case_images: PMC5402238_01
case_images: CT with administration of contrast media through a left peripheral vein. (a) Coronal maximum intensity projection image shows chronic occlusion of the left-sided central veins with cervical collateral veins from the left to the right side and here reaching the nonoccluded right-sided central veins; slight metal artifacts by the right-sided pacemaker. (b) Coronal multiplanar reconstruction image showing a partially quite tortuous u-shape horizontal-transverse midline vein in the jugulum (dotted ellipse), the AJVS with the JVA.
case_images: CRIRA2017-2790290.001.jpg
case_images: PMC5402238_01_CRIRA2017-2790290.001.jpg
case_images: fig1
case_images: Contrast enhanced computed tomography (CT) of the thorax showed chronic occlusion of the left-sided central veins with the presence of a cervical collateral venous flow from the left to the right side reaching the nonoccluded right-sided central veins, specifically the confluence to the right innominate vein (IV) and, as part of the collateral circulation, a transverse connecting, in parts quite tortuous, and u-shape midline jugular vein measuring about 3 mm in diameter (Figure 1).
case_images: Phlebography correlation of the left arm demonstrates the same collateral circulation as in the CT, fully comparable to Figure 1(a) (a). Note arrow indicating the exact location of the following vascular access. (b-d) Fluoroscopy with last-image hold images showing a guidewire stepwise navigated through the AJVS crossover to the right side and from here through the right innominate vein along the pacemaker leads into the inferior vena cava.
case_images: CRIRA2017-2790290.002.jpg
case_images: PMC5402238_01_CRIRA2017-2790290.002.jpg
case_images: fig2
case_images: Phlebography of the left arm demonstrated the venous anatomy of the shoulder region, as described above in the previously performed CT (Figure 2). A 0.035-inch angled tip hydrophilic guidewire was stepwise navigated through the tortuous midline u-shaped segment of the collateral vein and crossed over to the right side and from here at an acute angle via the right IV, along the pacemaker leads into the inferior vena cava (Figure 2).
case_images: Fluoroscopy-guided images showing guidewire (a) and catheter (b) placement into the inferior vena cava and final positioning of the venous port system (c).
case_images: CRIRA2017-2790290.003.jpg
case_images: PMC5402238_01_CRIRA2017-2790290.003.jpg
case_images: fig3
case_images: Access System Inc., Salt Lake City, USA) was then inserted over the wire just as easily and without complication or kinking up to the cavoatrial junction. A port pocket was prepared below the lateral end of the left clavicle, and the port catheter was tunnelled from the puncture side to the pocket completing the procedure as usual (Figure 3).