Elsevier

Clinical Radiology

Volume 70, Issue 6, June 2015, Pages 654-660
Clinical Radiology

Pictorial Review
Central venous obstruction in the thorax

https://doi.org/10.1016/j.crad.2015.01.014Get rights and content

Highlights

  • We show a range of causes of central venous disease in the thorax.

  • We provide information about different imaging and management strategies.

  • We show several cases with successes and complications of endovascular management.

Central venous stenosis and occlusion can occur secondary to a spectrum of conditions ranging from aggressive malignancy to benign extrinsic anatomical compression in otherwise healthy individuals. Irrespective of aetiology, significant morbidity in the acute setting and long term can occur unless prompt accurate diagnosis and appropriate management is initiated, the radiologist being central to both. The present review will provide radiologists with a thorough illustration and explanation of the range of central venous conditions in the thorax (including deep vein thrombosis, thoracic outlet syndrome, haemodialysis, and malignancy related causes), the salient imaging findings and interventional management using case examples from the authors' practice.

Introduction

Blood from the arms, head, and neck is drained via the central veins to the heart. For the purposes of this article, we consider the central veins to consist of the subclavian veins, innominate/brachiocephalic veins, and superior vena cava (SVC). The iliac veins, and inferior vena cava (IVC) comprise the central veins for drainage of the legs and abdominal structures and will not be discussed in this article. Central veins differ from peripheral veins in that they are larger, and have high flow rates with few or no valves. When functioning normally central veins have a single route of passage of blood. Collateral routes of flow only become apparent in the presence of disease in contrast to peripheral veins where blood can drain via several parallel routes. Disease in the central veins results in impairment of venous drainage. The clinical presentation of central venous disorders varies with the site, rate of onset, and aetiology of the disease. There are various anatomical variants of central veins in the thorax which are rarely associated with impaired function and are beyond the scope of this article.

An obstruction to flow of the central veins can be classified in a number of ways including aetiology of disease, anatomical location in relation to dependant area, or anatomical location in relation to lumen. For the purposes of this article we consider venous disease in relation to aetiology of disease.

Section snippets

Benign extrinsic compression

The most common site of extrinsic anatomical compression of central veins occurs in the subclavian vein as it crosses between the clavicle and the first rib. In its mildest form this can present with a feeling of fullness of the affected limb, often produced on exercise or forced abduction. This can be part of a global thoracic outlet syndrome with compressive symptoms affecting the adjacent artery and nerves. More commonly patients present acutely with Paget–Schroetter syndrome or effort

Dialysis patients

Dialysis patients have a high incidence of venous disease ranging from damage to small peripheral veins from repeated peripheral cannulation, through to stenosis and occlusion of central veins. The rate of central venous disease in this population is thought to range from 25–40%.3, 4 Causes of central venous disease in these patients include (1) trauma to vessels from central venous cannulation, particularly relevant in the dialysis population due to the large calibre of dialysis catheter used;

Malignant disease

Carcinoma of the bronchus is the most common malignant cause of superior vena cava obstruction. It is present in 10% of patients with small cell lung cancer (SCLC) and 1.7% of patients with non-small cell lung cancer (NSCLC) at the time of diagnosis.14 Typically a tumour arising in the right main or upper lobe bronchus may compress, encase, or invade the SVC causing luminal compromise and reduction of blood flow. Large-volume mediastinal or right paratracheal lymphadenopathy can also cause

Discussion

The symptomatology and onset of diseases of the central veins in the thorax is strongly correlated with the underlying aetiology and anatomical location of disease. A thorough clinical history and appropriate use of non-invasive diagnostic imaging will allow a diagnosis to be made in the majority of cases. Central venography via a fistula or peripheral vein is minimally invasive imaging that gives good anatomical detail of any underlying central stenosis or occlusion and also shows functional

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