Ann Thorac Surg 2006;82:2272-2274
© 2006 The Society of Thoracic Surgeons
Case Reports
Anomalous Right Upper Lobe Venous Drainage
Domenico Galetta, MD,
Giulia Veronesi, MD,
Francesco Leo, MD,
Piergiorgio Solli, MD,
Lorenzo Spaggiari, MD, PhD*
Department of Thoracic Surgery, European Institute of Oncology, University of Milan, Milan, Italy
Accepted for publication April 3, 2006.
* Address correspondence to Dr Spaggiari, Department of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, Milan, 20141 Italy. (Email: lorenzo.spaggiari{at}ieo.it).
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Abstract
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Anomalous pulmonary venous return is a rare congenital anomaly mainly involving the right lung and is often associated with congenital intracardiac malformations as atrial septal defect. We report a case of anomalous right upper lobe venous drainage resulting in two right upper lobe veins draining into the azygous vein and into the confluence between superior vena cava and azygous vein, respectively. Preoperative identification of such an aberrant venous drainage is useful for avoiding unexpected intraoperative bleeding.
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Introduction
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Anomalous pulmonary venous return is a rare congenital anomaly mainly involving the right lung [1]. It is found in 0.4% to 0.7% of the general population, and is often associated with congenital intracardiac malformations as atrial septal defect [1]. The anomalous venous connections have been classified into 4 groups: (1) supracardiac, (2) cardiac, (3) infra-diaphragmatic, and (4) mixed [2], the first one being the most frequent site of drainage. Supracardiac anomalous venous connections include many patterns of abnormalities (eg, a left vertical vein draining into the brachiocephalic vein or a right upper lobe vein draining into the superior vena cava [3], and rarely into the azygos vein [4]).
We describe a case of lung cancer with partial anomalous pulmonary venous connection resulting in an abnormal right upper lobe venous drainage directly into the right (systemic venous) side of the circulatory system.
A 62-year-old man was referred to our department for the surgical treatment of a clinical T2N0M0 nonsmall cell lung cancer. The patient’s medical history and physical examination was unremarkable. A surface electrocardiogram was normal. Two-dimensional and Doppler echocardiography revealed no intracardiac structural abnormalities. The patient underwent a right upper lobectomy. After removing mediastinal pleural adhesions, the right upper lobe was mobilized downward; an unusual connection between the right upper lobe and systemic venous system was identified (Fig 1). Two separate pulmonary veins originating from the superior aspect of the right upper lobe and draining into the azygous vein and into the confluence between the superior vena cava and the azygous vein, respectively, were diagnosed. During the maneuver, an accidental perforation of the proximal pulmonary venous branch was done and promptly controlled. The abnormal pulmonary veins and the azygous vein were isolated; a complete resection of the azygous vein arch, distally, and a tangential mechanic resection of the superior vena cava, proximally, was performed. The right superior pulmonary lobectomy was accomplished without postoperative complications.
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Fig 1. (A) Operative view. (B) Schematic representation. (APVs = anomalous pulmonary veins; AzV = azygous vein; PN = phrenic nerve; RUL = right upper lobe; SVC = superior vena cava; T = trachea; TA = troncus anterior.)
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Comment
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The first report of anomalous drainage of the pulmonary vein was made by Winslow as early as 1739 [5]. Thereafter, many reports have emerged on this topic. The most frequent anomaly is said to be the anomalous drainage into the superior vena cava. The double right upper lobe veins draining into the azygous vein and into the confluence between the superior vena cava and the azygous vein, are exceptional and never described in textbooks of thoracic surgery. We believe that this is the first case of such an anatomical variation reported in the recent English language literature.
Normally, the vein from the middle lobe generally unites with that from the right upper lobe, so that ultimately a trunk is formed; it perforates the fibrous layer of the pericardium and opens into the upper and back part of the left atrium. In our case, no venous branches were found in the usual anatomic site, except for a small vein originating from the middle lobe and draining into left atrium.
The reported venous anomaly was not preoperatively identified. However, on review of the computed tomographic scan the anomalous right upper lobe venous drainage could be clearly identified (Fig 2).
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Fig 2. Preoperative computed tomographic scan of the chest showing the anomalous right upper lobe venous drainage. (Arrowheads = anomalous veins; AzV = azygous vein; SVC = superior vena cava.)
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In conclusion, preoperative identification of such an aberrant venous drainage is useful for avoiding unexpected intraoperative bleeding. A computed tomographic scan is an effective means of identifying this variation and anticipating the course of anomalous pulmonary veins and their connections to the systemic venous system. A somewhat greater awareness of anatomical variations while interpreting computed tomographic studies may make pulmonary resection safer and more anatomically accurate.
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References
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- Van Meter C, LeBlanc JG, Culpepper WS, Ochsner JL. Partial anomalous pulmonary venous return Circulation 1990;82:195-198.
- Kirks DR, Griscom NT. Diagnostic imaging in infancy and childhood. Philadelphia: Lippincott-Raven; 1998.
- Giamberti A, Deanfield JE, Anderson RH, de Leval MR. Totally anomalous pulmonary venous connection directly to the superior caval vein Eur J Cardiothorac Surg 2002;21:474-477.[Abstract/Free Full Text]
- Thorsen MK, Scott JE, Mewissen MW, Youker JE. CT and MR imaging of partial anomalous pulmonary venous return to the azygos vein J Comput Assist Tomogr 1990;4:1007-1009.
- Compere DH, Forsyth HF. Anomalous pulmonary veins report of a case J Thorac Surg 1944;13:63-66.
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Abstract
Introduction
