an aberrant right subclavian artery was noted (Figure 5). Furthermore, there was mild compression of the brachiocephalic vein during this initial inspiratory phase, which warranted further investigation to rule out aortosternal venous compression (Figure 5(c)).
Axial contrast-enhanced CT images (CTA neck) (expiratory) demonstrate severe stenosis of the left brachiocephalic vein (purple arrow) with compression of the vein between the manubrium and the origin of the left common carotid artery. Anteroposterior (AP) diameter of 5.2 cm in the expiratory phase.
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fig6
CTA in an expiratory phase was subsequently performed, demonstrating findings of severe stenosis of the left brachiocephalic vein (Figure 6).
(a) With an intravenous cannula in the left antecubital fossa, the contrast was injected and a venogram was obtained in deep inspiration demonstrating patent left axillary, subclavian, brachiocephalic (purple arrow), and SVC. (b) Venogram (expiratory phase) demonstrates severe stenosis within the left brachiocephalic vein (purple arrow) with reflux of contrast within the left IJV. Collateral vasculature arising from the left IJV with communication to the right brachiocephalic is noted.
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fig7
Findings of the venogram demonstrated a patent left subclavian and superior vena cava (SVC) with no significant stenosis with respect to the left brachiocephalic vein in the inspiratory phase (Figure 7(a)). The subsequent expiratory phase (Figure 7(b)) demonstrated severe stenosis of the left brachiocephalic vein, with cephalad reflux of contrast in the left IJV.