Okajimas Folia Anat.Coexistence Jpn., 91(3): of 73–81, postaortic November, veins 201473 Anatomical study of the coexistence of the postaortic left brachiocephalic vein with the postaortic left renal vein with a review of the literature By Akira IIMURA1, Takeshi OGUCHI1, Masato MATSUO1 Shogo HAYASHI2, Hiroshi MORIYAMA2 and Masahiro ITOH2 1Dental Anatomy Division, Department of Oral Science, Kanagawa Dental University, 82 Inaoka, Yokosuka, Kanagawa 238-8580, Japan 2Department of Anatomy, Tokyo Medical University, 6-1-1 Shinjuku-ku, Tokyo, 160, Japan –Received for Publication, December 11, 2014– Key Words: venous anomaly, postaortic vein, left brachiocephalic vein, left renal vein Summary: In a student course of gross anatomy dissection at Kanagawa Dental University in 2009, we found an extremely rare case of the coexistence of the postaortic left brachiocephalic vein with the postaortic left renal vein of a 73-year-old Japanese male cadaver. The left brachiocephalic vein passes behind the ascending aorta and connects with the right brachio- cephalic vein, and the left renal vein passes behind the abdominal aorta. These two anomalous cases mentioned above have been reported respectively. There have been few reports discussing coexistence of the postaortic left brachiocephalic vein with the postaortic left renal vein. We discuss the anatomical and embryological aspect of this anomaly with reference in the literature. Introduction phalic vein (PALBV) with the postaortic left renal vein (PALRV). These two anomalous cases mentioned above Normally, the left brachiocephalic vein passes in have been reported respectively. There have been few or front of the left common carotid artery and the brachio- no reports discussing coexistence of the PALBV with the cephalic artery and connects with the right brachioce- PALRV. phalic vein. The superior vena cava is formed by the Based on the observations of these anomalous cases, right and left brachiocephalic veins. The azygos vein we discuss ourvariation case from the anatomical and joins the superior vena cava just before it enters the embryological aspects in the present study. right atrium in the upper right anterior part of the heart. There have been reports discussing a variation, which shows that the left brachiocephalic vein passes behind the Subject and Methods ascending aorta and connects with the right brachioce- phalic vein (Kerschner, 1888; Daser, 1902; Ghon, 1908; This article describes dissection of a 73-year-old Japa- Nützel, 1914; Martin, 1931; Walter, 1931; Adachi, 1933; nese male cadaver during routine educational dissection Freidman, 1945; Jakubczik and Zeigler, 1963; Yoshida at the laboratory of anatomy of Knagawa Dental Univer- and Fukuyama, 1975; Kitamura, 1981; Yoshida, 1984; sity. Tsujimura, 2007; Ohsawa, 2011). The cause of death was cerebral hemorrhage. Gross On the other hand, with regard to the renal veins, there dissections was performed according to the usual proce- has been a report discussing a anomaly, which shows that dures, and the PALBV and PALRV were morphologically the left renal vein passes behind the abdominal aorta. observed. Slide calipers were used for the measurements. During routine educational dissection, we encountered a case of coexistence of the postaortic left brachioce- Corresponding author: Akira Iimura, Dental Anatomy Division, Department of Oral Science, Kanagawa Dental University, 82 Inaoka, Yokosuka, Kanagawa 238-8580, Japan. E-mail: [email protected] 74 A. Iimura et al. Part I. The postaortic left brachiocepalic vein (PALBV) Results Right and left brachiocephalic veins The left internal jugular, left external jugular and left subclavian veins joined to form the left brachiocephalic vein (width 26.2 mm; diameter, 16.7 mm). The left brachiocephalic vein went downward into the thorax, and passed in front of the left subclavian artery. And the vein ran across the thorax from left to right, below the proximal portion of the aortic arch and behind the ascending aorta and joined the right brachiocephalic vein, which forms the superior vena cava. At this point the left brachiocephalic vein passed above the pulmonary artery through the lateral side of the ligamentum arteriosum Fig. 1. Diagram of the heart and vessels of this case. The left brachio- (Fig. 1 and 2). cephalic vein passed the ventral side on the left side of the aortic There was a bulge of 25.3 mm in diameter 23.8 mm arch. It then ran laterally on the left side of the ligamentum arte- to the left of the junction of the right and left brachio- riosum and on the dorsal side of the ascending aorta and joined cephalic veins. No veins equivalent to the normal left the right brachiocephalic vein to form the superior vena cava. At this site the left brachiocephalic vein passed lateral to the brachiocephalic vein, which passed in front of the ligamentum arteriosum. The left vertebral artery arose from the brachiocephalic artery and left common carotid artery, upper wall of the aorta as a point of divergence between the left were observed. The superior vena cava (diameter, 23.3 common carotid artery and left subclavian artery. mm) was formed by the union of the left brachiocephalic vein and right brachiocephalic vein (diameter, 16.2 mm; length, 53.9 mm). After receiving the azygos vein (diam- eter, 11.8 mm), the right brachiocephalic vein connected with the left brachiocepalic vein. The length of the supe- rior vena cava was shorter than the normal one, but the opening to the right atrium was normal (Fig. 3). The azygos vein was incompletely formed, and no hemiazygos veins were observed. This vein passed in front of the lumbar vertebral body from the lower side to the upper side and joined the right brachiocephalic vein. On the left side, several intercostal veins were connected to each other and drained into the azygos vein. The vein, which joined the azygos vein at the level of the 4th thoracic vertebra, received the 1st to 3rd intercostal veins. Accordingly, it is considered that this vein corresponds to the accessory hemiazygos vein.The vein, which joined the azygos vein at the levels of the 6th and 8th thoracic vertebrae, received nearby two intercostal veins. Other left intercostal veins independently connected with the azygos vein respectively. The azygos vein connected with the right brachiocephalic vein, not the superior vena cava. The (1st-4th) intercostal veins of the right upper chest had connected with each other, and entered the azygos vein (Fig. 4). Fig. 2. Anterior view of the heart. The right and left brachiocephalic Left vertebral artery veins descended so as to be on either side of the aortic arch. The The left vertebral artery ( diameter, 4.0 mm ) arose left brachiocephalic vein passed in front of the left side of the from the aortic arch between the left common carotid aortic arch and the left side of the ligamentum arteriosum. This vein went further behind the ascending aorta. artery and left brachiocephalic artery. The left vertebral artery ascended along the left common carotid artery, and entered the transverse foramen of the 5th cervical Coexistence of postaortic veins 75 Fig. 3. Posterior view of the heart. The left brachiocephalic vein Fig. 4. Azygos vein. The hemiazygos vein formation was insufficient. passed between the aorta and pulmonary artery, and joined the The left intercostal vein directly joined with the azygos vein, right brachiocephalic vein to form the superior vena cava. An otherwise two left intercostal veins united with each other to join azygos vein joined the right brachiocephalic vein just above the the azygos vein. In the upper intercostal part, formation of an junction between the right and left brachiocephalic veins. accessory hemiazygos vein was confirmed. vertebra. Normally, the vertebral artery enters the trans- verse foramen of the 6th cervical vertebra (Fig. 5). Discussion The incidence Such a anomaly is referred to by the PALBV. There have been some morphological reports on the PALBV in dissecting cadavers (Kerschner, 1888; Daser, 1902; Ghon, 1908; Nützel, 1914; Martin, 1931; Walter, 1931; Adachi, 1933; Freidman, 1945; Jakubczik and Zeigler, 1963; Yoshida and Fukuyama, 1975; Kitamura, 1981; Yoshida, 1984; Tsujimura, 2007; Ohsawa, 2009; R.Ohsawa, 2011). The reports on the anomaly except those based on dissec- tion, were based on the observations during the clinical diagnosis and operation. When the clinical diagnosis cases and operation cases were combined, the number Fig. 5. The left vertebral artery. The left vertebral artery arose from of reports would exceed 100. In the 1970s, the majority the upper wall of the aortic arch between the left common carot- id artery and the left subclavian artery, and had entered the 5th of the reports on the anomaly have dealt with the cases transverse foramen. observed by operation. After the 1980s however, the anomaly which was observed with diagnostic imaging apparatuses including computed tomography (CT) and magnetic resonance with cardiovascular disease into the following groups: imaging (MRI), has increasingly been reported. (Curtil, (1) Coexistence with cardiac disease; 1999; Bartoli, 1990; Kaneko, 1995; Nakanura, 1995; (2) Coexistence with cardiac disease and an anomaly of Gülsün, 2003; Yilmaz, 2007; Nagashima, 2010). Several the aortic arch; and reports have shown in the patients who have had congen- (3) Coexistence with an anomaly of the aortic arch. ital heart disease such as tetralogy of Fallot that the inci- The present anomalies; it is highly associated with dence of the anomaly is high. (Kitamura, 1981; Curtil, cardiac anomalies and aortic arch anomalies including 1999; Nagashima, 2010). the right aortic arch and cervical aortic arch (Nagashima, Nagashima classified the anomaly, which coexisted 2010). Minami(1993) indicated correlation of the high 76 A. Iimura et al. aortic arch with the postaortic left brachiocephalic cephalic vein passing the dorsal side of a branch of the vein. The incidence of the postaortic left brachioce- aortic arch; type c, the PALBV passing ventral side of the phalic vein was only 0.02% in patients without congen- ligamentum arteriosum (Adachi’s type I); and type d, the ital heart disease (Nagashima, 2010).