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Multi–Detector Row and Volume-rendered CT of the Normal and Accessory Flow Pathways of the Thoracic Systemic and Pulmonary Veins¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N Caroline St, Baltimore, MD 21287. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received January 18, 2002; revision requested March 5 and received April 3; accepted April 8. E.K.F. is cofounder of HipGraphics, Inc. Address correspondence to E.K.F. (e-mail: efishman@jhmi.edu).

View larger version (158K): [in a new window]   Figure 1.  Anterior volume-rendered CT image shows collateral vessels of the anterior neck and chest wall that developed in a patient with jugular vein thrombosis (not shown). These collateral vessels drain through the external jugular, left subclavian, transthoracic, and intercostal channels to the left brachiocephalic vein. Arrow = central venous catheter.

View larger version (159K): [in a new window]   Figure 2a.  Anterior (a) and inferior (b) volume-rendered CT images show the cephalic (thin solid arrow) and basilic (thick solid arrow) veins entering the axillary vein (open arrow), which continues centrally as the subclavian vein. The contrast material in the veins was assigned a color trapezoid.

View larger version (95K): [in a new window]   Figure 2b.  Anterior (a) and inferior (b) volume-rendered CT images show the cephalic (thin solid arrow) and basilic (thick solid arrow) veins entering the axillary vein (open arrow), which continues centrally as the subclavian vein. The contrast material in the veins was assigned a color trapezoid.

View larger version (127K): [in a new window]   Figure 3a.  (a) Anterior volume-rendered CT image shows the right (long solid arrow) and left (short solid arrow) brachiocephalic veins merging at the SVC (open arrow). (b) Anterior volume-rendered CT image shows the right brachiocephalic vein (solid arrow) joining the SVC (open arrow). (c) Anterior volume-rendered CT image shows the contrast material-enhanced left brachiocephalic vein (arrow) entering the SVC. (d) Anterior volume-rendered CT image shows the left brachiocephalic vein (long arrow) crossing the ascending aorta (short arrow).

View larger version (122K): [in a new window]   Figure 3b.  (a) Anterior volume-rendered CT image shows the right (long solid arrow) and left (short solid arrow) brachiocephalic veins merging at the SVC (open arrow). (b) Anterior volume-rendered CT image shows the right brachiocephalic vein (solid arrow) joining the SVC (open arrow). (c) Anterior volume-rendered CT image shows the contrast material-enhanced left brachiocephalic vein (arrow) entering the SVC. (d) Anterior volume-rendered CT image shows the left brachiocephalic vein (long arrow) crossing the ascending aorta (short arrow).

View larger version (146K): [in a new window]   Figure 3c.  (a) Anterior volume-rendered CT image shows the right (long solid arrow) and left (short solid arrow) brachiocephalic veins merging at the SVC (open arrow). (b) Anterior volume-rendered CT image shows the right brachiocephalic vein (solid arrow) joining the SVC (open arrow). (c) Anterior volume-rendered CT image shows the contrast material-enhanced left brachiocephalic vein (arrow) entering the SVC. (d) Anterior volume-rendered CT image shows the left brachiocephalic vein (long arrow) crossing the ascending aorta (short arrow).

View larger version (154K): [in a new window]   Figure 3d.  (a) Anterior volume-rendered CT image shows the right (long solid arrow) and left (short solid arrow) brachiocephalic veins merging at the SVC (open arrow). (b) Anterior volume-rendered CT image shows the right brachiocephalic vein (solid arrow) joining the SVC (open arrow). (c) Anterior volume-rendered CT image shows the contrast material-enhanced left brachiocephalic vein (arrow) entering the SVC. (d) Anterior volume-rendered CT image shows the left brachiocephalic vein (long arrow) crossing the ascending aorta (short arrow).

View larger version (139K): [in a new window]   Figure 4a.  (a) Anterior volume-rendered CT image obtained with color trapezoids applied to wire components shows a pacemaker in the left subclavian vein that extends through the vein and into the right side of the heart through the left brachiocephalic vein and SVC. The wire tips in the right atrium are seen (arrows). (b) Axial superior volume-rendered CT image shows the left brachiocephalic vein (long solid arrow) crossing the anterior mediastinum to enter the SVC (short solid arrow). Open arrow = aortic arch. Color trapezoids were applied. (c) Left lateral volume-rendered CT image shows the anteroposterior relationship of the left brachiocephalic vein (long arrow) and left subclavian artery (short arrow). (d) Left anterior oblique volume-rendered CT image shows a large unnamed anomalous branch (white arrow) of the left brachiocephalic vein (open arrow); the anomalous branch arises from the lateral aspect of the brachiocephalic vein and rejoins it more medially. Solid black arrow = left subclavian vein.

View larger version (134K): [in a new window]   Figure 4b.  (a) Anterior volume-rendered CT image obtained with color trapezoids applied to wire components shows a pacemaker in the left subclavian vein that extends through the vein and into the right side of the heart through the left brachiocephalic vein and SVC. The wire tips in the right atrium are seen (arrows). (b) Axial superior volume-rendered CT image shows the left brachiocephalic vein (long solid arrow) crossing the anterior mediastinum to enter the SVC (short solid arrow). Open arrow = aortic arch. Color trapezoids were applied. (c) Left lateral volume-rendered CT image shows the anteroposterior relationship of the left brachiocephalic vein (long arrow) and left subclavian artery (short arrow). (d) Left anterior oblique volume-rendered CT image shows a large unnamed anomalous branch (white arrow) of the left brachiocephalic vein (open arrow); the anomalous branch arises from the lateral aspect of the brachiocephalic vein and rejoins it more medially. Solid black arrow = left subclavian vein.

View larger version (154K): [in a new window]   Figure 4c.  (a) Anterior volume-rendered CT image obtained with color trapezoids applied to wire components shows a pacemaker in the left subclavian vein that extends through the vein and into the right side of the heart through the left brachiocephalic vein and SVC. The wire tips in the right atrium are seen (arrows). (b) Axial superior volume-rendered CT image shows the left brachiocephalic vein (long solid arrow) crossing the anterior mediastinum to enter the SVC (short solid arrow). Open arrow = aortic arch. Color trapezoids were applied. (c) Left lateral volume-rendered CT image shows the anteroposterior relationship of the left brachiocephalic vein (long arrow) and left subclavian artery (short arrow). (d) Left anterior oblique volume-rendered CT image shows a large unnamed anomalous branch (white arrow) of the left brachiocephalic vein (open arrow); the anomalous branch arises from the lateral aspect of the brachiocephalic vein and rejoins it more medially. Solid black arrow = left subclavian vein.

View larger version (177K): [in a new window]   Figure 4d.  (a) Anterior volume-rendered CT image obtained with color trapezoids applied to wire components shows a pacemaker in the left subclavian vein that extends through the vein and into the right side of the heart through the left brachiocephalic vein and SVC. The wire tips in the right atrium are seen (arrows). (b) Axial superior volume-rendered CT image shows the left brachiocephalic vein (long solid arrow) crossing the anterior mediastinum to enter the SVC (short solid arrow). Open arrow = aortic arch. Color trapezoids were applied. (c) Left lateral volume-rendered CT image shows the anteroposterior relationship of the left brachiocephalic vein (long arrow) and left subclavian artery (short arrow). (d) Left anterior oblique volume-rendered CT image shows a large unnamed anomalous branch (white arrow) of the left brachiocephalic vein (open arrow); the anomalous branch arises from the lateral aspect of the brachiocephalic vein and rejoins it more medially. Solid black arrow = left subclavian vein.

View larger version (122K): [in a new window]   Figure 5a.  (a) Anterior volume-rendered CT image shows the internal thoracic veins (long arrows) in a patient with obstruction of the left brachiocephalic vein and SVC. Note the relationship of the pericardiophrenic vein (short arrow). (b) Posterior volume-rendered CT image of the sternum shows the internal thoracic veins (arrows) as they course medial to the costochondral junctions. (c) Anterior volume-rendered CT image shows the lateral thoracic vein (large solid arrow) entering the lateral subclavian vein (open arrow). A central venous catheter (small solid arrow) is seen entering the SVC.

View larger version (113K): [in a new window]   Figure 5b.  (a) Anterior volume-rendered CT image shows the internal thoracic veins (long arrows) in a patient with obstruction of the left brachiocephalic vein and SVC. Note the relationship of the pericardiophrenic vein (short arrow). (b) Posterior volume-rendered CT image of the sternum shows the internal thoracic veins (arrows) as they course medial to the costochondral junctions. (c) Anterior volume-rendered CT image shows the lateral thoracic vein (large solid arrow) entering the lateral subclavian vein (open arrow). A central venous catheter (small solid arrow) is seen entering the SVC.

View larger version (119K): [in a new window]   Figure 5c.  (a) Anterior volume-rendered CT image shows the internal thoracic veins (long arrows) in a patient with obstruction of the left brachiocephalic vein and SVC. Note the relationship of the pericardiophrenic vein (short arrow). (b) Posterior volume-rendered CT image of the sternum shows the internal thoracic veins (arrows) as they course medial to the costochondral junctions. (c) Anterior volume-rendered CT image shows the lateral thoracic vein (large solid arrow) entering the lateral subclavian vein (open arrow). A central venous catheter (small solid arrow) is seen entering the SVC.

View larger version (159K): [in a new window]   Figure 6a.  (a) Right anterior oblique volume-rendered CT image shows an enhanced SVC (large solid arrow) coursing behind the ascending aortic arch (small solid arrow) to enter the right atrium (open arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids. Color trapezoids were assigned to the SVC (large arrow), which can be seen curving anterior to the right pulmonary hilum (small arrow). (c) Superior volume-rendered CT image obtained with airway trapezoids shows a view down the thoracic inlet. Color trapezoids were applied to the vasculature, and the SVC (large arrow) is seen anterior to the carina (small arrow). (d) Left posterior oblique volume-rendered CT image shows the inferior vena cava (large arrow) entering the right atrium (small arrow).

View larger version (161K): [in a new window]   Figure 6b.  (a) Right anterior oblique volume-rendered CT image shows an enhanced SVC (large solid arrow) coursing behind the ascending aortic arch (small solid arrow) to enter the right atrium (open arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids. Color trapezoids were assigned to the SVC (large arrow), which can be seen curving anterior to the right pulmonary hilum (small arrow). (c) Superior volume-rendered CT image obtained with airway trapezoids shows a view down the thoracic inlet. Color trapezoids were applied to the vasculature, and the SVC (large arrow) is seen anterior to the carina (small arrow). (d) Left posterior oblique volume-rendered CT image shows the inferior vena cava (large arrow) entering the right atrium (small arrow).

View larger version (108K): [in a new window]   Figure 6c.  (a) Right anterior oblique volume-rendered CT image shows an enhanced SVC (large solid arrow) coursing behind the ascending aortic arch (small solid arrow) to enter the right atrium (open arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids. Color trapezoids were assigned to the SVC (large arrow), which can be seen curving anterior to the right pulmonary hilum (small arrow). (c) Superior volume-rendered CT image obtained with airway trapezoids shows a view down the thoracic inlet. Color trapezoids were applied to the vasculature, and the SVC (large arrow) is seen anterior to the carina (small arrow). (d) Left posterior oblique volume-rendered CT image shows the inferior vena cava (large arrow) entering the right atrium (small arrow).

View larger version (104K): [in a new window]   Figure 6d.  (a) Right anterior oblique volume-rendered CT image shows an enhanced SVC (large solid arrow) coursing behind the ascending aortic arch (small solid arrow) to enter the right atrium (open arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids. Color trapezoids were assigned to the SVC (large arrow), which can be seen curving anterior to the right pulmonary hilum (small arrow). (c) Superior volume-rendered CT image obtained with airway trapezoids shows a view down the thoracic inlet. Color trapezoids were applied to the vasculature, and the SVC (large arrow) is seen anterior to the carina (small arrow). (d) Left posterior oblique volume-rendered CT image shows the inferior vena cava (large arrow) entering the right atrium (small arrow).

View larger version (111K): [in a new window]   Figure 7a.  (a) Left lateral volume-rendered CT image of the heart shows the coronary sinus (long solid arrow) fed by a small cardiac vein (short solid arrow). The left anterior descending coronary artery (open arrow) is noted. (b) Posterior volume-rendered CT image shows the coronary sinus (long straight solid arrow) entering the right atrium (open arrow). The right coronary artery (short straight solid arrow) and a branch tributary of the small cardiac vein (curved arrow) are also seen. (c) Inferior volume-rendered CT image shows the middle cardiac vein (short solid arrow) in the posterior interventricular groove. The coronary sinus (long solid arrow) and right coronary artery (open arrow) are also seen.

View larger version (108K): [in a new window]   Figure 7b.  (a) Left lateral volume-rendered CT image of the heart shows the coronary sinus (long solid arrow) fed by a small cardiac vein (short solid arrow). The left anterior descending coronary artery (open arrow) is noted. (b) Posterior volume-rendered CT image shows the coronary sinus (long straight solid arrow) entering the right atrium (open arrow). The right coronary artery (short straight solid arrow) and a branch tributary of the small cardiac vein (curved arrow) are also seen. (c) Inferior volume-rendered CT image shows the middle cardiac vein (short solid arrow) in the posterior interventricular groove. The coronary sinus (long solid arrow) and right coronary artery (open arrow) are also seen.

View larger version (154K): [in a new window]   Figure 7c.  (a) Left lateral volume-rendered CT image of the heart shows the coronary sinus (long solid arrow) fed by a small cardiac vein (short solid arrow). The left anterior descending coronary artery (open arrow) is noted. (b) Posterior volume-rendered CT image shows the coronary sinus (long straight solid arrow) entering the right atrium (open arrow). The right coronary artery (short straight solid arrow) and a branch tributary of the small cardiac vein (curved arrow) are also seen. (c) Inferior volume-rendered CT image shows the middle cardiac vein (short solid arrow) in the posterior interventricular groove. The coronary sinus (long solid arrow) and right coronary artery (open arrow) are also seen.

View larger version (120K): [in a new window]   Figure 8a.  (a) Anterior volume-rendered CT image shows the pericardiophrenic veins (long arrows) draped around the heart. The thymic vein plexus and intermammary vein collateral vessels (short arrow) are also seen. (b) Left lateral volume-rendered CT image shows the two left pericardiophrenic veins (white arrows) on the surface of the heart. The internal mammary veins (open arrow) and left superior intercostal vein (solid black arrow) are also seen. The patient had obstruction of the left brachiocephalic vein and SVC. (c) Right anterior oblique volume-rendered CT image shows the pericardiophrenic vein (long white arrow) along the right border of the heart (view equivalent to placement of the patient in the right anterior oblique position). The connection to the phrenic vein (short white arrow), the right internal mammary vein (straight black arrow), and an unnamed collateral vessel (curved arrow) are also seen. (d) Superior volume-rendered CT image shows the two left pericardiophrenic veins (white arrow) along the left border of the heart. The superior intercostal vein (curved arrow) and intermammary plexus (straight black arrow) are also seen. (e) Inferior MIP CT image shows the phrenic veins (large arrows) with a "hot spot" of contrast material in the quadrate lobe (segment 4b) (small arrow), which is related to obstruction of the SVC. The exact cause of the "hot" quadrate lobe is unclear, but it is thought to be related to collateral flow through the liver. (f) Inferior volume-rendered CT image of the right hemidiaphragm shows the numerous phrenic veins on its surface (long arrows). A pericardial effusion is noted (short arrow).

View larger version (113K): [in a new window]   Figure 8b.  (a) Anterior volume-rendered CT image shows the pericardiophrenic veins (long arrows) draped around the heart. The thymic vein plexus and intermammary vein collateral vessels (short arrow) are also seen. (b) Left lateral volume-rendered CT image shows the two left pericardiophrenic veins (white arrows) on the surface of the heart. The internal mammary veins (open arrow) and left superior intercostal vein (solid black arrow) are also seen. The patient had obstruction of the left brachiocephalic vein and SVC. (c) Right anterior oblique volume-rendered CT image shows the pericardiophrenic vein (long white arrow) along the right border of the heart (view equivalent to placement of the patient in the right anterior oblique position). The connection to the phrenic vein (short white arrow), the right internal mammary vein (straight black arrow), and an unnamed collateral vessel (curved arrow) are also seen. (d) Superior volume-rendered CT image shows the two left pericardiophrenic veins (white arrow) along the left border of the heart. The superior intercostal vein (curved arrow) and intermammary plexus (straight black arrow) are also seen. (e) Inferior MIP CT image shows the phrenic veins (large arrows) with a "hot spot" of contrast material in the quadrate lobe (segment 4b) (small arrow), which is related to obstruction of the SVC. The exact cause of the "hot" quadrate lobe is unclear, but it is thought to be related to collateral flow through the liver. (f) Inferior volume-rendered CT image of the right hemidiaphragm shows the numerous phrenic veins on its surface (long arrows). A pericardial effusion is noted (short arrow).

View larger version (129K): [in a new window]   Figure 8c.  (a) Anterior volume-rendered CT image shows the pericardiophrenic veins (long arrows) draped around the heart. The thymic vein plexus and intermammary vein collateral vessels (short arrow) are also seen. (b) Left lateral volume-rendered CT image shows the two left pericardiophrenic veins (white arrows) on the surface of the heart. The internal mammary veins (open arrow) and left superior intercostal vein (solid black arrow) are also seen. The patient had obstruction of the left brachiocephalic vein and SVC. (c) Right anterior oblique volume-rendered CT image shows the pericardiophrenic vein (long white arrow) along the right border of the heart (view equivalent to placement of the patient in the right anterior oblique position). The connection to the phrenic vein (short white arrow), the right internal mammary vein (straight black arrow), and an unnamed collateral vessel (curved arrow) are also seen. (d) Superior volume-rendered CT image shows the two left pericardiophrenic veins (white arrow) along the left border of the heart. The superior intercostal vein (curved arrow) and intermammary plexus (straight black arrow) are also seen. (e) Inferior MIP CT image shows the phrenic veins (large arrows) with a "hot spot" of contrast material in the quadrate lobe (segment 4b) (small arrow), which is related to obstruction of the SVC. The exact cause of the "hot" quadrate lobe is unclear, but it is thought to be related to collateral flow through the liver. (f) Inferior volume-rendered CT image of the right hemidiaphragm shows the numerous phrenic veins on its surface (long arrows). A pericardial effusion is noted (short arrow).

View larger version (127K): [in a new window]   Figure 8d.  (a) Anterior volume-rendered CT image shows the pericardiophrenic veins (long arrows) draped around the heart. The thymic vein plexus and intermammary vein collateral vessels (short arrow) are also seen. (b) Left lateral volume-rendered CT image shows the two left pericardiophrenic veins (white arrows) on the surface of the heart. The internal mammary veins (open arrow) and left superior intercostal vein (solid black arrow) are also seen. The patient had obstruction of the left brachiocephalic vein and SVC. (c) Right anterior oblique volume-rendered CT image shows the pericardiophrenic vein (long white arrow) along the right border of the heart (view equivalent to placement of the patient in the right anterior oblique position). The connection to the phrenic vein (short white arrow), the right internal mammary vein (straight black arrow), and an unnamed collateral vessel (curved arrow) are also seen. (d) Superior volume-rendered CT image shows the two left pericardiophrenic veins (white arrow) along the left border of the heart. The superior intercostal vein (curved arrow) and intermammary plexus (straight black arrow) are also seen. (e) Inferior MIP CT image shows the phrenic veins (large arrows) with a "hot spot" of contrast material in the quadrate lobe (segment 4b) (small arrow), which is related to obstruction of the SVC. The exact cause of the "hot" quadrate lobe is unclear, but it is thought to be related to collateral flow through the liver. (f) Inferior volume-rendered CT image of the right hemidiaphragm shows the numerous phrenic veins on its surface (long arrows). A pericardial effusion is noted (short arrow).

View larger version (129K): [in a new window]   Figure 8e.  (a) Anterior volume-rendered CT image shows the pericardiophrenic veins (long arrows) draped around the heart. The thymic vein plexus and intermammary vein collateral vessels (short arrow) are also seen. (b) Left lateral volume-rendered CT image shows the two left pericardiophrenic veins (white arrows) on the surface of the heart. The internal mammary veins (open arrow) and left superior intercostal vein (solid black arrow) are also seen. The patient had obstruction of the left brachiocephalic vein and SVC. (c) Right anterior oblique volume-rendered CT image shows the pericardiophrenic vein (long white arrow) along the right border of the heart (view equivalent to placement of the patient in the right anterior oblique position). The connection to the phrenic vein (short white arrow), the right internal mammary vein (straight black arrow), and an unnamed collateral vessel (curved arrow) are also seen. (d) Superior volume-rendered CT image shows the two left pericardiophrenic veins (white arrow) along the left border of the heart. The superior intercostal vein (curved arrow) and intermammary plexus (straight black arrow) are also seen. (e) Inferior MIP CT image shows the phrenic veins (large arrows) with a "hot spot" of contrast material in the quadrate lobe (segment 4b) (small arrow), which is related to obstruction of the SVC. The exact cause of the "hot" quadrate lobe is unclear, but it is thought to be related to collateral flow through the liver. (f) Inferior volume-rendered CT image of the right hemidiaphragm shows the numerous phrenic veins on its surface (long arrows). A pericardial effusion is noted (short arrow).

View larger version (134K): [in a new window]   Figure 8f.  (a) Anterior volume-rendered CT image shows the pericardiophrenic veins (long arrows) draped around the heart. The thymic vein plexus and intermammary vein collateral vessels (short arrow) are also seen. (b) Left lateral volume-rendered CT image shows the two left pericardiophrenic veins (white arrows) on the surface of the heart. The internal mammary veins (open arrow) and left superior intercostal vein (solid black arrow) are also seen. The patient had obstruction of the left brachiocephalic vein and SVC. (c) Right anterior oblique volume-rendered CT image shows the pericardiophrenic vein (long white arrow) along the right border of the heart (view equivalent to placement of the patient in the right anterior oblique position). The connection to the phrenic vein (short white arrow), the right internal mammary vein (straight black arrow), and an unnamed collateral vessel (curved arrow) are also seen. (d) Superior volume-rendered CT image shows the two left pericardiophrenic veins (white arrow) along the left border of the heart. The superior intercostal vein (curved arrow) and intermammary plexus (straight black arrow) are also seen. (e) Inferior MIP CT image shows the phrenic veins (large arrows) with a "hot spot" of contrast material in the quadrate lobe (segment 4b) (small arrow), which is related to obstruction of the SVC. The exact cause of the "hot" quadrate lobe is unclear, but it is thought to be related to collateral flow through the liver. (f) Inferior volume-rendered CT image of the right hemidiaphragm shows the numerous phrenic veins on its surface (long arrows). A pericardial effusion is noted (short arrow).

View larger version (157K): [in a new window]   Figure 9.  Right anterior oblique volume-rendered CT image (equivalent to placement of the patient in the right anterior oblique position) shows a saphenous vein bypass graft (arrow) of the right coronary artery. The graft extends from the ascending aorta to an anastomosis in the proximal right coronary artery.

View larger version (158K): [in a new window]   Figure 10a.  (a) Right lateral volume-rendered CT image shows the azygos vein (large arrow) arching anteriorly to the SVC (small arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids shows the azygos vein (solid arrow) arching anteriorly toward the SVC and lateral to the trachea (open arrow). (c) Right lateral volume-rendered CT image obtained with airway trapezoids shows the relationship of the azygos vein (long arrow) to the right hilum (short arrow). (d) Anterior volume-rendered CT image shows the accessory hemiazygos vein (large arrow) behind the aorta (small arrow). (e) Left anterior oblique volume-rendered CT image (equivalent to placement of the patient in the left anterior oblique position) shows the accessory hemiazygos vein (large white arrow) fed by multiple intercostal veins (small white arrows). Black arrow = third rib.

View larger version (133K): [in a new window]   Figure 10b.  (a) Right lateral volume-rendered CT image shows the azygos vein (large arrow) arching anteriorly to the SVC (small arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids shows the azygos vein (solid arrow) arching anteriorly toward the SVC and lateral to the trachea (open arrow). (c) Right lateral volume-rendered CT image obtained with airway trapezoids shows the relationship of the azygos vein (long arrow) to the right hilum (short arrow). (d) Anterior volume-rendered CT image shows the accessory hemiazygos vein (large arrow) behind the aorta (small arrow). (e) Left anterior oblique volume-rendered CT image (equivalent to placement of the patient in the left anterior oblique position) shows the accessory hemiazygos vein (large white arrow) fed by multiple intercostal veins (small white arrows). Black arrow = third rib.

View larger version (137K): [in a new window]   Figure 10c.  (a) Right lateral volume-rendered CT image shows the azygos vein (large arrow) arching anteriorly to the SVC (small arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids shows the azygos vein (solid arrow) arching anteriorly toward the SVC and lateral to the trachea (open arrow). (c) Right lateral volume-rendered CT image obtained with airway trapezoids shows the relationship of the azygos vein (long arrow) to the right hilum (short arrow). (d) Anterior volume-rendered CT image shows the accessory hemiazygos vein (large arrow) behind the aorta (small arrow). (e) Left anterior oblique volume-rendered CT image (equivalent to placement of the patient in the left anterior oblique position) shows the accessory hemiazygos vein (large white arrow) fed by multiple intercostal veins (small white arrows). Black arrow = third rib.

View larger version (116K): [in a new window]   Figure 10d.  (a) Right lateral volume-rendered CT image shows the azygos vein (large arrow) arching anteriorly to the SVC (small arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids shows the azygos vein (solid arrow) arching anteriorly toward the SVC and lateral to the trachea (open arrow). (c) Right lateral volume-rendered CT image obtained with airway trapezoids shows the relationship of the azygos vein (long arrow) to the right hilum (short arrow). (d) Anterior volume-rendered CT image shows the accessory hemiazygos vein (large arrow) behind the aorta (small arrow). (e) Left anterior oblique volume-rendered CT image (equivalent to placement of the patient in the left anterior oblique position) shows the accessory hemiazygos vein (large white arrow) fed by multiple intercostal veins (small white arrows). Black arrow = third rib.

View larger version (142K): [in a new window]   Figure 10e.  (a) Right lateral volume-rendered CT image shows the azygos vein (large arrow) arching anteriorly to the SVC (small arrow). (b) Left lateral volume-rendered CT image obtained with airway trapezoids shows the azygos vein (solid arrow) arching anteriorly toward the SVC and lateral to the trachea (open arrow). (c) Right lateral volume-rendered CT image obtained with airway trapezoids shows the relationship of the azygos vein (long arrow) to the right hilum (short arrow). (d) Anterior volume-rendered CT image shows the accessory hemiazygos vein (large arrow) behind the aorta (small arrow). (e) Left anterior oblique volume-rendered CT image (equivalent to placement of the patient in the left anterior oblique position) shows the accessory hemiazygos vein (large white arrow) fed by multiple intercostal veins (small white arrows). Black arrow = third rib.

View larger version (175K): [in a new window]   Figure 11a.  (a) Right anterior oblique volume-rendered CT image shows the intercostal vein tributaries (short arrows) of the azygos vein (long arrow). (b) Anterior oblique volume-rendered CT image shows the intercostal veins (short solid arrows) connecting the lateral thoracic vein (long solid arrow) and the azygos vein (open arrow). (c) Posterior volume-rendered CT image of the anterior chest wall shows the intercostal veins (short arrow) coursing medially to the internal thoracic vein (long arrow). (d) Axial superior two-dimensional CT image shows the left superior intercostal vein (straight white arrow) extending around the aortic arch (curved arrow). The left brachiocephalic vein (large black arrow) and accessory hemiazygos vein (small black arrow) are also seen. (e) Left lateral volume-rendered CT image shows the superior intercostal vein (large straight solid arrow) extending around the aortic arch as the aortic nipple. The internal mammary (curved arrow), pericardiophrenic (medium-sized straight solid arrow), phrenic (small straight solid arrow), and accessory hemiazygos (open arrow) veins are also seen. The patient had an obstructive thrombus in the left brachiocephalic vein and SVC.

View larger version (150K): [in a new window]   Figure 11b.  (a) Right anterior oblique volume-rendered CT image shows the intercostal vein tributaries (short arrows) of the azygos vein (long arrow). (b) Anterior oblique volume-rendered CT image shows the intercostal veins (short solid arrows) connecting the lateral thoracic vein (long solid arrow) and the azygos vein (open arrow). (c) Posterior volume-rendered CT image of the anterior chest wall shows the intercostal veins (short arrow) coursing medially to the internal thoracic vein (long arrow). (d) Axial superior two-dimensional CT image shows the left superior intercostal vein (straight white arrow) extending around the aortic arch (curved arrow). The left brachiocephalic vein (large black arrow) and accessory hemiazygos vein (small black arrow) are also seen. (e) Left lateral volume-rendered CT image shows the superior intercostal vein (large straight solid arrow) extending around the aortic arch as the aortic nipple. The internal mammary (curved arrow), pericardiophrenic (medium-sized straight solid arrow), phrenic (small straight solid arrow), and accessory hemiazygos (open arrow) veins are also seen. The patient had an obstructive thrombus in the left brachiocephalic vein and SVC.

View larger version (127K): [in a new window]   Figure 11c.  (a) Right anterior oblique volume-rendered CT image shows the intercostal vein tributaries (short arrows) of the azygos vein (long arrow). (b) Anterior oblique volume-rendered CT image shows the intercostal veins (short solid arrows) connecting the lateral thoracic vein (long solid arrow) and the azygos vein (open arrow). (c) Posterior volume-rendered CT image of the anterior chest wall shows the intercostal veins (short arrow) coursing medially to the internal thoracic vein (long arrow). (d) Axial superior two-dimensional CT image shows the left superior intercostal vein (straight white arrow) extending around the aortic arch (curved arrow). The left brachiocephalic vein (large black arrow) and accessory hemiazygos vein (small black arrow) are also seen. (e) Left lateral volume-rendered CT image shows the superior intercostal vein (large straight solid arrow) extending around the aortic arch as the aortic nipple. The internal mammary (curved arrow), pericardiophrenic (medium-sized straight solid arrow), phrenic (small straight solid arrow), and accessory hemiazygos (open arrow) veins are also seen. The patient had an obstructive thrombus in the left brachiocephalic vein and SVC.

View larger version (102K): [in a new window]   Figure 11d.  (a) Right anterior oblique volume-rendered CT image shows the intercostal vein tributaries (short arrows) of the azygos vein (long arrow). (b) Anterior oblique volume-rendered CT image shows the intercostal veins (short solid arrows) connecting the lateral thoracic vein (long solid arrow) and the azygos vein (open arrow). (c) Posterior volume-rendered CT image of the anterior chest wall shows the intercostal veins (short arrow) coursing medially to the internal thoracic vein (long arrow). (d) Axial superior two-dimensional CT image shows the left superior intercostal vein (straight white arrow) extending around the aortic arch (curved arrow). The left brachiocephalic vein (large black arrow) and accessory hemiazygos vein (small black arrow) are also seen. (e) Left lateral volume-rendered CT image shows the superior intercostal vein (large straight solid arrow) extending around the aortic arch as the aortic nipple. The internal mammary (curved arrow), pericardiophrenic (medium-sized straight solid arrow), phrenic (small straight solid arrow), and accessory hemiazygos (open arrow) veins are also seen. The patient had an obstructive thrombus in the left brachiocephalic vein and SVC.

View larger version (153K): [in a new window]   Figure 11e.  (a) Right anterior oblique volume-rendered CT image shows the intercostal vein tributaries (short arrows) of the azygos vein (long arrow). (b) Anterior oblique volume-rendered CT image shows the intercostal veins (short solid arrows) connecting the lateral thoracic vein (long solid arrow) and the azygos vein (open arrow). (c) Posterior volume-rendered CT image of the anterior chest wall shows the intercostal veins (short arrow) coursing medially to the internal thoracic vein (long arrow). (d) Axial superior two-dimensional CT image shows the left superior intercostal vein (straight white arrow) extending around the aortic arch (curved arrow). The left brachiocephalic vein (large black arrow) and accessory hemiazygos vein (small black arrow) are also seen. (e) Left lateral volume-rendered CT image shows the superior intercostal vein (large straight solid arrow) extending around the aortic arch as the aortic nipple. The internal mammary (curved arrow), pericardiophrenic (medium-sized straight solid arrow), phrenic (small straight solid arrow), and accessory hemiazygos (open arrow) veins are also seen. The patient had an obstructive thrombus in the left brachiocephalic vein and SVC.

View larger version (81K): [in a new window]   Figure 12.  Drawing of the pulmonary veins. The heart has been removed, and the relationship of the four pulmonary veins can be appreciated (arrows).

View larger version (148K): [in a new window]   Figure 13a.  (a) Left anterior oblique volume-rendered CT image shows the superior and inferior pulmonary veins (short straight arrows) draining medially under the main pulmonary artery (long straight arrow) and aortic arch (curved arrow). (b) Right lateral volume-rendered CT image shows the right superior and inferior pulmonary veins (short arrows) behind the SVC (long arrow). (c) Posterior volume-rendered CT image shows the pulmonary veins (thick straight arrows) entering the left atrium (curved arrow). Note the relationship to the pulmonary arteries (thin straight arrows). (d) Volume-rendered CT image obtained from the patient’s right side with airway and color trapezoids shows the superior and inferior pulmonary veins (white arrows) anterior and inferior to the left main-stem bronchus (black arrow). (e) Volume-rendered CT image obtained from the patient’s left side with airway and color trapezoids shows the superior and inferior pulmonary veins (short solid arrows) and their relationship to the SVC (open arrow), right upper lobe bronchus (long solid arrow), and right lower lobe bronchus (arrowhead).

View larger version (165K): [in a new window]   Figure 13b.  (a) Left anterior oblique volume-rendered CT image shows the superior and inferior pulmonary veins (short straight arrows) draining medially under the main pulmonary artery (long straight arrow) and aortic arch (curved arrow). (b) Right lateral volume-rendered CT image shows the right superior and inferior pulmonary veins (short arrows) behind the SVC (long arrow). (c) Posterior volume-rendered CT image shows the pulmonary veins (thick straight arrows) entering the left atrium (curved arrow). Note the relationship to the pulmonary arteries (thin straight arrows). (d) Volume-rendered CT image obtained from the patient’s right side with airway and color trapezoids shows the superior and inferior pulmonary veins (white arrows) anterior and inferior to the left main-stem bronchus (black arrow). (e) Volume-rendered CT image obtained from the patient’s left side with airway and color trapezoids shows the superior and inferior pulmonary veins (short solid arrows) and their relationship to the SVC (open arrow), right upper lobe bronchus (long solid arrow), and right lower lobe bronchus (arrowhead).

View larger version (146K): [in a new window]   Figure 13c.  (a) Left anterior oblique volume-rendered CT image shows the superior and inferior pulmonary veins (short straight arrows) draining medially under the main pulmonary artery (long straight arrow) and aortic arch (curved arrow). (b) Right lateral volume-rendered CT image shows the right superior and inferior pulmonary veins (short arrows) behind the SVC (long arrow). (c) Posterior volume-rendered CT image shows the pulmonary veins (thick straight arrows) entering the left atrium (curved arrow). Note the relationship to the pulmonary arteries (thin straight arrows). (d) Volume-rendered CT image obtained from the patient’s right side with airway and color trapezoids shows the superior and inferior pulmonary veins (white arrows) anterior and inferior to the left main-stem bronchus (black arrow). (e) Volume-rendered CT image obtained from the patient’s left side with airway and color trapezoids shows the superior and inferior pulmonary veins (short solid arrows) and their relationship to the SVC (open arrow), right upper lobe bronchus (long solid arrow), and right lower lobe bronchus (arrowhead).

View larger version (127K): [in a new window]   Figure 13d.  (a) Left anterior oblique volume-rendered CT image shows the superior and inferior pulmonary veins (short straight arrows) draining medially under the main pulmonary artery (long straight arrow) and aortic arch (curved arrow). (b) Right lateral volume-rendered CT image shows the right superior and inferior pulmonary veins (short arrows) behind the SVC (long arrow). (c) Posterior volume-rendered CT image shows the pulmonary veins (thick straight arrows) entering the left atrium (curved arrow). Note the relationship to the pulmonary arteries (thin straight arrows). (d) Volume-rendered CT image obtained from the patient’s right side with airway and color trapezoids shows the superior and inferior pulmonary veins (white arrows) anterior and inferior to the left main-stem bronchus (black arrow). (e) Volume-rendered CT image obtained from the patient’s left side with airway and color trapezoids shows the superior and inferior pulmonary veins (short solid arrows) and their relationship to the SVC (open arrow), right upper lobe bronchus (long solid arrow), and right lower lobe bronchus (arrowhead).

View larger version (123K): [in a new window]   Figure 13e.  (a) Left anterior oblique volume-rendered CT image shows the superior and inferior pulmonary veins (short straight arrows) draining medially under the main pulmonary artery (long straight arrow) and aortic arch (curved arrow). (b) Right lateral volume-rendered CT image shows the right superior and inferior pulmonary veins (short arrows) behind the SVC (long arrow). (c) Posterior volume-rendered CT image shows the pulmonary veins (thick straight arrows) entering the left atrium (curved arrow). Note the relationship to the pulmonary arteries (thin straight arrows). (d) Volume-rendered CT image obtained from the patient’s right side with airway and color trapezoids shows the superior and inferior pulmonary veins (white arrows) anterior and inferior to the left main-stem bronchus (black arrow). (e) Volume-rendered CT image obtained from the patient’s left side with airway and color trapezoids shows the superior and inferior pulmonary veins (short solid arrows) and their relationship to the SVC (open arrow), right upper lobe bronchus (long solid arrow), and right lower lobe bronchus (arrowhead).

View larger version (122K): [in a new window]   Figure 14a.  (a) Anterior volume-rendered CT image shows the complex plexus of thymic, inferior thyroid, and intermammary veins (arrow), which is seen between the internal thoracic veins. (b) Left lateral volume-rendered CT image shows the complex of thymic, inferior thyroid, and intermammary veins (arrow), which is seen posterior to the internal thoracic veins in the anterior mediastinum.

View larger version (143K): [in a new window]   Figure 14b.  (a) Anterior volume-rendered CT image shows the complex plexus of thymic, inferior thyroid, and intermammary veins (arrow), which is seen between the internal thoracic veins. (b) Left lateral volume-rendered CT image shows the complex of thymic, inferior thyroid, and intermammary veins (arrow), which is seen posterior to the internal thoracic veins in the anterior mediastinum.

View larger version (155K): [in a new window]   Figure 15a.  (a) Anterior volume-rendered CT image shows the veins of the right anterior chest wall (arrows) in a patient with obstruction of the left brachiocephalic vein. Collateralization to the deep systemic veins is through transthoracic, external jugular, intercostal, and thyroid veins. (b) Right anterior volume-rendered CT image shows the veins of the right anterior chest wall (arrows).

View larger version (152K): [in a new window]   Figure 15b.  (a) Anterior volume-rendered CT image shows the veins of the right anterior chest wall (arrows) in a patient with obstruction of the left brachiocephalic vein. Collateralization to the deep systemic veins is through transthoracic, external jugular, intercostal, and thyroid veins. (b) Right anterior volume-rendered CT image shows the veins of the right anterior chest wall (arrows).