We reported a case of isolated anomaly of the left brachiocephalic vein which is diagnosed during a permanent pacemaker implantation. It is a very rare anomaly and makes the left sided pacemaker implantation impossible.
Anomalies of the great thoracic veins are uncommon [
A 77-year-old woman with the diagnosis of sick sinus syndrome was referred to our institution for permanent pacemaker implantation. Left pectoral site was prepared for implantation according to routine practice. Left subclavian puncture was performed successfully. But we could not advance the guidewire into the LBCV. Instead of getting into LBCV, the guidewire made a sharp turn and propagates downwards after subclavian vein. The repetitive attempts showed the same result. On cine venography, an accessory hemiazygos vein was seen which takes blood from LBCV and drains into azygos vein. Because of the challenging anatomy, we decided to make the implantation from the right side. And at the same session, we implanted DDD-R (Zephyr DR Saint Jude Medical, USA) permanent pacemaker by using the right subclavian vein, without difficulty.
Then we performed a multidetector thorax CT angiography to see real venous anatomy and accompanying defects clearly.
CT angiography (Figures
Reformatted CT angiography image shows the anomaly in the venous phase.
Volume rendering CT image shows the anomaly from the backside.
Venous anomalies of the thorax involve pulmonary and systemic veins. They might be encountered on a broad spectrum. Spectrum can range from simple incidental finding on radiographic procedures to complex venous anomaly generally accompanying congenital heart disease [
Most common anomaly of the pulmonary veins is partial anomalous of pulmonary venous return. The prevelance of this anomaly is 0,3% in autopsy series [
The most common venous anomaly of the thorax is LPSVC. And this is the major congenital venous anomaly, which precludes left sided pacemaker implantation. Despite the existence of this anomaly, implanting cardiac device successfully is reported in the literature [
Although we implanted the permanent pacemaker successfully from the right side at the same session, repeated punctures can raise the risk of pneumothorax. So, after failed attempts from the left side, a chest X-ray can be performed and procedure can be deferred.
To avoid multiple subclavian vein punctures, peripheral venography can be done before the procedure. This will help to differentiate common venous anomalies and decrease the risk of access site complications. We do not perform routine peripheral venography before pacemaker implantations in our institute, but in this case it would be extremely helpful in detecting the venous anomaly and managing the procedure.
In conclusion physicians who deal with thoracal venous procedures must be familiar with venous anomalies of the thorax. And the absence of LBCV is a very rare reason which makes left sided cardiac device implantation impossible.
The authors declare that there is no conflict of interests regarding the publication of this paper.