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                                               Vertebral v.
                                                                                    Lt anterior jugular v.

                                       Rt anterior jugular v.                       Lt internal jugular v.
                                   Rt internal jugular vein                       Ant. jugular arch
                                                                                        Lt external
                                     Left external
                                     jugular vein                                       jugular v.

                           Rt superior intercostal
                                                                                        Lt subclabian v.
                            Rt internal mammary v.
                                                                                          Lt superior
                                       Lateral                                            intercostal v.
                                     thoracic v.
                                                                                         Lt thoracic v.
                                  intercostal v.                                         Lt internal mammary v.
                                                        v.                               Accessory
                                                                                         hemiazygous v.
                                  intercostal v.
                    Figure 14-2. Schematic illustration of major collateral pathways that compensate for the presence of central venous obstruction. (Redrawn
                    from Chasen MH, Charnsangavej C. Venous chest anatomy: clinical implications. Eur J Radiol. 1998;27:2-14, with permission from Elsevier.)
                    Lt, left; SVC, superior vena cava; V, vein.

                    PATHOGENESIS AND ETIOLOGIES                     an extraordinary high prevalence of CVD for patients
                                                                    who have a history of subclavian catheters of 42 to 50%
                        Causes of occlusion are varied, and may be categorized   in contrast to internal jugular vein catheters (4,19). A
                    into three pathology: intraluminal thrombosis/blockage,   suggested mechanisms of CVD development includes
                    narrowing/stenosis, and extrinsic mass effect. Clinically,   central venous catheter-induced injury to the venous
                    patients with venous occlusions frequently experience   endothelium together with secondary inf ammatory damage
                    swelling prior to the occlusion location.       to the vessel wall which occurred during insertion. Other
                        For the chest, mass effect from pulmonary or    proposed mechanisms include the occurrence of a foreign
                    mediastinal malignancy may anatomically occlude venous   body within the vein, sliding dislocation of the catheter
                    f ow. SVC is the common example of mass effect causing   with respiration, postural and head motility, along with
                    venous blockage. Stenosis or luminal narrowing may also   increased turbulence and f ow from the creation of an
                    develop secondary to chronic exposure to indwelling   AV access. Turbulent blood-f ow has been demonstrated
         430        catheter, sequela of previous thrombosis, or radiation.   to induce a provocative inf ammatory response, platelet

                    Lastly, intraluminal blockage and thrombosis may occur   deposition, venous wall thickening, and stimulate intimal
                    from an indwelling catheter, tumor, hypercoagulable state   hyperplasia (20-22). Placement on the left-hand side of
                    (leading to acute thrombus), or trauma.         neck, location in subclavian vein, longer duration, and
                        The most common cause of CVD is indwelling    placement of multiple catheters, appear to predispose to
                    catheters including dialysis catheters, pacemaker or     the progression of CVD.
                    def brillator wires. There has been a strong correlation of      Venous thoracic outlet syndrome is an extremely rare
                    CVD, with prior implantation of central venous catheters   disorder (1-2 persons in 100,000 population) (23), which
                    for dialysis and pacemaker wires (5,17). In one study,   can cause progressively axillosubclavian vein thrombosis
                    27% of CVD patients had a history of prior central    (Paget-Schroetter syndrome) or effort thrombosis. The
                    venous catheter implantation (18). Moreover, there is   subclavian vein is very predisposed to trauma as it
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