Use of internal mammary vein as alternative central venous access

Clinical History

A 57-year-old female patient with history of short gut syndrome required long-term parenteral nutrition. Attempts to insert central venous line have failed and a venogram was performed to demonstrate the cause. A CT venogram was subsequently performed to assess venous drainage of thorax and to locate an alternative access.

Imaging Findings

The venogram demonstrated bilateral brachiocephalic vein occlusions, accounting for the failed attempts of central venous line insertions.

The CT venogram showed a prominent right internal mammary vein with direct drainage to superior vena cava, suitable for central venous access.

The Chest X-ray showed a right mammary vein central venous catheter with the tip within the atrium.

Discussion

Central venous catheters are lines placed in a large vein, for medicine or parenteral nutrition administration, venous blood sampling and central venous pressure measurement. The central catheters are usually placed in the internal jugular vein, subclavian vein and femoral vein, as they are relatively safe and easily accessible. However, in many cases where patients require prolonged venous catheterisation, venous stenosis and occlusion can sometimes occur, precluding traditional approach of a central venous catheter insertion, which was the case of our patients.

In our case, although reasonably sized subclavian and internal jugular veins were identified, the guide wire failed to advance after a short course. The venogram was a reasonable approach to demonstrate the cause which showed bilateral brachiocephalic vein occlusion, accounting for the failed procedures. Hence, a CT venogram was performed to access the venous drainage of thorax, in attempt to identify an alternative central venous access. A prominent superficial right internal mammary vein was identified on the CT, with direct drainage to superior vena cava, bypassing the brachiophalic vein occlusion, making it suitable for central venous access. Under direct ultrasound guidance, the right internal mammary vein was located and a 6.6 Fr single lumen Broviac line was inserted through the vein with no complication

The internal mammary vein, also known as internal thoracic vein, arises from the superior epigastric vein and runs into the first intercostal space along with the internal thoracic arteries. It drains the chest wall and empties into the brachiocephalic vein. Use of internal mammary vein as central venous access has been described in only very few cases [1, 2, 3].

In our opinion, in selected patients, the insertion of central venous catheter into the internal mammary vein is relatively easy and safe. The use of internal mammary vein as central venous access should be considered in patients with difficult central venous access. This will prevent patients from having more invasive procedures, such as transhepatic approach central venous access or thoracotomy, which should really be used as a last resort.

Differential Diagnosis List

Final Diagnosis

Right internal mammary vein use as alternative central venous access.

URL:	https://www.eurorad.org/case/10346
DOI:	10.1594/EURORAD/CASE.10346
ISSN:	1563-4086