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Table of Contents
Year : 2021  |  Volume : 70  |  Issue : 4  |  Page : 255-257

Multiple anomalies of derivatives of the left cardinal veins

1 Department of Anatomy and Embryology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
2 Radiology and Medical Imaging, Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
3 Division of Pathologic Anatomy, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
4 Division of Anatomy, Department 1, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Date of Submission21-Jan-2020
Date of Acceptance18-Aug-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Adelina Maria Jianu
Victor Babes' University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041, Timisoara
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Source of Support: None, Conflict of Interest: None

DOI: 4103/JASI.JASI_9_20

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We hereby report several anomalies of the cardinal veins derivatives. First, a continuous hemiazygos trunk was identified replacing the hemiazygos, accessory hemiazygos, and left superior intercostal veins. Second, a reno-hemiazygos-lumbar trunk was found to connect the left ascending lumbar and renal veins. In the same patient, a persisting left superior vena cava was also found. These findings are related to developmental anomalies of both supra-and subcardinal veins. Such combination of different anatomic vascular variants in the same patient recommends an evaluation of the vascular anatomy prior to surgical and interventional procedures.

Keywords: Anatomic variation, external jugular vein, hemiazygos vein, persisting left superior vena cava, reno-hemiazygos-lumbar trunk

How to cite this article:
Jianu AM, Bîrsăşteanu F, Pop F, Rusu MC. Multiple anomalies of derivatives of the left cardinal veins. J Anat Soc India 2021;70:255-7

How to cite this URL:
Jianu AM, Bîrsăşteanu F, Pop F, Rusu MC. Multiple anomalies of derivatives of the left cardinal veins. J Anat Soc India [serial online] 2021 [cited 2022 Aug 17];70:255-7. Available from: https://www.jasi.org.in/text.asp?2021/70/4/255/333197

  Introduction Top

Developmental variations of the cardinal veins are uncommon.[1]

The persisting left superior vena cava (PLSVC) was first described in 1738 and is determined by the persistence of the left anterior cardinal vein caudal to the left brachiocephalic (innominate) vein.[2]

The hemiazygos and left renal veins can connect through a reno-hemiazygos-lumbar trunk (RHLT), also known as “tronc reno-rahidien”.[3]

Here is reported a CT study in which different venous variations were found in the same patient.

  Case Report Top

A 58-year-old female diagnosed with pulmonary neoplasm was referred to the Telescan Center Timisoara for complete evaluation. Computed tomography (CT) scan showed a 3 cm nodular image in the superior segment of left upper lobe with infiltrative changes in the surrounding parenchyma, enlarged right hilar lymph nodes (12 mm), bronchiectasis in the anterior segment of left upper lobe and superior segment of left lower lobe with fibrotic changes secondary to radiotherapy. An iodine radiocontrast agent was injected in the left brachial vein (100 ml, with 6 ml/s flow), followed by 40 ml saline medium mixed with 10 ml iodine contrast. Due to a variant anastomotic pathway and the high flow injection, the contrast medium opacified retrogradely both the hemiazygos and azygos veins. We used a 16-slice scanner; 1.2 mm collimation and reconstructions of 3 mm thickness with no overlap for primary diagnosis; and 1.5 mm thickness with 50% overlap for multiplanar, maximum intensity projection (MIP), and three-dimensional volume rendering technique.

The azygos vein appeared anatomically normal; it resulted from the right ascending lumbar and subcostal veins, drained the right posterior intercostal veins and was draining in the initial segment of the superior vena cava.

We found a complex of congenital venous anomalies, at both ends of the hemiazygos system. A prominent hemiazygos trunk (HT) continued the ascending lumbar vein which, in turn, was anatomically connected to the main trunk of the left renal vein by a RHLT [Figure 1]. After receiving the left subcostal vein, the hemiazygos vein went through the posterior mediastinum where it drained left posterior intercostal veins. The HT was connected-anterior to the 10th thoracic vertebra, to the azygos vein, by an interazygos vein and further continued upward, successively replacing the accessory hemiazygos and the left superior intercostal veins [Figure 2]. The distal part of the HT, corresponding to the left superior intercostal vein, crossed the aortic arch and joined the left brachiocephalic vein [Figure 3].
Figure 1: Anatomic variation of left supra-and and subcardinal veins derivatives, detailed in MIP (A) and 3D VR (B and C) captured images. 1. Aorta; 2. Persisting left superior vena cava (the arrowhead in B indicates it at the level of the Marshall's fold and the double-headed arrow in B indicates the oblique vein of left atrium); 3. Accessory hemiazygos vein; 4. Pulmonary trunk; 5. Left superior intercostal vein; 6. Interazygos vein; 7. Azygos vein; 8. Inferior vena cava; 9. Hemiazygos vein; 10. Left renal vein; 11. Reno-hemiazygos-lumbar trunk

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Figure 2: Anatomy of the veins at the base of neck and in the upper mediastinum, detailed in MIP (a) and 3D VR (b) captured images. 1. Right internal jugular vein; 2. Right subclavian vein; 3. Left internal jugular vein; 4. Left subclavian vein; 5. Inferior thyroid vein; 6. Left superior intercostal vein; 7. Persisting left superior vena cava; 8. Aorta; 9. Left superior brachiocephalic vein; 10. Brachial veins (the arms are abducted); 11. Left first rib

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Figure 3: Diagram of the reported variant. 1. Superior vena cava; 2. Left brachiocephalic vein; 3. Right brachiocephalic vein; 4. Left superior intercostal vein; 5. Persisting left superior vena cava; 6. Accessory hemiazygos vein; 7. Interazygos vein; 8. Hemiazygos vein; 9. Azygos vein; 10. Inferior vena cava; 11. Reno-hemiazygos-lumbar trunk; 12. Left renal vein

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We also found a rudimentary PLSVC, connecting the coronary sinus and the distal portion of the HT [Figure 1]. The intrapericardial course, with segments corresponding to the fold of Marshall, and the oblique vein of the left atrium were permeable, allowing the PLSVC to empty into the coronary sinus.

Apart from the CT study, an adult cadaver was used to demonstrate the PLSVC and the derivatives of the left anterior cardinal system by dissection [Supplement Figure 1].

  Discussion Top

To understand these complex venous variants, the development of the embryonic cardinal veins should be recalled. From the 4th to the 7th week of the embryo, the cardinal, and then, the supra-, sub-, and sacrocardinal veins are formed.[4] Further remodeling of the cardinal veins system will establish the final anatomy of the vena cava system, as follows:[4] (a) the superior vena cava develops from the right anterior cardinal vein and the right common cardinal vein; (b) the azygos vein forms from the cranial part of the right supracardinal vein; (c) the left brachiocephalic vein normally results from the anastomosis of the anterior cardinal veins (the precardinal anastomosis); (d) the left superior intercostal vein results from the terminal end of the left anterior cardinal vein that adds the cranial end of the left supracardinal vein; (e) the distal portions of the left supracardinal vein will lose connection with the cephalic end and will form the hemiazygos and accessory hemiazygos veins; (f) the left renal vein will result from the anastomosis of the subcardinal veins; the proximal part of the left subcardinal vein will disappear.

In the case, we report here, the left supracardinal vein did not appear to be segmented, thus leading to the HT variant. Moreover, the left anterior cardinal vein kept the initial morphological pattern, and the PLSVC resulted. The RHLT appears as a connection that initially linked the left subcardinal vein and the primitive left renal vein.

The absence of the precardinal anastomosis (inter-precardinal vein) has been thought to explain a left superior vena cava that continued to the accessory hemiazygos vein without anastomosis with the coronary sinus.[5] This is not the case here. However, this case indicates a possible misdiagnosis that can happen when a dilated left superior intercostal vein [such as the reported one or the one presented in [Supplement Figure 1]], is mistaken with the left brachiocephalic vein.

The occurrence of the left RHLT varies from 16.4% to 90.9%.[6],[7] The renal-hemiazygos pathway belongs to the extrahepatic collateral routes in Budd-Chiari syndrome.[6]

Knowledge of variations of head-and-neck and upper mediastinum veins is important to surgeons and interventional radiologists, an unidentified anatomic venous variation could lead to catheter misplacements, which are reported with rates from 1% to 6%,[8] or leading to iatrogenic damage. The azygos-hemiazygos system can serve as an alternative for catheter placement.[9] Moreover, the anatomic variations of the renal vessels should be carefully documented before renal transplants or radical nephrectomy. Multidetector row CT is a reliable technique useful in preoperative evaluation of living renal donors.[10] Nevertheless, surgical approaches of the spine should be performed after the individual vascular anatomy is documented, especially when anterior approaches are designed.

This case report showed that multiple anatomic variants can occur in one patient. Thus, evaluation of patients should be performed carefully and thoroughly, and certain surgical interventions may need to be preceded by radiological explorations to accurately describe the vascular anatomy of the region.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Castro EC, Devine W, Galambos C. The anatomy of a novel malformation of the cardinal vein system. Pediatr Dev Pathol 2010;13:318-21.  Back to cited text no. 1
Goyal SK, Punnam SR, Verma G, Ruberg FL. Persistent left superior vena cava: A case report and review of literature. Cardiovasc Ultrasound 2008;6:50.  Back to cited text no. 2
Scholbach T. From the nutcracker-phenomenon of the left renal vein to the midline congestion syndrome as a cause of migraine, headache, back and abdominal pain and functional disorders of pelvic organs. Med Hypotheses 2007;68:1318-27.  Back to cited text no. 3
Sadler TW, Langman J. Langman's Medical Embryology. 12th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2012.  Back to cited text no. 4
Sakamoto H, Akita K, Sato K, Sato T. Left superior vena cava continuing to the accessory hemiazygos without anastomosis with the coronary sinus. Surg Radiol Anat 1993;15:151-4.  Back to cited text no. 5
Erden A, Erden I, Karayalçin S, Yurdaydin C. Budd-Chiari syndrome: Evaluation with multiphase contrast-enhanced three-dimensional MR angiography. AJR Am J Roentgenol 2002;179:1287-92.  Back to cited text no. 6
Li G, Dong J, Lu JS, Zu Q, Yang SX, Li HZ, et al. Anatomical variation of the posterior lumbar tributaries of the left renal vein in retroperitoneoscopic left living donor nephrectomy. Int J Urol 2011;18:503-9.  Back to cited text no. 7
Revis B, Fallahzadeh MK, Singh N. Malposition of a hemodialysis catheter in the accessory hemiazygos vein. J La State Med Soc 2014;166:26-7.  Back to cited text no. 8
Sola JE, Thompson WR. Thoracoscopic-assisted placement of azygos vein central venous catheter in a child. Am J Transplant 2008;8:715-8.  Back to cited text no. 9
Sahani DV, Rastogi N, Greenfield AC, Kalva SP, Ko D, Saini S, et al. Multi-detector row CT in evaluation of 94 living renal donors by readers with varied experience. Radiology 2005;235:905-10.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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