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Literature regarding etiology and trends of incidence of major thoracic vein thrombosis in the United States is limited. To study the causes, complications, in-hospital mortality rate, and trend in the incidence of major thoracic vein thrombosis which could have led to superior vena cava syndrome (SVCS) between 2010 and 2018. Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments (ED) and in-patient sample in the United States were analyzed using diagnostic codes. A linear p-trend was used to assess the trends. Of the total 1082 million ED visits, 37,807 (3.5/100,000) (mean age 53.81 ± 18.07 years, 55% females) patients were recorded with major thoracic vein thrombosis in the ED encounters. Among these patients, 4070 (10.6%) patients had one or more cancers associated with thrombosis. Pacemaker/defibrillator-related thrombosis was recorded in 2820 (7.5%) patients, while intravascular catheter-induced thrombosis was recorded in 1755 (4.55%) patients. Half of the patients had associated complication of pulmonary embolism. A total of 59 (0.15%) patients died during these hospital encounters. The yearly trend for the thrombosis for every 100,000 ED encounters in the United States increased from 2.17/100,000 in 2010 to 5.98/100,000 in 2018 (liner p-trend

Background Although epicardial structures around the atrium such as adipose tissue possess arrhythmogenicity, little is known about atrial tachycardias (ATs) originating from epicardial sites (Epi‐ATs). This study aimed to elucidate the prevalence, characteristics, and outcome after radiofrequency catheter ablation (RFCA) of Epi‐ATs and to reveal the association between Epi‐ATs and the epicardial structures. Methods The electrocardiographic, electrophysiologic, and anatomical properties and results of RFCA were analyzed in 42 patients with a total of 49 ectopic ATs. Results Six Epi‐ATs (12%) were observed in six patients (14%). Four of six were respiratory cycle‐dependent ATs and one was a swallowing‐induced AT. The Epi‐AT origins were adjacent to a pulmonary vein (five cases) and vein of Marshall (one case). A Valsalva maneuver or atropine infusion to define the arrhythmia mechanism affected the appearance of the Epi‐ATs. The congruity rate between epicardial adipose tissue and the AT origin was significantly higher (100% vs. 44%, p = .045), and the epicardial adipose tissue volume of the atrium was significantly larger (104.1 vs. 64.6 ml, p = .04) in the Epi‐AT group. Endocardial RFCA targeting the AT foci resulted in acute success in five of five cases. However, electrical isolation including of the AT foci resulted in acute failures (two of three cases) or a recurrence (one of one case). Conclusions Six Epi‐ATs were associated with thoracic veins and epicardial arrhythmogenic structures. The main cause provoking the Epi‐ATs was associated with autonomic nerve activity.

Azygos system of veins is the main source of venous drainage from the thoracic wall. Knowledge of azygos vein anomalies could be of importance to cardiothoracic surgeons and radiologists. We report a rare variation of azygos vein as seen in an adult male cadaver aged 65 years approximately. The azygos vein was formed by the union of left ascending lumbar and subcostal veins. It coursed upwards on the left side of descending thoracic aorta and crossed the left subclavian artery and the left vagus to terminate into the left brachiocephalic vein. It received left superior intercostal vein and left fifth to eleventh posterior intercostal veins. The hemiazygos and accessory hemiazygos veins were situated on the right side of the vertebral column. They received the right posterior intercostal veins and terminated into the azygos vein at the level of eighth thoracic vertebra.

The superior vena cava is formed during the fetal period by the development of anastomoses between the right and left anterior cardinal veins, and the regression of the central part of the left anterior cardinal vein. The persistence of this part of the left anterior cardinal vein causes the formation of a left superior vena cava, which is a rare anomaly in cadaver dissection. We report the case of a persistent left superior vena cava with a normal right superior vena cava in a 95-year-old male cadaver, which was discovered during anatomical dissection for medical students at Kawasaki Medical School in 2016. The left superior vena cava was formed by the confluence of the left internal jugular and left subclavian veins and terminated in the right atrium via what would normally be the coronary sinus. The right and left superior venae cavae received intercostal veins via a right and left azygos vein, respectively. However, the right azygos vein was shorter than the normal azygos vein and received only the second to fifth intercostal veins, whereas the left azygos vein received the fifth to eleventh left intercostal veins and the sixth to eleventh right intercostal veins. We consider that the anomalies of the azygos venous system were the result of regression of right supracardinal vein and the persistence of the left supracardinal vein during development. An awareness of such variations of major thoracic veins is important for the interpretation of unusual CT images.

Introduction Most hemodialysis patients start renal replacement therapy with a central venous catheter (CVC). The left internal jugular vein (LIJV) is the second-choice vein for CVC positioning, after the right IJV. However, to reach the right atrium, the CVC must pass through the left brachiocephalic vein (LBV), which also drains blood from the left arm through the subclavian vein. The purpose of this study is to describe how the anatomy of the central venous system and in particular that of the LBV affects vascular access in hemodialysis patients. Materials and methods Three-dimensional (3D) virtual model reconstructions of the central thoracic veins of three hemodialysis patients were obtained from contrast-enhanced computed tomography scans acquired in the venous phase. The images were exported as DICOM files and loaded on open-source software for visualizing and analyzing the medical imaging (3D Slicer, Windows version 4.8.1). Results As expected, the 3D reconstructions showed that the LBV has a tortuous path with three main angulations that could be associated with external compression and stenosis. These could determine the difficulties and increased risks of venous injury during CVC placement, and an increased risk of medium to long-term catheter-associated vein thrombosis and stenosis. Conclusions The anatomical features of the LBV indicate that the path of a CVC from the LIJV to the right atrium is tortuous and can easily be complicated by vein injury, negatively affecting the creation of future arterio-venous vascular accesses in the left arm.

Venous thoracic outflow syndrome may occur as a result from compression of the subclavian and/or axillary vein and consequently, decreased blood flow and increased risk of thrombus formation. A previously healthy 34-year-old woman who, after intensive crossfit training, experienced sudden intense pain and swelling in her right upper arm was referred for computed tomography of her right upper arm and thoracic veins. The computed tomography was performed using bilateral injection of low dose, diluted contrast medium. The computed tomography venography revealed an elongated contrast medium embraced thrombus in the right subclavian and axillary vein. By using a dual injection consisting of diluted contrast medium, artifact-free visualization of arm veins and sufficient enhancement of thoracic veins can be achieved. Keywords: Ct, Contrast agents-intravenous, Upper extremities, Computed tomography venography

A 45-year-old female dialysis patient with sudden onset of severe pain in the left shoulder and chest was referred for computed tomography of her left arm and thoracic veins. The computed tomography venography revealed 2 completely occluded venous grafts and 2 pronounced stenoses of the subclavian vein. By using a dual injection of diluted and undiluted contrast medium, artifact-free visualization of arteriovenous fistula, arm veins and adequate enhancement of thoracic veins were obtained. Keywords: Computed tomography, Arteriovenous fistula, Contrast agents-intravenous

Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are the main imaging methods for vasculature of the chest and abdomen. CTA has advantages such as demonstration of the vessel wall, perivascular tissue, and end-organ parenchyma in addition to luminal assessment with short scan times. The main advantage of MRA is not exposing the patient to ionizing radiation that enables repeated acquisitions, especially in children. Despite a preferred contrast-enhanced MRA, non-contrast MRA options are also available for patients with renal failure. In this chapter, imaging of pulmonary arteries, thoracic veins, aorta, abdominopelvic veins, mesenteric vessels, and renal vessels with CTA and MRA were summarized.

Background: In dialysis patients with exhausted usual central venous access sites, the translumbar hemodialysis catheter (TLC) provides a viable option for dialysis access. The technical success of catheter insertion, associated complications, and long-term patency of TLC were evaluated in this study. Material/Methods: This retrospective study included 37 patients with occluded central thoracic veins in whom 39 TLC implantation procedures were performed and 196 patients with internal jugular vein hemodialysis catheters (JVC). TLC implantation was performed as a hybrid procedure with computed tomography (CT)-navigated translumbar inferior vena cava cannulation and subsequent fluoroscopy-guided hemodialysis catheter placement. Results: The rates of technical success of the implantations and minor periprocedural complications were 97.4% and 10.3% in the TLC group and 98.6% and 4.2% in the JVC group, respectively. The median follow-up in the TLC and JVC groups was 673 days and 310 days, respectively. The primary-assisted patency at the 1-year and 3-year follow-up was 88.7% and 72.0% in the TLC group and 81.6% and 67.0% in the JVC group, respectively, with no statistically significant difference between the 2 groups. The incidence rate of infection-related and patency-related complications calculated for 1000 catheter-days was 0.15 and 0.11 in the TLC group and 0.33 and 0.25 in the JVC group, respectively. Conclusions: The CT-guided implantation of the TLC is a useful option to create dialysis access with a low complication rate and satisfactory long-term patency in patients without usual venous access. Web of Science 26 art. no. e927723

Vanishing bone metastasis (pseudopathological vertebral body enhancement) is a pitfall in the interpretation of contrast-enhanced computed tomography (CT) scans of patients with thoracic vein obstruction, mainly in the superior vena cava and brachiocephalic veins, typically being related to thrombosis due to malignant tumors. On the basis of the CT findings, pseudopathological vertebral body enhancement can be misdiagnosed as sclerotic bone metastasis, leading to unnecessary treatment. Although not rare, pseudopathological vertebral body enhancement is usually underdiagnosed by radiologists. The aim of this study is to review the pathophysiology of this phenomenon, illustrating the most common collateral venous pathways in thoracic vein obstruction and making the correlation with the CT findings.

Key points The developmental changes of the caval (SVC) and pulmonary vein (PV) myocardium electrophysiology are traced throughout postnatal ontogenesis. The myocardium in SVC as well as in PV demonstrate age-dependent differences in the ability to maintain resting membrane potential, to manifest automaticity in a form of ectopic action potentials in basal condition and in responses to the adrenergic stimulation. Electrophysiological characteristics of two distinct types of thoracic vein myocardium change in an opposite manner during early postnatal ontogenesis with increased proarrhythmicity of pulmonary and decreased automaticity in caval veins. Predisposition of PV cardiac tissue to proarrhythmycity develops during ontogenesis in time correlation with the establishment of sympathetic innervation of the tissue. The electrophysiological properties of caval vein cardiac tissue shift from a pacemaker-like phenotype to atrial phenotype in accompaniment with sympathetic nerve growth and adrenergic receptor expression changes. Abstract The thoracic vein myocardium is considered as a main source for atrial fibrillation initiation due to its high susceptibility to ectopic activity. The mechanism by which and when pulmonary (PV) and superior vena cava (SVC) became proarrhythmic during postnatal ontogenesis is still unknown. In this study, we traced postnatal changes of electrophysiology in a correlation with the sympathetic innervation and adrenergic receptor distribution to reveal developmental differences in proarrhythmicity occurrence in PV and SVC myocardium. A standard microelectrode technique was used to assess the changes in ability to maintain resting membrane potential (RMP), generate spontaneous action potentials (SAP) and adrenergically induced ectopy in multicellular SVC and PV preparations of rats of different postnatal ages. Immunofluorescence imaging was used to trace postnatal changes in sympathetic innervation, β1- and α1A-adrenergic receptor (AR) distribution. We revealed that the ability to generate SAP and susceptibility to adrenergic stimulation changes during postnatal ontogenesis in an opposite manner in PV and SVC myocardium. While SAP occurrence decreases with age in SVC myocardium, it significantly increases in PV cardiac tissue. PV myocardium starts to demonstrate RMP instability and proarrhythmic activity from the 14th day of postnatal life which correlates with the appearance of the sympathetic innervation of the thoracic veins. In addition, postnatal attenuation of SVC myocardium automaticity occurs concomitantly with sympathetic innervation establishment and increase in β1-ARs, but not α1A-AR levels. Our results support the contention that SVC and PV myocardium electrophysiology change during postnatal development, resulting in higher PV proarrhythmicity in adults.

A 65-year-old male underwent a second ablation procedure for recurrent paroxysmal atrial fibrillation (AF). Twelve-lead ECG during sinus rhythm exhibited biphasic and split P-wave with a prolonged duration, which called notched P-wave (NPW). Radio-frequency applica-tion in the coronary sinus (CS) resulted AF termination and elimination of triggering ectopy with NPW disappearance. The CS musculature which played a principal role in triggering and maintaining AF formed the NPW. In patients with repetitive recurrent AF after the estab-lishment of the PV isolation who exhibit NPW during sinus rhythm, the CS might be one of the arrhythmogenic sources of AF.

Background Phasic venous flow variation with respiration is surrounded by controversy and not well understood. The current concept assigns a major role to the “abdominal pump.” According to this model, inspiratory increases in abdominal pressure compress the vena cava, increasing its internal venous pressure and propelling blood upstream. Some have assigned a secondary role to the “thoracic pump,” with the negative intrapleural pressure aiding blood flow toward the heart. The aim of the present study was to examine the phasic changes in flow, pressure, and volume in the central veins and named tributaries. Methods Caliber area changes were measured using intravascular ultrasonography in 37 patients undergoing iliac vein stenting. The pressure was measured in 48 patients using transducer tip catheters with electronic zero calibration. Duplex ultrasound flow in the head and neck and truncal and limb veins during inspiration and expiration was measured in 15 normal volunteers. Results The caliber of the abdominal inferior vena cava had increased by 32% and its lateral pressure had decreased significantly during inspiration. Intravenous pressure in the central veins of the chest and right atrium was positive at 6 to 14 mm Hg. Negative pressures were rarely seen and then only transiently. The internal jugular vein displayed little phasic variation. The upper limb veins displayed weak inspiratory phasicity. Phase polarity was reversed in the lower limbs, with near flow stoppage during inspiration. Conclusions These observations conflict with the current notions of venous flow phasicity, which are based on push–pull pressure changes in the abdominal and thoracic veins. The paradoxical inspiratory inferior vena cava caliber increase probably explains the concurrent pressure decrease. Sustained negative pressures in the thoracic central veins and right atrium did not occur. We have proposed an alternate hypothesis for venous flow phasicity based on alternate stretching and relaxation of the mobile section of the great veins with respiratory movement.

Introduction The axillary and cephalic veins are used for various clinical purposes but their anatomy is not fully understood. Increased knowledge and information about them as well as superficial veins in the upper arm would be useful. Objective The aim of this study is to contribute to the literature regarding the anatomy of the venous drainage of the upper extremity. Methods The veins of forty upper extremities from twenty one adult cadavers were injected and their axillary regions dissected. The course and pattern of drainage of the venous tributaries in the axillary region were identified and recorded. Results The basilic, brachial, subscapular, lateral thoracic and superior thoracic veins drained mainly into the axillary vein, in common with most textbook descriptions. However, the thoracoacromial veins were observed to drain into the cephalic vein in 70.0% of upper limbs. In addition, a venous channel connecting the distal part and proximal part of the axilla was found along the posterolateral wall of the axilla in 77.5% of the upper limbs. In 95.0% of upper limbs, we discovered a superficial vein which ran from the axillary base and drained directly into the axillary vein. Conclusion The veins from the inferomedial part of the axilla drain into the axillary vein, whereas the veins from the superolateral part of the axilla drain into the cephalic vein. The venous drainage of the axilla is variable and in common with venous drainage elsewhere, does not necessarily follow the pattern of the arterial supply.

We present a 40-year old patient with symptomatic persistent AF. This case illustrates the importance of thoracic veins in the pathogenesis of atrial fibrillation. In this case, PV isolation resulted in a drastic cycle length prolongation with AF persisting with periods of organized activation sequence allowing for localization of the culprit area: a bursting SVC, whose isolation led to sinus resumption.

Background: Pulsed field ablation (PFA) is a uniquely tissue-selective, nonthermal cardiac ablation modality. Delivery parameters such as the electrical waveform composition and device design are critical to PFA’s efficacy and safety, particularly tissue specificity. In a series of preclinical studies, we sought to examine the electrophysiological and histological effects of PFA and compare the safety and feasibility of durable pulmonary vein and superior vena cava (SVC) isolation between radiofrequency ablation and PFA waveforms. Methods: A femoral venous approach was used to gain right and left atrial access under general anesthesia in healthy swine. Baseline potentials in right superior pulmonary and inferior common vein and in SVC were assessed. Bipolar PFA was performed with monophasic (PFA Mono ) and biphasic (PFA Bi ) waveforms in 7 and 7 swine sequentially and irrigated radiofrequency ablation in 3 swine. Vein potentials were then assessed acutely, and at ≈10 weeks; histology was obtained. Results: All targeted veins (n=46) were successfully isolated on the first attempt in all cohorts. The PFA Bi waveform induced significantly less skeletal muscle engagement. Pulmonary vein isolation durability was assessed in 28 veins: including the SVC, durability was significantly higher in the PFA Bi group (18/18 PFA Bi , 10/18 PFA Mono , 3/6 radiofrequency, P =0.002). Transmurality rates were similar across groups with evidence of nerve damage only with radiofrequency. Pulmonary vein narrowing was noted only in the radiofrequency cohort. The phrenic nerve was spared in all cohorts but at the expense of incomplete SVC encirclement with radiofrequency. Conclusions: In this chronic porcine study, PFA-based pulmonary vein and SVC isolation were safe and efficacious with demonstrable sparing of nerves and venous tissue. This preclinical study provided the scientific basis for the first-in-human endocardial PFA studies.

Background Accurate anatomical landmarks to locate the thoracodorsal nerve are important in axillary clearance surgery. Methods Twenty axillary dissections were carried out on ten preserved Sri Lankan cadavers. Cadavers were positioned dorsal decubitus with upper limbs abducted to 900. An incision was made in the upper part of the anterior axillary line. The lateral thoracic vein was identified and traced bi-directionally. The anatomical location of the thoracodorsal nerve was studied in relation to the lateral border of pectoralis minor and from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein. Results The lateral thoracic vein was invariably present in all the specimens. All the lateral thoracic veins passed lateral to the lateral border of pectoralis minor except in one specimen, where the lateral thoracic vein passed along its lateral border. The thoracodorsal nerve was consistently present posterolateral to the lateral thoracic vein. The mean distance to the lateral thoracic vein from the lateral border of pectoralis minor was 28.7 ± 12.6 mm. The mean horizontal distance, depth, and displacement, from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein to the thoracodorsal nerve were 14.5 ± 8.9 mm, 19.7 ± 7.3 mm and 25 ± 5 mm respectively. The thoracodorsal nerve was found in a posterolateral direction, at a 540 ± 120 angle to the horizontal plane, 95% of the time. Conclusions The lateral thoracic vein is an accurate guide to the thoracodorsal nerve. We recommend exploring for the thoracodorsal nerve from a point 2 cm from the confluence of the lateral thoracic vein and the axillary vein for a distance of 25 ± 5 mm in a posterolateral direction, at a 540 ± 120 angle to the horizontal plane.

Introduction: Various anomalies in the development of the great thoracic veins of the embryo can be incidentally discovered in the normal adult. Duplication of superior vena cava (SVC) is a...

Thoracic veins congenital abnormalities are important uncommon developmental anomalies that have a wide range of presentation from isolated incidental findings to a part of more complex anomalies. It can be categorized into systemic venous system and pulmonary venous system. It is of important value to understand the mediastinal vascular anatomy to help to identify variable vascular anomalies. In this study we attempt to describe some incidentally encountered mediastinal large venous anatomical variants in patients undergoing MDCT chest in order to avoid further unnecessary studies.

Introduction The guidelines suggest that an adjuvant substrate modification in addition to pulmonary vein isolation (PVI) may be needed for persistent atrial fibrillation (PerAF) assuming that catheter ablation is less successful for PerAF than paroxysmal AF (PAF). To revisit the above assumption, we compared the outcome of the same catheter ablation strategy between PAF and PerAF. Methods and Results Two-hundred and thirty-three consecutive patients (mean age 60±10 years, 53 PerAF and 8 long-lasting PerAF) without structural heart disease underwent catheter ablation of AF by the same strategy using an empiric thoracic vein isolation (a wide circumferential PVI plus empiric superior vena cava isolation) as a major part of the strategy without any adjuvant substrate modification. The duration of AF in the patients with PerAF was 6 ± 4 months. During 25±10 months of follow-up after single procedures, 71 (30%) patients had atrial tachyarrhythmia recurrences without antiarrhythmic drugs. A Kaplan-Meier analysis of the recurrence-free survival rate after a single procedure and after repeat procedures revealed no significant difference between the patients with PAF and those with PerAF (Log-rank, p=0.38 and p=0.27, respectively). A Cox regression multivariate analysis of the variables including the age, gender, PerAF, body mass index, left ventricular ejection fraction, and left atrial volume index demonstrated that none of the variables were an independent predictor of an atrial tachyarrhythmia recurrence after a single ablation procedure. Conclusion In patients without underlying heart disease, the procedural outcome of an empiric thoracic vein isolation is comparable for PAF and PerAF. This article is protected by copyright. All rights reserved

Background Patients with Intestinal Failure (IF) require reliable intravenous access for provision of Parenteral Nutrition. Venous access for Home Parenteral Nutrition (HPN) patients with Type 3 IF can be compromised due to thrombosis of deep veins. Preferred choice of veins for central venous catheter are the supra cardiac veins. Femoral tunnelled CVC are avoided due to concerns of catheter related blood stream infection (CRBSI) and are considered as a last resort when all other thoracic CVC access is exhausted. We assess the outcomes of tunnelled femoral catheters in our cohort of HPN patients. Methods We did a retrospective analysis of a prospectively collected data of all HPN patients and venous access from January 2013 to December 2018 managed at a National HPN Unit. The details of venous access, complications of CVC, sex and details of stoma extracted from database. Results In a cohort of 9 HPN patients with tunnelled femoral CVC, 6 were females and 3 were males leading to a total of 8418 days. A total 3 episodes of CRBSI were recorded in 1 patient. All of the 3 episodes (methicillin – sensitive Staphylococcus aureus (MSSA), Escherichia Coli and CNS) were successfully salvaged. The average no of days for femoral CVC was 935 days. The rate of CRBSI was 0.35 per 1000 catheter days. 8 patients had stoma or open abdominal wound. There were no episodes of ipsilateral femoral DVT. The CVC was replaced for 2 patients due to fracture of CVC. Conclusion Tunnelled femoral CVC CRBSI rate ( 0.35) is comparable to thoracic veins CVC CRBSI rate(0.31) in our unit. Furthermore femoral access could be considered as a reliable access to provide HPN. It may be considered as an option if more than 2 thoracic deep veins are occluded to prevent complete occlusion of SVC. We feel tunnelled femoral CVC is a safe option to consider for HPN

This paper hypothesizes, based on fluid dynamics principles, that in multiple sclerosis (MS) non-laminar, vortex blood flow occurs in the superior vena cava (SVC) and brachiocephalic veins (BVs), particularly at junctions with their tributary veins. The physics-based analysis demonstrates that the morphology and physical attributes of the major thoracic veins, and their tributary confluent veins, together with the attributes of the flowing blood, predict transition from laminar to non-laminar flow, primarily vortex flow, at select vein curvatures and junctions. Non-laminar, vortex flow results in the development of immobile stenotic valves and intraluminal flow obstructions, particularly in the internal jugular veins (IJVs) and in the azygos vein (AV) at their confluences with the SVC or BVs. Clinical trials' observations of vascular flow show that regions of low and reversing flow are associated with endothelial malformation. The physics-based analysis predicts the growth of intraluminal flaps and septa at segments of vein curvature and flow confluences. The analysis demonstrates positive correlations between predicted and clinically observed elongation of valve leaflets and between the predicted and observed prevalence of immobile valves at various venous flow confluences. The analysis predicts the formation of sclerotic plaques at venous junctions and curvatures, in locations that are analogous to plaques in atherosclerosis. The analysis predicts that increasing venous compliance increases the laminarity of venous flow and reduces the prevalence and severity of vein malformations and plaques, a potentially significant clinical result. An over-arching observation is that the correlations between predicted phenomena and clinically observed phenomena are sufficiently positive that the physics-based approach represents a new means for understanding the relationships between venous flow in MS and clinically observed venous malformations.

Background High-quality non-invasive imaging of the deep venous system in the thorax is challenging, but nevertheless required for diagnosis of vascular pathology as well as for patient selection and preoperative planning for endovascular procedures. Purpose To compare the diagnostic quality of Gadofosveset-enhanced thoracic magnetic resonance venography, seven consecutive patients with suspected or known disease affecting the central thoracic veins were compared to seven consecutive magnetic resonance venography using conventional gadolinium-based contrast agents. Materials and methods Diagnostic capability, defined as the ability to assess vessel patency and pathologic conditions, for the major thoracic deep venous segments was assessed by two-independent readers. Both reviewers rated the overall subjective image quality on a four-graded scale, and inter-rater variability was analyzed using unweighted and weighted Cohen's kappa values. Results Diagnostic capability was generally considerably higher in the Gadofosveset group for all examined vessel segments. The overall images quality rating was significantly higher for the Gadofosveset group with a mean rating of 2.9 and 2.7 for the two-independent readers, compared to 1.2 and 1.0 for the control croup. Inter-rater variability showed less variability for the Gadofosveset group with a quadratic-weighted Cohen's Kappa value of 0.58 compared to 0.36 for the control group. Conclusion Our results show that Gadofosveset-enhanced magnetic resonance venography of the central thoracic veins is a reliable technique in clinical routine practice that results in diagnostic images, superior to conventional gadolinium-based contrast medium.

Introduction Intensive care unit (ICU) patients are a risk group to develop thrombosis and/or thromboembolism. The purpose of this study was to analyze the frequency and localization of clinically silent thrombotic events (TE) detected on CT. Materials and methods From 2006 to 2013 a total of 370 patients from the ICU of our university clinic were investigated by postcontrast CT. In all cases CT was performed for detecting septic foci. There were 135 women and 235 men. CT scans included cervical, thoracic, abdominal, and pelvic regions. CT images of all patients were re-interpreted by 2 radiologists by consensus. Only thromboses detected for the first time on CT were included into the analysis. Collected data were evaluated by means of descriptive statistics. Frequencies and localizations of TE in surgical and non surgical patients were analyzed by Chi-square test. Significance level was p Results In 31.9% several TE were diagnosed. There were venous thrombosis (89.8%), cardiac thrombus (2.6%), and pulmonary embolism (7.6%). More often jugular veins were affected followed by brachiocephalic veins, and iliac veins. The frequency of TE in surgical patients was 31.1%, and 32.1% in non surgical patients. Patients after surgery had more often thrombosis of extremities veins in comparison to non surgical patients. In 61.9% of all TE the identified thrombotic complications were not diagnosed at the time of CT investigations. Conclusion TE can be identified in 31.9% of ICU patients as incidental finding on CT. There were venous thromboses, pulmonary embolism, and cardiac thrombus. Most frequently neck and thoracic veins were affected. 61.9% of all TE were not diagnosed at the time of CT investigations. Radiologists should check carefully CT scans for presence of different TE.

Persistent left cranial vena cava (PLCVC) is an uncommon congenital thoracic venous anomaly in dogs. This study examines the clinical and CT findings of dogs diagnosed with PLCVC incidentally. In this study, complete type of PLCVC was diagnosed in 26 dogs with CT angiography. Shih tzu (17 cases) and Pekingese dogs (3 cases) were overrepresented. There was no gender predisposition, and the average age at presentation was 10.3 years. Of 26 dogs, one dog had a bridging vein connecting right and left cranial vena cavae, and another dog showed azygos vein terminating PLCVC. On the thoracic CT images in the third dog, the right cranial vena cava was absent so that right brachiocephalic vein ended to PLCVC. However, the right costocervical vein drained another vein coursing caudally to the right atrium with azygos vein. In conclusion, CT angiography is a very useful method to diagnose PLCVC and variations of related thoracic vein anomalies in dogs.

Introduction The efficacy of thoracic vein isolation (TVI), an approach to trigger atrial fibrillation (AF), for the management of AF has been established. Our goal was to identify the predictors for late recurrence of atrial tachyarrhythmias (ATAs), for which the patients and procedural and/or echocardiographic parameters were retrospectively analyzed. Although substrate modification in the atrium for the treatment of AF ablation remains controversial, the background associated with the outcome has not been fully investigated. We retrospectively studied 33 patients with paroxysmal AF and 21 with persistent AF undergoing defragmentation followed by TVI. We evaluated the late/early recurrences, defined as ATA at 3 months after/within the single procedure. Methods and Results During a median follow-up period of 22 (11-37) months, 28 patients (52%) experienced a late recurrence. There was a higher incidence of late recurrences in the patients with disease durations of ≥12.4 months, which was the optimal cut-off point measured in the receiver operating characteristic curve analysis, or in those with left atrial diameter >50 mm or with earlier recurrences than the others (19% versus 72%, p=0.01; 0% versus 37%, p=0.02; or 13% versus 53%, p

We describe the case of a patient with persistence of left superior vena cava and right atrial tachycardia originating between right superior vena cava and crista terminalis. We present the initial suspect of anatomical anomaly, the diagnosis and the interventional treatment of the arrhythmia. Potential challenges and the role of anomalous thoracic veins in promoting rhythm disturbances are also discussed.

> “I’ll follow him around the Horn, and around the Norway maelstrom, and around perdition’s flames before I give him up.” > > -Captain Ahab, Moby Dick > “The mysterious thing you look for your whole life will eventually eat you alive.” > > -Laurie Anderson on Moby Dick Optimal strategy and end points for ablation of persistent atrial fibrillation (AF) have not been well established. Although antral pulmonary vein isolation (PVI) is often effective for ablation of paroxysmal AF, it is an insufficient stand-alone strategy for many patients with persistent AF. Selection of adjunctive targets and determination of procedural end points are variable and at the discretion of the operator. Several studies suggested that termination of AF should be the procedural end point during ablation in patients with persistent AF, as a higher probability of maintaining sinus rhythm after the ablation was reported, despite a long procedure duration and a high rate of repeat ablation procedures. However, these studies were not consistently reproducible, and conversion usually occurred to an atrial tachycardia rather than sinus rhythm after extensive ablation. In patients with persistent AF, there is insufficient experimental, mechanistic, or clinical evidence to support termination of AF during ablation as a procedural end point. Response by Lim et al on p 980 Rapid and repetitive depolarizations originating within or at the antra of the pulmonary veins (PVs) and the other thoracic veins are the predominant mechanism in the initiation and perpetuation of paroxysmal atrial fibrillation (PAF).1–3 Antral isolation of PVs and elimination of focal triggers and drivers from other thoracic veins often result in termination and noninducibility of PAF in response to various pharmacological and pacing protocols. Patients with PAF whose AF terminated during ablation and were rendered noninducible, also were more likely to remain in sinus rhythm during long-term clinical follow-up.4 …

We report the case of a 73-year-old man with severe edema of the right upper extremity. Computed tomography, magnetic resonance imaging, and venography revealed an intravenous tumor in the middle portion of the right subclavian vein. The tumor was completely resected, and an accompanying thrombus was also removed using the transmanubrial osteomuscular sparing approach. The patient recovered well without any complications or recurrence. The histopathologic diagnosis was intravenous lobular capillary hemangioma, which is also called pyogenic granuloma. To our knowledge, this is the first reported surgical case involving this type of benign tumor originating in a thoracic vein.

Background Although electrical thoracic vein (TV) isolation is an established strategy during atrial fibrillation (AF) ablation, discriminating TV potentials from far-field signals is critical for the achievement. Methods and Results One hundred consecutive drug-refractory symptomatic paroxysmal AF patients who underwent AF catheter ablation were included. All patients underwent circumferential pulmonary vein (PV) isolation during distal coronary sinus (CS) pacing with a cycle length of 600 ms. A superior vena cava (SVC) isolation was added during high right atrial (HRA) pacing with the same cycle length in 79 patients in whom SVC potentials were identified. The interval between the near-field PV potentials and far-field atrial signals significantly prolonged more during distal CS pacing than sinus rhythm (SR) in the left superior (26.0 [18.5–32.8] ms to 36.0 [24.3–55.5] ms, P < 0.01) and left inferior PVs (21.0 [14.0–30.0] ms to 40.0 [23.0–56.0] ms, P < 0.01), but not in the right superior (34.0 [20.0–40.0] ms to 23.0 [18.0–36.0] ms, P = 0.13) and right inferior PVs (22.0 [16.0–28.0] ms to 25.0 [18.0–38.0] ms, P = 0.05). The interval between the SVC potentials and far-field atrial signals significantly prolonged more during HRA pacing than SR (20.0 [0–32.0] ms to 34.0 [24.0–46.0] ms, P < 0.01). Electrical isolation was successfully achieved in all TVs without any complications except for transient right phrenic nerve palsy in two patients. Conclusions Discrimination of ipsilateral left PVs and SVC potentials is facilitated by pacing from the distal CS and HRA, respectively. Better recognition of TV potentials would help to achieve electrical isolation.

The azygos vein (AV) is typically described (illustrated) as ascending vertically on the right of thoracic vertebrae. Most thoracic vein studies have focused on tributary patterns, but some have noted more leftward AV courses. This study statistically documents variation in AV course independent of tributary patterns. A more statistical approach to the probable position of AV at different vertical levels may aid clinicians in locating and assessing it in clinical contexts. The AV course was exposed in 84 cadavers by removing overlying viscera between the aortic hiatus and tracheal bifurcation. Subjectively, non-pathological specimens were digitally photographed in anterior view. For each photo, a scaled grid was used to mark the horizontal position of the AV center at each of five vertical levels. The summated numerical distributions showed the following: ∼5% of the AVs ascended on the right side (classical) position, ∼30% did not cross the midline, ∼70% included part or all of their course left of the midline, and ∼14% reached the extreme left side. Based on this data, the modal AV course (1) begins at, or to the right of, the midline, (2) deviates leftward, (3) crosses the midline below mid-level, (4) reaches a leftward maximum at about 3/5 of its course, (5) then deviates rightward (often only reaching the midline at the uppermost level). In several noticeable cases, the leftward maximum was associated with large connections to left-side veins, suggesting a possible tension mechanism exerting traction on the AV over time.

Coexistence of a persistent left superior vena cava (PLSVC) with a common inferior pulmonary vein (CIPV) is very rare. The electrical assessment of those thoracic veins was performed during the atrial fibrillation ablation.

Aims Fluoroscopy is necessary to implant cardioverter defibrillators using the conventional approach. Modern electroanatomic navigation systems allow the visualization of multiple catheters and, as they are capable of rendering precise geometrical reconstructions of cardiac chambers, have been used for fluoroscopy-free electrophysiological procedures. The aim of our study was to assess the feasibility of non-fluoroscopic implants using a three-dimensional navigation system. Methods and results The NavX system was used to create the virtual anatomies of heart chambers and thoracic veins. Defibrillator leads were placed at stable positions using exclusively the electrical and anatomical information provided by the navigator. A single fluoroscopy shot confirmed final lead positions. Thirty-five consecutive patients had 30 single-chamber and 5 dual-chamber defibrillators implanted. Cardiac chambers geometries were developed in 10 ± 4.3 min. Ventricular and atrial leads were implanted, with suitable positions and electrical parameters being achieved, in 18 ± 22 and 16 ± 9 min, respectively. The final confirmatory shot was the only fluoroscopy needed in 31 (89%) cases. Two patients needed fluoroscopy-guided relocation of the ventricular lead due to high defibrillation threshold and a breakdown of the active-fixation mechanism, respectively. In one patient the ventricular lead was totally extracted and reimplanted because a loop has formed in the vena cava, and one patient required fluoroscopy-guided subclavian puncture. In five cases (16%), the position of the proximal defibrillation coil was minimally modified with fluoroscopy due to incomplete geometric reconstruction of the superior vena cava. Conclusion Fluoroscopy-free defibrillators implantation is feasible using a navigation system. Suitable placement of the proximal coil is a critical stage and requires a reliable and complete reconstruction of the superior vena cava.

Background The majority of patients with recurrence of arrhythmia after the initial atrial fibrillation (AF) ablation procedure have resumption of pulmonary vein (PV) conduction. Adenosine-infusion test after PV isolation identifies acute dormant PV conduction during the index procedure. Objective To evaluate the utility of adenosine-infusion test at a repeat AF ablation procedure. Methods This study included 50 consecutive patients (38 men; mean age 65±9 years) who underwent second ablation procedure for recurrent atrial tachyarrhythmia(s). At the index procedure, which was undertaken for paroxysmal AF, all patients underwent PV isolation and 48 of 50 (96%) underwent superior vena cava (SVC) isolation followed by adenosine infusion. PV and SVC were reisolated—if found reconnected—at the start of the second procedure. Thereafter, adenosine-infusion test was undertaken for all PVs in all patients. Results At the index procedure, adenosine infusion revealed dormant PV conduction in 15 of 50 (30%) patients. At the second procedure, after 10±10 months, PV and SVC reconnections were observed in 46 of 50 (92%) and 33 of 48 (68.8%) patients and they were reisolated. Subsequently, adenosine-infusion test revealed dormant PV conduction in 9 of 50 (18%) patients, including 3 of 50 (6%) who had no PV reconnection at the start of the procedure. In these 3 patients, transient AF resulted after adenosine infusion, and at mean 8.0±3.4 months, they were free from any atrial arrhythmia after the elimination of dormant PV conduction alone. Conclusions Adenosine-infusion test reveals dormant thoracic vein conduction associated with arrhythmia recurrence in the chronic phase after the initial PV isolation.

Background Triggers from thoracic veins have been implicated not only in the initiation, but also in the perpetuation of paroxysmal atrial fibrillation (PAF). To investigate their role we studied the distribution and stability of dominant frequencies (DFs) during PAF and the response to isolation of the triggering pulmonary vein (PV). Methods and Results Triggering structures inducing PAF were identified during isoproterenol challenge in 26 patients (15 males, 55 ± 8.5 years). During sustained PAF, sequential recordings were made with a decapolar circular mapping catheter from each PV and the left atrial posterior wall (LAPW), together with coronary sinus (CS) and right atrium (RA) recordings. DF was determined using fast Fourier transformation. Recordings were repeated after ≥15 minutes of PAF. Radiofrequency ablation was directed first at the triggering PVs. PAF initiated from the PVs in 24 patients and from RA in two. There was a significant frequency gradient from the triggering structure to the PVs, CS, LAPW, and RA (P < 0.0001). During the second recording, DF decreased at all sites (P < 0.02), but the frequency gradient remained unchanged. Despite isolation of the triggering PV, PAF continued in 53% of patients, although DF measured in the CS was lower. AF termination occurred with contralateral PV isolation in half of the remaining patients and further AF slowing was noted in the rest. Conclusions Triggering structures harbor the fastest activity during sustained PAF pointing to their leading role in arrhythmia perpetuation. However, nontriggering PVs also seem to contribute to PAF maintenance.

Background— Pulmonary vein reconnection after electrical isolation is commonly observed in the context of atrial fibrillation ablation and is associated with recurrent atrial tachyarrhythmias. Adenosine test was been performed to identify acute dormant conduction immediately after pulmonary vein isolation at index procedure. However, the utility of adenosine test at repeat procedure has not been reported. Methods and Results— We report 5 paroxysmal atrial fibrillation cases without any structural heart disease in which dormant thoracic vein conduction was associated with recurrent atrial tachyarrhythmias. All patients had undergone circumferential ipsilateral pulmonary vein isolation at the index procedure. Superior vena cava isolation was performed if superior vena cava–triggered atrial fibrillation was identified. At the index procedure, adenosine test did not provoke venous reconduction. At the repeat procedure, adenosine provoked clinical arrhythmia in 4 out of 5 cases after transient reconnection between culprit thoracic vein and atrium despite absence of reconnection at the start of the procedure. After the elimination of the dormant conduction gaps, all patients were free from recurrent arrhythmia. Conclusions— Adenosine provokes dormant thoracic vein conduction associated with the late recurrence of atrial tachyarrhythmias after previous thoracic vein isolation. Thus, adenosine provocation test can specifically help identify and target the cause of recurrent atrial arrhythmia.

Objective and background: Central vein stenosis occurs commonly after instrumentation of the major thoracic veins. We aimed to investigate factors that contributed to this condition in an Asian hemodialysis population, and the results of intervention. Patients and methods: Hemodialysis patients diagnosed with central vein stenosis between January 2003 and December 2008, were identified from the records of the National University Hospital, Singapore. Eligible controls had a minimum of 2 years of hemodialysis via an arteriovenous fistula and/or central venous catheter, without clinical or radiological evidence of central vein stenosis. Results: Central vein stenosis was diagnosed in 108 patients. The most common presenting features were arm swelling (32%) and failed hemodialysis catheter insertion (28%). The median frequency of permanent hemodialysis catheter insertion in those who subsequently developed venous stenosis (1.44 per patient per year) was 4 times that of controls (0.36 per patient per year; p Conclusion: Central vein stenosis is associated with a higher frequency of hemodialysis catheter insertion and access surgery. Efforts to decrease permanent hemodialysis catheter use should reduce the incidence of central vein stenosis.

Anatomy of Myocardial Extensions in Thoracic Veins. Introduction: Radiofrequency ablation for atrial fibrillation (AF) frequently involves energy delivery at the ostia of the thoracic veins. Detailed evaluation of the myocardium extending into the caval veins, vein of Marshall, as well as at the pulmonary vein ostia has not been completely evaluated. Methods and Results: Post-mortem assessment of 620 formalin-fixed hearts (mean age 60 ± 23 years, 44% female) was performed. The hearts were examined for integrity of venous structures and their atrial connections. Systematic gross anatomic evaluation including measurements on myocardial extensions in these veins was performed. Macroscopic myocardial extensions into pulmonary veins were noted in 99% of specimens evaluated and were circumferentially symmetric (99.6%). Myocardial extensions into the superior vena cava (SVC) occurred in 78% with the majority being circumferentially asymmetric (61%). Occasionally, myocardium extended into the azygos vein (6%). There were no myocardial extensions in the inferior vena cava (IVC). In some cases, the right atrial pectinate muscle extended into the coronary sinus (7%). The vein of Marshall was consistently located anterior to the left-sided pulmonary veins and posterior to the left atrial appendage, overlying the left atrial endocardial ridge. Conclusions: Myocardial extensions into the pulmonary veins are usually circumferential at the ostia validating the necessity for wide area rather than segmental ablation to isolate these veins during AF ablation. Myocardial extensions into the SVC are common and less likely to be circumferential, whereas extensions into the IVC are not present. The left atrial ridge is a reliable endocardial target for radiofrequency ablation of the vein of Marshall. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1304-1309, December 2012)

The objective of this study was to investigate the prevalence, electrophysiologic properties, and clinical implications of dissociated pulmonary vein (PV) activity after PV antrum isolation (PVAI) in patients with paroxysmal atrial fibrillation (AF). One hundred seventy-three consecutive patients (61 ±10 years old, 141 men) with drug-refractory paroxysmal AF who underwent AF ablation were analyzed. After identification of arrhythmogenic foci, PVAI was performed in all patients. Of the total 346 isolated ipsilateral PVs, 97 (28.0%) were silent, 35 (10.1%) demonstrated isolated ectopic beats, 209 (60.4%) demonstrated a regular ectopic rhythm, and 5 (1.4%) demonstrated fibrillatory activity. The culprit thoracic vein was identified in 77 patients (44.5%). After isolation of ipsilateral PVs, venous activity was observed in 68 (79.1%) and 178 (68.5%) PVs among the 86 PVs with AF triggers and 260 PVs without AF triggers, respectively (p = 0.06). There was no significant difference in the incidence of acute PV reconnections exposed by adenosine triphosphate between the 97 silent ipsilateral PVs and 209 ipsilateral PVs with dissociated PV activity after the PVAI (20.6% vs 19.1%, p = 0.78). After a mean follow-up of 48.7 ± 7.9 months there was no significant difference in rates of freedom from atrial tachyarrhythmias after a single procedure between patients with and those without dissociated activity (62.1% vs 63.3%, p = 0.74, log-rank test). In conclusion, although dissociated PV activity appearing after PV isolation is an important electrophysiologic finding to prove bidirectional conduction block between the left atrium and the PV during the procedure, the clinical implications might be limited.

Recurrent vasculitis and vein thrombosis, including involvement of the superior vena cava, are serious complications of Behcet's disease, and may present an obstacle during implantation of permanent endocardial transvenous pacemaker and/or automatic defibrillator. Six male patients, known to suffer from Behcet's disease, who required pacemaker and/or defibrillator therapy were investigated. Both invasive (phlebography) and non-invasive (echo-Doppler and isotopic angiography) vascular imaging techniques were available. In one patient, total occlusion of the upper thoracic veins was demonstrated by angiography. In a second patient, following implanted defibrillator, partial left subclavian vein obstruction was demonstrated by the two noninvasive methods. In the remaining four patients, patency of the upper thoracic veins was demonstrated, prior to and following pacemaker implantation, by the two noninvasive methods, with a good correlation. As echo-Doppler or isotopic angiography are widely available, easy to perform and reproducible, it is suggested that upper thoracic vein patency in patients with Behcet's disease should be evaluated prior to and following such vascular procedure, by one of these methods, in order to prevent unnecessary attempts to cannulate obstructed or stenosed vessels.

Infants and rats with congenital diaphragmatic hernia (CDH) have malformations of the heart and the great arteries caused by neural crest (NC) dysregulation during embryogenesis. Abnormally narrow jugular veins have been found in babies during cannulation for ECMO. However, the venous system has not been examined in depth so far. We hypothesized that abnormal patterning and/or size of the thoracic veins could occur in rats with CDH. This hypothesis was tested by microscopic magnetic resonance imaging (MMRI), a high-resolution tool able to detect subtle changes of vessels in small animals. Fetuses from pregnant rats fed either 100 mg i.g. nitrofen or vehicle on E9.5 were recovered near term. A 7 T MMRI system with a coronal multislice fast spin echo sequence allowed diagnosis of CDH (n = 19), and T2 SE high-resolution sequences made assessment of the pattern and width of cervico-thoracic veins possible. Values were corrected for body size by dividing them by the length of thoracic vertebrae T3–T5. The results in nitrofen and control (n = 11) groups were compared by non-parametric tests (*p

Ablation procedures for atrial fibrillation (AF) have become an established and increasingly used option for managing patients with symptomatic arrhythmia. The anatomic structures relevant to the pathogenesis of AF and ablation procedures are varied and include the pulmonary veins (PVs), other thoracic veins, the left atrial myocardium, and autonomic ganglia. Exact regional anatomic knowledge of these structures is essential to allow correlation with fluoroscopy and electrograms, and, importantly, to avoid complications from damage of adjacent structures within the chest. We have presented this information in a 2-part series. In the present article, we examine the general anatomic characteristics of the PVs, superior vena cava, and vein of Marshall. Features of particular relevance for the invasive electrophysiologist are pointed out. In a subsequent article, we discuss the regional anatomy of the left and right atria and anatomic considerations in preventing complications during AF ablation.

The thoracic venous system can be visualized and characterized well with MR imaging. In this article, MR sequences that are suited for this purpose (including the more advanced techniques) are reviewed. The normal thoracic venous anatomy and a brief summary of its embryogenesis is provided. The appearances of congenital and acquired abnormalities of the systemic and pulmonary thoracic veins are described. This article also discusses recent applications of MR imaging in the evaluation of the pulmonary veins and the left atrium in patients who have atrial fibrillation.