Compression of the Left Innominated Vein between the Brachiocephalic Trunk and Left Carotid Artery

Aortosternal Venous Compression: A Review of Two Cases

“…The prevalence of AVC has not been well characterized due to its rarity. A study in hemodialysis patients undergoing fistulograms identified some degree of extrinsic compression of the brachiocephalic vein in 44% of patients [ 7 ].…”

“…Contrast-enhanced chest CT and diagnostic venography are imaging modalities that can be utilized to diagnose AVC. Initial imaging with ultrasound may demonstrate sluggish flow and/or intraluminal thrombus in the left subclavian, brachiocephalic, or left IJV, however, these findings are nonspecific as they primarily relate to proximal stenosis or obstruction, and thus further investigation into AVC or brachiocephalic vein compression is warranted with cross-sectional imaging [ 7 ]. Based on a retrospective review of the literature, the importance of cross-sectional imaging for the evaluation of anatomical variation and in establishing the etiology of venous compression has been established [ 2 , 8 , 9 ].…”

“…Therefore, in the appropriate clinical setting, chest CT (with inspiratory and expiratory phase) can be utilized as the initial imaging modality to exclude an extrinsic venous compression etiology such as a mediastinal mass, aortic aneurysmal dilation, or compression secondary to the aortic arch anomaly. Even though the rare association of AVC with the aberrant right subclavian artery is noted in the literature, such a finding can be visualized on contrast-enhanced CT [ 7 ]. Once the brachiocephalic vein compression is suspected on CT, the next step of performing a diagnostic venogram can aid in real-time fluoroscopic evaluation, again in the setting of the inspiratory and expiratory phase, with the latter demonstrating venous compression.…”

“…A literature review also demonstrated that self-expanding stents can successfully treat symptomatic stenosis of the brachiocephalic vein, particularly in hemodialysis patients where dialysis access may be threatened [ 4 ]. However, due to the extrinsic nature of compression, stents are not recommended in AVC patients due to limited patency and allowable volume changes of the vascular space during respiration [ 7 , 14 ]. In the setting of the patient not being a surgical candidate and failing conservative management, the stenosis could potentially be treated with self-expandable stents.…”

“…In the setting of the patient not being a surgical candidate and failing conservative management, the stenosis could potentially be treated with self-expandable stents. Notably, balloon expandable stents should also be avoided in AVC management as they can be crushed and can migrate secondary to external compression [ 7 ]. In severe cases of venous compression syndromes, operative decompression of the thoracic inlet including manubrioplasty has been employed as a radical approach to address the underlying anatomy [ 12 ].…”