Anatomical Study of the Coexistence of the Postaortic Left Brachiocephalic Vein with the Postaortic Left Renal Vein with a Review of the Literature

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

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 brachiocephalic 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 brachiocephalic 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 (diameter, 11.8 mm), the right brachiocephalic vein connected with the left brachiocepalic vein. The length of the superior 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 transverse 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 dissection, 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 carotid 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). On the other hand, vein passing the dorsal side of the ligamentum arteriosum Curtil (1999) reported that the incidence of the varita- (Adachi’s type II). tion in patients with congenital cardiopathy was 0.5%. Yoshida added a type, which involves an intricate Nagashima (2010) reported that the incidence of the congenital cardiovascular disease, to Kitamura’s 4 anomaly in patients with congenital cardiovascular types. Curtil (1999) indicated 3 types of PALBV, which disease was 0.57%, being nearly consistent with that by was composed of Adachi’s 2 types and an additional Curtil (1999). These two investigators reached agreement type. This additional type of PALBV passes a place at a on the incidence. In addition, Nagashima (2010) reported distance from the ligamentum arteriosum. that there is no sex difference in the incidence of the variation which coexisted with congenital cardiovascular Embryology disease. Embryologically, it has been said that the right and left anterior cardinal veins and the right common cardinal Structural characteristics vein, which appear during the fetal period, participate Adachi (1933) has indicated two characteristics of in formation of the brachiocephalic veins and the supe- the anomaly: One is that the superior vena cava in the rior vena cava (Davies and Coupland, 1967;, Hamilton, anomaly is shorter than in the normal case; and the other 1972). In normal formation of the left brachiocephalic is that the azygos vein drains into the right brachioce- vein, the left anterior cardinal vein and left common phalic vein, not into the superior vena cava. The reasons cardinal vein disappear. for these characteristics are that the left brachiocephalic And then, it has been considered that the superior vena vein passes behind the ascending aorta and that the junc- cava and the brachiocephalic veins are composed of three tion between two brachiocephalic veins is lower than in parts, the right common cardinal vein, the right anterior a normal case. As previously indicated, coexistence of cardinal vein, and the ventral anastomosis between the these anomalies and congenital cardiac disease is also right and left anterior cardinal veins. one of the characteristics. In our case, the anomalous left With regard to formation of the PALBV, Adachi vertebral artery arose from the aortic arch. (1933) assumed, as follows: The PALBV developed Furthermore, Daser (1902) and Jakubczik (1963) have because the anastomosis between the right and left ante- reported the same cases as ours, Tsujimura (2007) and rior cardinal veins was formed behind the primodium Ohsawa (2009) have indicated the coexistence with the of the ascending aorta for some reason. Walter (1931) double aortic arch, and Kaneko (1955) has reported the reported that the PALBV developed from the venous coexistence with the right aortic arch. These observations network lying behind the primodium of the ascending may indicate that the rates of coexistence of the PABL aorta. Adachi (1933)assumed about formation of the with not only the venous anomaly but also the arterial anteaortic and postaortic left brachiocephalic vein, as anomaly are high. follows: In the early stage of development there were At the 8th week of normal fetal development, the two kinds of transverse vessel, which connect between ventral precardinal anastomosis develops between the the right and left anterior cardinal veins. One of them right and left precardinal veins. On the other hand, the passed the anterior side of the ascending aorta,and the aortic arch is formed between the 6th and 7th weeks of other passed the posterior side of it. For some unknown fetal development. It is therefore considered that the reason, however the anterior transverse connection cause of the abnormalities arose duringthe period of the disappears and the posterior one enlarges, and forms morphogenesis of the brachiocephalic vein and aortic the PALBV. Kim (1999) suggested that, in addition to a arch. ventral precardinal anastomosis, some minor intercon- nections would exist between the right and left anterior Classification cardinal veins in the early stage of development in the Adachi (1933) classified the PALBV into two mediastinum, and that if the normal left brachiocephalic following types on the basis of positional relation vein failed to develop, one of these minor interconnec- between the left brachiocephalic vein and the ligamentum tions would act as the PALBV . arteriosum. In type I, the PALBV passes the ventral side Furthermore, Kim (1999) indicated that the causes of of the ligamentum arteriosum and enters the dorsal side the interference with normal development of veins are of the ascending aorta; in type II, the vein passes the anomalies of the aorta, which include the cervical aortic dorsal side of the ligamentum arteriosum and enters the arch, double aortic arch, and the right aortic arch. Conse- dorsal side of the ascending aorta. quently, alteration of the aortic arch, which narrows the Kitamura (1981) classified the PALBV into 4 prevascular space and enlarges the subaortic space, following types: Type a, normal; type b, the left brachio- increases potential for development of the PALBV. The Coexistence of postaortic veins 77

we need to pay attention to the positional relationship between the ductus arteriosus and PALBV in the surgical operation of patent ductus arteriosus.

Abbreviaation for Figures Part I AA: aortic arch ACHV: accessory hemiazygos vein ALIG: arteriosum lilgament AZV: azygos vein CCV: common cardinal vein CS: coronary sinus IVC: inferior vena cava LACV: left anterior cardinal vein LBV: left brachiocephalic vein LCCA: left commoncarotid artery LHSV: left horn of sinus venous Fig. 6. Diagrams of the venous development and differentiation. In the LPA: left pulmonary artery early stage of development, the anterior and the posterior cardi- LPV: left pulmonary vein nal veins and the common cardinal vein were formed symmetri- LSA: left subclavian artery cally. LVA: left vertebral artery PALBV: postaortic left brachipcephalic vein RACV: right anterior cardinal vein PALBV, which develops after obstruction of the normal RBA: right brachiocephalic artery LBV (Nagashima, 2010), supports the hypothesis of Kim RBV: right brachiocephalic vein (1999). A probability for the PALBV coexist to with the RICV: right intercostal vein arterial variation is high. In this regard, the case reported RPA: right pulmonary artery by Kim (1999) is consistent with our case of anomaly of RPCV: right posterior cardinal vein the vertebral artery. The directionality is consistent with SVC: superior vena cava the opinion that both the brachiocephalic vein and verte- TG: thyroid grand bral artery are also formed during the period from the 7th to 8th embryonic weeks (Fig. 6). Part II. The postaortic left renal vein (PALRV) Clinical importance Kitamura (1981) indicated that the increasing cardio- There are hardly any reports discussing detailed vascular imaging diagnosis reveals the clinical impor- morphological observations on the postaortic left renal tance of these anomalies. Actually, many reports on vein (PALRV) in Japan. From Kitamura’s report (1978) PALBV cases in the 1980s have been made as clinical onward, there have been only three reports (Okamoto, reports owing to the development of medical diag- 1990; Izumiyama, 1997; Yoshinaga, 2000). The devel- nostic imaging apparatuses. (Cloez, 1982; Webb, 1982; opment of clinical imaging examinations involving CT Fujimoto, 1992; Curtil, 1999) and MRI has increased the number of reports on PALRV. Although the PALBV does not indicate any clin- However, there was litte or no detailed description of ical symptom, probabilities for the PALBV to coexist morphological observations on PALRV. Faced with this with congenital heart malformation and aortic anomaly situation, we discussed the anatomical and embryological are high (Curtil 1999, Gülsün 2003, Tsujimura 2007, aspects of the variation on the basis of observations of Nagashima 2010). Therefore, it is important to perform our case. the preoperative examination, assuming that the PALBV is present (Curtil, 1999; Gülsün, 2003; Tsujimura, 2007; Nagashima, 2010). From the standpoint of chest surgery, Results Nakamura (1995) has recommended that PALBV should not be confused with the pulmonary artery or lymph The left adrenal vein did not enter the left renal vein. It node, when making the diagnosis of PALBV. arose from the adrenal gland ( diameter of its origin, 5.4 Furthermore, he has said that it is important to pay mm), run transversely just beneath the superior mesen- attention to damage on this blood vessel, for the sake of teric artery, and entered the inferior vena cava at the same safely performig surgical operation. The vascular varia- level of the 2nd lumbar vertebral body same as the right tion indicates a close positional relationship between the renal vein. Three venous branches of the left kidney arose ductus arteriosus and ligamentum arteriosum. Therefore, from the renal hilus, and combined at the level of the 3rd 78 A. Iimura et al.

Fig. 7. The PALRV located in the abdominal cavity. In the lower part Fig. 8. Enlarged image of the abdominal cavity. The left adrenal vein, of the abdominal aorta which is lower than the origin of the left which passed the lower edge of the superior mesenteric artery, adrenal vein, the abdominal aortic aneurysm was recognized. was confirmed. Since the left renal vein passes just behind the On the right side of the abdominal aorta the inferior vena cava abdominal aortic aneurysm, it is predicted that the aneurysm is existed. Normally, the right kidney is located lower than the left strongly compressing this vein. The left renal vein receives the kidney. In this case, however, the left kidney was located ap- left testicular vein on the caudal side. proximately one vertebral body lower than the right kidney. The right renal vein joined the inferior vena cava at the level of the origin of the superior mesenteric artery. The left renal vein arose from the renal hilum and passed downward obliquely behind the abdominal aorta. Eventually, this vein joined the inferior vena cava at the level of the 3rd lumbar vertebra. The left adrenal vein, which usually joins the left renal vein, passed in front of the abdominal aorta and joined the inferior vena cava at the level of the right renal vein.

lumbar vertebral body to form the left renal vein (Fig 7, 8 and 9). The left testicular vein (diameter, 2.9 mm) joined the left renal vein 17.4 mm proximal to the confluence of the three venous branches.The left renal vein received a lumbar vein at the lower edge of this renal vein, and received a vein that connected with an azygos vein at the upper edge of the renal vein. The left renal vein passed beneath the abdominal aorta and entered the inferior vena cava at the level of the 4th lumber vertebral body. Fig. 9. After resection of the abdominal aorta which exists on the This site of the inferior vena cava was located 41.2 mm anterior side of the left renal vein. The left renal vein was com- distal to the place where the adrenal vein joined the infe- pressed to spread over the cranial and caudal sides. The ascend- rior vena cava. The diameter of the place where the left ing lumbar vein joined the left renal vein from the upper part. renal vein is joined to the inferior vena cava was 9.7 mm. The distance between the place where the left renal vein joined the inferior vena cava and the point of divergence (diameter, 8.3 mm) joined the inferior vena cava. At the between the bilateral common iliac veins was 71.5 mm. site 40.5 mm distal to the point of confluence of the right The inferior vena cava (AV diameter, 20.7 mm) is formed renal vein, the right testicular vein joined the left lateral by confluence of the bilateral common iliac veins at the wall of the inferior vena cava. On the proximal side of the level of the 5th lumbar vertebral body. The inferior vena inferior vena cava at the point of confluence of the left cava ascended along the right side of the lumbar vertebral adrenal vein, the inferior vena cava was 19.2mm in diam- body and received the left renal vein in the mid-course eter, and further extended upward. The right renal artery of the ascent. At the site 50.7 mm proximal to the point arose from the abdominal aorta at the level of the supe- of confluence of the left renal vein, the right renal vein rior mesenteric artery. There was a difference in height Coexistence of postaortic veins 79

Fig. 10 and 11. The specimen resected en bloc from of the kidney, adrenal gland, and renal venous system. The measurements in this specimen. The left kidney was located lower than the right kidney, and the width and length were shorter than those of the right kidney. However, the spread of the renal hilum of the left kidney was more than the right kidney. It is obvious that there was a difference in height of the junction between the right and left renal veins and the inferior vena cava. Behind the abdominal aorta, the left renal vein was receiving the ascending lumbar vein and the 3rd lumbar vein. Consequently, the diameter of the junction between the inferior vena cava and the left renal vein was extended. between the sites where the right and left renal arteries attributed to formation of the PALRV (McClure and arose from the abdominal aorta. There was a difference in Butler, 1925; Kitamura, 1979). Namely, the PALRV height between the right and left renal arteries. The differ- would be formed if the dorsal part of the sub-supracar- ences in height between these two renal arteries corre- dinal anastomosis and the intersupracardinal anastomosis sponded to half the length of the lumbar vertebral body persisted and if the ventral part of the sub-supracar- (Fig. 10 and 11). dinal anastomosis and the intersubcardinal anastomosis regressed. The renal venous system and the parietal veins including its longitudinal anastomotic veins develop Discussion symmetrically. However, because the right inferior vena cava developed as the main drain passage of the infe- Incidence rior venous system, some differences arose between the Kitamura (1979) has referred to reports discussing right and left sides of the inferior venous system. Based the PALRV (Seib, 1934: 2.1%; Pick, 1940: 3.4%; Davis, on these theories, Izumiyama (1997) has presented a 1958: 2%; Reis, 1956: 2.4%; Davis, 1968: 1.8%), figure showing the development of the inferior venous and indicated that the mean incidence of this vein is system. Izumiyama (1997) has indicated the primitive 1.8–3.4%. Recent anatomical reports on the incidence of model of the symmetrical venous network formed by the anomaly have shown 0.49% by Yoshinaga (2000), the renal venous system and the parietal veins. Based on 0.74% by Okamoto (1990), and 0.75% by Izumiyama the model, the following is understood : A venous part, (1997). In these reports, the range of the incidence was which usually disappears, persists and another venous narrow. In recent years, owing to the development of part, which usually persists, disappears. In this process medical diagnostic imaging apparatuses, clinical case of anomalous veins are constructed. In many cases, the renal the anomaly is being increasingly reported. In these clin- collar is formed by two rami which branched off from the ical reports, however any detailed assessment like the one 2nd lumbar vein. One of them connects with the left renal shown in anatomical reports has not been performed. vein, and the other connects with the right inferior vena cava. It has been believed that this hypothesis is applied Embryological aspect to the 3rd lumbar vein as well. In the investigation by It has been said that the disappearance of the ventral Izumiyama (1997), it has been reported that the renal part of the renal collar and its remainig dorsal part, are collar was formed by the 2nd lumbar vein in 7/149 cases, 80 A. Iimura et al. the 3rd lumbar vein in 6/149 cases, and the 4th lumbar vein in 1/149 cases. Some reports have shown that there is no influence of height of the lumbar vein on formation of the renal collar. In two cases by Izumiyama, however, the postaortic left renal vein has passed through the 3rd lumbar vein. Even in our case, the PALRV was formed at the level of the 3rd lumbar vein, and the left renal vein was located lower than the right renal vein. Incontrast, at the same level as the right renal vein, the left adrenal vein passed the lower edge of the point of divergence of the superior mesenteric artery and ran across in front of the abdominal aorta. Eventually, it drained into the inferior vena cava (Fig. 7). Usually, the left adrenal vein joins to the left renal vein which passes in front of the abdominal aorta. We considered that the route between this adrenal vein and the inferior vena cava was the same as the normal left renal vein. Fig. 12. The diagram of the developmental process of the venous net- In view of the development of the inferior vena cava, the work. Citation from Izumiyama (1997). Izumiyama explained reason why the dorsal route was located in lower than formation of the PALRV from the diagram which indicated the the ventral route is the embryological differences among renal venous system and parietal venous system by using the parts of the inferior vena cava. The central portion of the aorta as an axis. The lumbar vein of each height formed com- munication with the ascending lumbar vein and joined the right inferior vena cava which receives the renal vein system, inferior vena cava. Usually, the lumbar venous system passes is derived from the subcardinal vein. The lower portion of behind the abdominal aorta, while the left renal venous system the inferior vena cava, which receives the parietal vnous passes in front of the abdominal aorta. As a result, the renal vein system, is derived from the supracardinal vein. The dorsal collar is formed by the anastomosis between the lumbar venous route is closely related to the parietal vein, and embryo- system and renal venous system. After these morphogenetic phenomena, the following transformation occurs. If the renal logically the parietal vein is formed by the supracardinal venous passage in front of the abdominal aorta disappeared, and vein.Consequently, the dorsal route, which has close rela- the lumbar venous system behind the abdominal aorta remained, tion to the parietal vein, was located in the position lower the post aortic left renal veins would be formed : dark gray area. than the usual. The left adrenal vein of our present case passed in front of the In 4 cases reported by Okamoto (1990), in which the abdominal aorta, and this venous passage has been formed by the normal left renal venous route: light gray area. antero-aortic renal vein and post-aortic renal vein coexisted, all the posaortic renal veins were located lower than the antero-aortic renal vein. In the previous reports and our present case, a tendency of the lower left renal vein Gupta, 2011). to pass behind the abdominal aorta was confirmed. All of Nowadays, abdominal surgery is changing from the above described observations indicate that the PALRV laparotomy to laparoscopic surgery. Therefore, to avoid has close association with height of the left kidney (Fig. vascular injury due to inadvertence as well, meticulous 12). confirmation of the abdominal vascular system before surgery is increasingly be coming important. Clinical implication There are two kinds of significant problem with the Abbreviation for Figures Part II PALRV;one is the renal function due to the anomaly, AbA: abdominal aorta and the other is surgical treatment of the kidney and ASLV: accending lumbar vein its circumferential organs. Functionally, it is said that IVC: inferior vena cava compression to the left renal vein between the aorta and LAG: left adrenal grand the lumbar vertebrae increases the pressure of the left LAV: left adrenal vein renal vein, probably having led to hematuria and conges- LK: left kidney tion of the left kidney (Jong Kil Nam; 2010, Anupma LRA: left renal artery Gupta; 2011). It is important to know the presence of LRV: left renal vein anomalies of the renal vein, such as PALRV and renal LTV: left testicular vein collar, before surgical procedure of the abdominal aortic LU: left ureter aneurysm, retroperitoneal tumors, and kidney (Banya,H- LV: lumbar vein origuchi, 1996; Toda R;, 2001; R Gabrielli, 2009; Rajan RCIV: right common iliac vein Kumar Singla, 2010; Jong Kil Nam, 2010; Anupma RK: right kidney Coexistence of postaortic veins 81

RRV: right renal vein 1888; 3:808–823. RTV: right testicular vein 2) Daser, P. Ueber eine seltene Lage-Anomalie der Vena anonyma siniostra. Anat. Anz. 1902; 20:553–555. RU: right ureter 3) Ghon. A. Über eine seltene Entwicklungsstörung des Gefässys- SMA: superior mesenteric artery tems. Verhandelungen der deutschen pathologischen Gesellschaft in Kiel. Zbl. Path. 1908; 19:Erg-H 242. 4) Nützel, H. Beitrag zur Kenntnis der Missbildungen im Bereiche Conclusions der oberen Hohlvene. Frankf. Z. Path. 1914; 15:1–19. 5) Walter L. Über eine seltene Lageanomalie der Vena anonyma sinistra nebst Betrachtungen über Anomalien und Asymmetrien We encountered a rare anomalous case which included des Venensystems im Bereich des Kopfes und Halses. Z Anat two different venous anomalies in the same individual. 1931; 95:769–805. One of them was the PALBV, and the other was the 6) Martin. C. P. A case of congenital abnormality of the heart with PALRV. With regard to individual anomalies, there have apparently an unusual abnormality of the great vessels. J. Anat 1931; 65:395–398. independently been some reports. However, there have 7) Adachi B. Das Venensystem der Japaneer Lief 1 Kenkyusha, Kyoto been few or no reports discussing a case, in which these 1933. similar types of anomalies were present in the same indi- 8) Friedman S.M. Report of two unsusual venous abnormalities (Left vidual. This is a very rare case of these anomalies. postrenal inferior vena cava; Post-aortic left innomnate vein). Anat Embryologically, in the formative process of each Reco. 1945; 92(1):71–76. 9) Jakubczik,I, Ziegler H. Seltene Anormalien der Grossen intrathor- anomalies, the vein which joins the vena cava has existed acalen Blut- und Lymphgefassstamme. Anat. Anz. 1963; 122:257– in the anterior and posterior parts of the aorta, in the early 268. stage of development. Normally, the anterior vein forms 10) Davis DV, Coupland R.E. Gray’s Anatomy. ed34th ed 1967; the left brachiocephalic vein or left renal vein, while the 186–217. Longmans, Green and Co. Latd. London posterior vein disappears. In these anomalies, however, 11) Hamilton W. J, Boyd J. D, Mossman H. W. Human Embryology. 4thed. 1972; 261–281. Wiliams and Wilkins. Baltimore. the anterior vein disappeared, and the posterior vein 10) Yoshida Y, Fukuyama U. A case of the left brachiocephalic vein remained. Although the sites of anomalies are different passing behind the ascending aorta. Chiba Igaku 1975; 51:157– from each other, it is suggested that there was also the 159. (in Japanese) possibility of common factors for formation of anomalies 12) Kitamura S, Sakai A, Nishiguchi T. A case of the left innom- having existed. inate vein passing behind the ascending aorta. Anat. Reco 1981; 201:567–572. Subsequently, the right side of these cardinal veins 13) Webb W, R, Gamusu G, Speckman J, M, Kaiser J. A, Lipton M. developed dominantly, and the left side of the cardinal J. Computed tomographic demonstration of mediastinal venous veins regressed and disappeared. Adachi (1933) assumed, anomalies. AJR 1982; 139:157–161. as follows: The two transverse connections are present 14) Cloez JL, Ravault F, Marcon F, Pernot C. Tronc veineux innomine on the ventral and dorsal sides of the primodium of the en position sous-aortique:inert de lechocardiographie decontraste par voie suprasternale. Aach Mal Coeur Vaiss 1982; 75:939–943. ascending aorta, respectively, in the early stage of devel- 15) Yoshida Y, Seki aY, Yasutaka S. A case of the left brachiocephalic opment. Normally, the ventral connection forms the left vein passing behind the ascending aorta in man. Acta Anat Nippon brachiocephalic vein and the dorsal one disappears. 1984; 59:168–176. However, reversal phenomenon, disappearance of the 16) J-M.Bartoli, G Chagnaud, G Moulin, Di Stefano-Louineau,M ventral transverse connection and enlargement of the Bory, M Kasbarian. Pseudocoartation of the aorta associated with retro-aortic left brachiocephalic vein:a case report. Surg Radiol dorsal one, occurs and forms the PALBV. Anat 1990; 12:307–309. Clinically, the PALBV coexists with congenital heart 17) Fujimoto K, Abe T,Kumabe T, Hayabuchi N, Nosaki Y. disease and aortic arch anomalies at a high incidence. Anomaolus left brachiocephalic (innominate) vein: MR demon- The PALRV forms the complicate venous network in the stration. AJR 1992; 159:479–480. left renal vein. Therefore, making the minute diagnosis 18) Nakamura H, Teramoto S, Suzuki Y, Taniguchi Y, Hara Y, Mori T. A surgical case of invasive thymoma with postaortic left innomi- of these anomalies is indispensable in surgery of these nate vein. Gen. thorac. Cardiovasc. Surg 1995; 43(10):66–68. (in anomalous cases. Nowadays, many surgical procedures Japanese) are being performed by thoracoscopy and laparoscopy. In 19) Kaneko Y, Nakajima J, Ohtsuka T, Kohno T, Furuse A. Broncho- these surgical procedures, the operative field is so small genic carcinoma associated with right aortic arch and postaortic that broad structures surrounding the aorta are hardly left brachiocephalic vein. Gen. thorac. Cardiovasc. Surg 1995; 43(8):59–63. confirmed. Faced with this situation, the preoperative 20) Curtil A, Tronc F, Champsaur G, Bozio A, Sassolas F, Carret J. P, inspection must be carefully performed to avoid damage Vallee B. The left retro-aortic brachiocephalic vein: Morphological on periaortic vessels. data and diagnostic ultrasound 27 cases. Surg Radiol Anat. 1999; 21:251–254. 21) Kim SH, Chung JW, Im JG, Choi YW, Choe YH, Han CH. Subaortic left innominate vein:Radiologic findings and consider- References ation of embryogenesis. J. Thorac Imaging 1999; 14:142–146. 22) Gülsün M, Gokoglu A. Subaortic left brachicephalic vein:com- Part I puted tomography and magnetic resonance angiography findings. 1) Kerschner L. Zur Morphologie der Vena Cava Inferior. Anat Anz Surg Radiol Anat 2003; 25:335–338. 82 A. Iimura et al.

23) M. Yilmaz, M.F. Sargon, O.F. Dogan, I. Pasaoglu. A very rare 33) Kitamura S, Sakai A,Yoshioka T. A rare case of the retroaortic anatomic variation of the left brachiocephalic vein: left retro-aortic renal vein. Acta Anat Nippon 1979; 54:129–135. (in Japanese) brachiocephalic vein with tetralogy of Fallot. Surg Radiol Anat 34) Okamoto K. The posterior renal vein (new definition) together 2003; 25:158–160. with its morphological significance. Okajimas Folia Anat Jpn 24) Tsujimura R, Nabeka, Terashita T, Shimokawa T, Matsuda S, 1990; 67(2–3):203–218. Kobayashi N. A double aortic arch with a deformed trachea 35) Izumiyama M, Horiguchi M. Two cases of the retroaortic left renal accompanied by a subaortic left innominatee vein. Ann Anat 2007; vein and a morphogenetic consideration of the anomalous vein. 189:197–201. Acta Anat Nippon 1997; 72(6):535–543. (in Japanese) 25) Nagashima M, Shikata F. Anomalous subaortic left brachioce- 36) Yoshinaga K, Kawai K and Kodama K. An Anatomical study phalic vein in surgical cases and literature review. Clinical Anat of the retroaortic left renal vein. Okajimas Folia Anat Jpn 2000; 2010; 23:950–955. 77(2–3):47–52 26) Ohsawa R, Kyuno T. Ohtani Y, Ohtani O. A case of double aortic 37) Toda R, Iguro Y. Double lefty renal vein associated with abdom- arch accompained by sub-aortic and pre-aortic left brachiocephalic inal aortic aneurysm. Ann Thorac Cardiovasc Surg 2001; veins and anomalous origin and course of left vertebral artery. 7(2):113–115. Anat Sci, Int. 2011; 86:164–166. 38) R.Gabrielli, M.S.Rosati, L. Irace, S. Perotti, A. Siani, G. Marcuci, B. Gossetti. Rupture of abdominal aortic aneurysm into retro- Part II aortic left renal vein: A case report. Ejves Extra 2009; 18:21–23. 27) McClure,C.F.W.and Butler,E.G. The development of the vena cava 39) Rajan Kumar Singla, Tripta Sharma, Rimpi Gupta. Retro-aortic inferior in man. Am.J. Anat. 1925; 35:331–383. left renal vein with left suprarenal vein draining into inferior vena 28) Seib,G.A. The azygos system of veins in American whites and cava. InernationalJ..of Anatomical Variation 2010; 3:134–137. negroes, including obserbations on the inferior caval venous 40) Jong Kil Nam, Sung Woo Park, Sang Don Lee, Moon Kee Chung. system. Am. J. Phys. Anthropol. 1934; 19:39–163. The clinical significance of a retroaortic left renal vein. Korean J. 29) Pick, J. W. and Anson, B. J. The renal vascular pedicle. An Urology 2010; 51:276–280. anatomical study of 430 body halves. J. Urol. 1940; 44:411–434. 41) Ueno Y. Yi S.Q, Yamaguchi T, Hori K, Miyaki T, Itoh M, Ozaki N, 30) Davis, R. A., Milloy, F. J. Jr. and Anso. n, B. J. Lumbar, renal and A morphogenetic consideration of the anomalous left renal vein: associated parietal and visceral veins based upon a study of 100 retroaortic and circumaortic left renal vein, anastomoses with the specimens. Surg.Gynecol.Obstet. 1958; 107:1–22. lumbar vein. Record of Japanese Research Society of Clinical 31) Reis,R.H. and Esenther,G. Variations in the patterns of renal Anatomy 2011; 11:42–43. (in Japanese) vessels and their relations to the type of posterior vena cava in 42) Anupma Gupta, Raman Gupta. Congenital variations off renal man. Am. J. Anat. 1959; 104:295–318. veins: Embryological background and clinical implications. 32) Davis, C. J. and Lungberg, G. D. Retroaortic left renal vein. J. Journal of Clinical and Diagnostic Research 2011; 5(6):1140– Clin. Pathol 1968; 50:700–703. 1143.