Ann Thorac Surg 2009;88:305. doi:10.1016/j.athoracsur.2008.10.015
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
An Unusual Location of a Persistent Vein of Marshall
Steven P. Goldberg, MDa,*,
Brian M. Fonseca, MDb,
Adel K. Younoszai, MDb,
David N. Campbell, MDa
a Division of Cardiothoracic Surgery, The Children's Hospital, Aurora, Colorado
b Division of Pediatric Cardiology, The Children's Hospital, Aurora, Colorado
* Address correspondence to Dr Goldberg, Pediatric Cardiac Surgery, The Children's Hospital, 13123 E 16th Ave, B200, Aurora, CO 80045 (Email: sgoldberg17{at}yahoo.com).
An 18-year-old young man was referred to our institution for surgical repair of an ascending aortic aneurysm associated with a nonobstructive bicuspid aortic valve. His preoperative echocardiogram initially demonstrated what appeared to be an accessory left pulmonary vein that drained cranially into the innominate vein. The rest of his pulmonary venous anatomy was well seen and drained normally to the left atrium.
This prompted a magnetic resonance angiogram with three-dimensional volume rendering (Fig 1). In addition to the aneurysmal ascending aorta, the magnetic resonance imaging revealed an ascending venous connection between the left upper pulmonary vein and the innominate vein. The characteristic of this vessel was of a persistent vein of Marshall, the embryological remnant of the left anterior cardinal vein.
At operation, the dissection lateral to the left pulmonary vein, in the expected location of a vertical vein of the type usually associated with total anomalous pulmonary venous return (TAPVR), failed to yield anything. We then noted that a vessel was located in between the branch pulmonary arteries. Figure 2
demonstrates the vein arising medial to the origin of the left pulmonary artery (a silk tie is on the ductal stump).
As it was further dissected, it was seen to arise from the confluence of the upper pulmonary veins as they merged with the left atrium, ascended in the pulmonary bifurcation, and joined the innominate vein at its leftward portion, immediately after its formation by the left subclavian and jugular veins. It was ligated in multiple locations along its length before we instituted cardiopulmonary bypass and the ascending aortic replacement.
The vein of Marshall is a persistence of the left-sided common cardinal vein. Originally, paired anterior and posterior cardinal veins provide systemic venous drainage of the cephalad and caudal portions of the embryo, respectively. They join posterior to the heart to form the common cardinal vein, which empties into the sinus venosus. Distally, the anterior cardinal veins are derived from the cerebral vasculature, which have as their origin point the sagittal, sigmoid, and cavernous sinuses, entering the internal jugular system. In the 20- to 22-mm embryo, all of the venous return is gradually shifted to the right side of the body to enter the developing right atrium. The left-sided cardinal veins begin to regress in response to less flow, and the proximal portion of the common cardinal vein becomes the coronary sinus, whereas its tapered distal part becomes the vein (and ligament) of Marshall. A persistence of the anterior cardinal vein would result in a left-sided superior vena cava.
Our patient did not have a true left superior vena cava, nor did he have any true features of TAPVR save this ascending vertical vein. It coursed in a most unusual location, in between the branch pulmonary arteries on its way to the systemic venous system.
