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Abstract

  1. Top of page
  2. Abstract
  3. Case Presentation
  4. Discussion
  5. Teaching Point
  6. References

This case report describes a 45-year-old patient who was referred to our center for surgical creation of long-term vascular access. Angiographic mapping revealed the left cephalic vein draining directly into the internal jugular vein rather than the axillary vein. The patient was scheduled for an ulnar artery to cephalic vein fistula.

In normal anatomy, the cephalic vein originates at the radial end of the dorsal venous arch. It crosses superficially to the anatomic snuffbox and ascends anteriorly to the brachioradialis muscle of the forearm (1). In the upper arm, the cephalic vein ascends lateral to the biceps brachii (2) and between the pectoralis major and deltoid muscles (1). At the shoulder, it pierces the clavipectoral fascia to empty into the axillary vein (1–3). This report describes a rare variant of the cephalic vein emptying into the internal jugular vein. We believe this to be the first report of such a vascular variant.

Case Presentation

  1. Top of page
  2. Abstract
  3. Case Presentation
  4. Discussion
  5. Teaching Point
  6. References

A 45-year-old man was referred to our vascular access center for creation of long-term vascular access. The patient was undergoing hemodialysis via a right chest dialysis catheter. Physical examination of his chest, abdomen, and peripheral arterial system were all unremarkable. A venogram (Fig. 1) of his upper extremities performed after ultrasonographic vein mapping showed a left cephalic vein variant with outflow directly into the internal jugular vein instead of the axillary vein (Fig. 2). The patient then underwent a left ulnar artery to cephalic vein fistula.

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Figure 1.  Venogram of the patient’s upper extremities showing a left cephalic vein variant with outflow directly into the internal jugular vein instead of the axillary vein.

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image

Figure 2.  Illustration depicting the patient’s abnormal vascular anatomy.

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Discussion

  1. Top of page
  2. Abstract
  3. Case Presentation
  4. Discussion
  5. Teaching Point
  6. References

As the embryo develops, the cardiovascular and vascular systems (4) will also develop to bring oxygen and nutrients from the maternal circulation through the placenta (4,5). Germ cells overlying the yolk sac, the connecting stalk, and the chorion (3–6) will form the primitive arteries and veins of the embryo (4). During the eighth week of development, the internal jugular veins are formed (4,5) along with the brachiocephalic veins (5). Nearby tributaries will form the external jugular veins (4).

As the upper extremity limb buds develop, the capillary plexus on the ulnar border will develop into the subclavian, axillary, and basilic veins while the capillary plexus on the radial border atrophies (3,4). The subclavian vein does not empty into the internal jugular vein initially, but will later in development (4). An outgrowth from the external jugular vein will form the cephalic vein (6), which will empty into the external jugular vein initially and later, empty into the axillary vein (6).

The present report describes the case of a patient whose cephalic vein emptied into the internal jugular vein instead of into the axillary vein. We searched the literature and found reports of absent cephalic veins, aberrant courses, and cephalic vein emptying into the external jugular vein or basilic vein (1,2), but found no reports of the cephalic vein emptying into the internal jugular vein. In our experience, this is the only case of this vascular variant noted in more than 3000 venograms and fistulograms performed at our center.

Teaching Point

  1. Top of page
  2. Abstract
  3. Case Presentation
  4. Discussion
  5. Teaching Point
  6. References

Knowledge of the exact course of the cephalic vein along with recognition of variants is important to avoid confusion with collateral veins associated with stenosis of the cephalic arch or misdirection of guide wires or catheters during endovascular procedures (2,3).

References

  1. Top of page
  2. Abstract
  3. Case Presentation
  4. Discussion
  5. Teaching Point
  6. References
  • 1
    Kim DI, Han SH: Venous variations in neck region: cephalic vein. IJAV3:208210, 2010
  • 2
    Saaid A, Drysdale I: Unusual termination of the cephalic vein. Clin Anat21:786787, 2008
  • 3
    Cunningham DJ, Robinson A: Cunningham’s Textbook of Anatomy, 5th edn. New York:William Wood and Company, 1926.
  • 4
    Neas JF: The cardiovascular system: vessels and circulation, in Embryology Atlas. Available at: http://cwx.prenhall.com/bookbind/pubbooks/martini10/chapter22/custom3/deluxe-content.html. Accessed Jan. 2011.
  • 5
    Moore KL, Persaud TVN: The Developing Human: Clinically Oriented Embryology, 5th edn. Philadelphia: W.B. Saunders Company, 1993.
  • 6
    Buchanan AM: Manual of Anatomy, Systematic and Practical, Including Embryology. Vol. 1, 3rd edn. St. Louis: C.V. Mosby Company, 1917.