Korean J Radiol.  2014 Apr;15(2):185-187. 10.3348/kjr.2014.15.2.185.

Superior Vena Cava Syndrome Associated with Right-to-Left Shunt through Systemic-to-Pulmonary Venous Collaterals

• Juan YH
• Saboo SS
• Anand V
• Chatzizisis YS
• Lin YC
• Steigner M

• KMID: 1705571
• DOI: http://doi.org/10.3348/kjr.2014.15.2.185

Abstract

Superior vena cava (SVC) obstruction is associated with the gradual development of venous collaterals. We present a rare form of systemic-to-pulmonary subpleural collateral pathway that developed in the bridging subpleural pulmonary veins in a 54-year-old woman with complete SVC obstruction. This uncommon collateral pathway represents a rare form of acquired right-to-left shunt due to previous pleural adhesions with an increased risk of stroke due to right-to-left venous shunting, which requires lifelong anticoagulation.

Keyword

Superior vena cava syndrome; Pulmonary venous collaterals; Computed tomography

MeSH Terms

*Collateral Circulation/physiology
Female
Humans
Middle Aged
Multidetector Computed Tomography
Phlebography/methods
Pulmonary Veins/physiopathology/*radiography
Stroke/complications
Superior Vena Cava Syndrome/physiopathology/*radiography
Veins/physiopathology

Figure

• 

  Fig. 1 Multidetector computed tomographic venography images of chest in 54-year-old woman with complete SVC obstruction and abundant venous collaterals. A. Coronal reformatted image demonstrates complete chronic SVC obstruction with abundant adjacent mediastinal collateral venous drainage (white thin arrow). B-D. Axial (B) and oblique sagittal maximum-intensity-projection images (C) along with volume-rendered images (D) reveal multiple venous collaterals in chest wall (white bold arrows) and paravertebral regions (arrowhead), representing involvement of lateral thoracic and paravertebral collateral pathways. Note dense contrast in patent left-sided venous collaterals (yellow bold arrow, B-D) extending from chest wall, crossing pleura, subpleural pulmonary veins and lingular lobe before draining into left superior pulmonary vein, which is consistent with connections between lateral thoracic pathway and systemic-to-pulmonary venous collateral pathway and bridging subpleural pulmonary veins. SVC = superior vena cava

Reference

1. Eren S, Karaman A, Okur A. The superior vena cava syndrome caused by malignant disease. Imaging with multi-detector row CT. Eur J Radiol. 2006; 59:93–103.

2. Kim HC, Chung JW, Yoon CJ, Lee W, Jae HJ, Kim YI, et al. Collateral pathways in thoracic central venous obstruction: three-dimensional display using direct spiral computed tomography venography. J Comput Assist Tomogr. 2004; 28:24–33.

3. Sze DY, Fleischmann D, Ma AO, Price EA, McConnell MV. Embolization of a symptomatic systemic to pulmonary (right-to-left) venous shunt caused by fibrosing mediastinitis and superior vena caval occlusion. J Vasc Interv Radiol. 2010; 21:140–143.

4. Kapur S, Paik E, Rezaei A, Vu DN. Where there is blood, there is a way: unusual collateral vessels in superior and inferior vena cava obstruction. Radiographics. 2010; 30:67–78.

5. Kim HC, Chung JW, Park SH, Kim HB, Jae HJ, Lee W, et al. Systemic-to-pulmonary venous shunt in superior vena cava obstruction: depiction on computed tomography venography. Acta Radiol. 2004; 45:269–274.

6. Koetters KT. Superior vena cava syndrome. J Emerg Nurs. 2012; 38:135–138.

7. Lawler LP, Fishman EK. Thoracic venous anatomy multidetector row CT evaluation. Radiol Clin North Am. 2003; 41:545–560.

8. Sheth S, Ebert MD, Fishman EK. Superior vena cava obstruction evaluation with MDCT. AJR Am J Roentgenol. 2010; 194:W336–W346.

9. Kim HJ, Kim HS, Chung SH. CT diagnosis of superior vena cava syndrome: importance of collateral vessels. AJR Am J Roentgenol. 1993; 161:539–542.