I would like to comment about a recent finding on my last Jan 2023 CTV. This is related to a dynamic left Brachiocephalic Vein (BV) compression. This is important for me because my brain is drained by dominant left IJV which connects to left BV so any narrowing or compression could potentially cause congestion or possible retrograde flow back to the brain if BV compression gets severe enough to occlude the vein. It is also important because collaterals via Deep Cervical Vein also drain into the BV along with left Subclavian Vein (So this has implication on upright position as well as supine). Also, some folks in here such as @GCD have similar drainage pattern and compression on his left BV. So they might benefit from knowing they are not alone
My left BV compression is primarily done by the left Clavicle Bone (Collar Bone) (CB) and right Brachiocephalic Artery (BA) and AORTA to some extend on the last tail of the BV. The compression is relieved by raising my arms possible because the CB moves away from BV area as you will soon see my images below as this is apparent in my 2021 CTA where I did the chest CTA by raising my arms up (as demanded by technologist) hence no compression is apparent and left BV is fully patent. But the story is different on my last 2023 CTV where I did it without my arms raised. The compression is apparent. I will let the picture below do the talk.
Here is an internet image showing the arteries and veins of the area to guide you.
Here are the Axial images of 2021 CTA showing no compression as my arms were raised while the images were taken. left BV (Cyan arrow), left CB (Red arrow), Sternum (Orange arrow), left BA (Blue arrow), left CCA (Yellow arrow), left Subclavian Artery (SV) (Green Arrow), Vena Cava (VC) (Black arrow) and AORTA (Purple Arrow). As you can see no compression.
Here are the Axial images of 2023 CTV showing compression as my arms were NOT raised while the images were taken. left BV (Cyan arrow), left CB (Red arrow), Sternum (Orange arrow), left BA (Blue arrow), left CCA (Yellow arrow), left Subclavian Artery (SV) (Green Arrow), Vena Cava (VC) (Black arrow) and AORTA (Purple Arrow). As you can see there is a compression.
I will discuss the limited research papers on this type left BV compression in the subsequent posts but if you want to know what this can do, you might want to take a look at @DogLover post here. You can see the retrograde flow back to the neck since her left BV is occluded.
@KoolDude - I’m sorry you’ve found a more complex reason for your remaining symptoms & especially one that’s not straightforward to fix. Some years ago, @Cupcake5 was diagnosed w/ BV occlusion & was told there was nothing that could be done to help her. As we thankfully heard from the Vascular Outflow Webinar, there are doctors who are diligently working toward new, improved methods to treat these more complex problems.
My first thought when I read your post was, if they can shave C-1 to make more room for the IJV, couldn’t a similar process be used on the collar bone to make more room for the BV? Both C-1 & the CB are significant in their physical support in our bodies, and we’ve seen success w/ C-1 shaving when done minimally, so perhaps, a similar process would work w/ the CB to make more space for the BV. Maybe that’s just wishful thinking on my part.
BTW - In the top image of the internet pic of veins & arteries, it looks like they switched the right pulmonary artery & right pulmonary vein (i.e. artery points to blue & vein to red). Am I right?
Well dang it!!!
Would you say your left clavicle is inherently larger than the right? And knowing this, would a vascular surgeon be the choice of doctor (considering there is an intervention?).
Understand you are likely in the middle of figuring out your next steps… so no need to respond… Just hoping you find answers.
Thanks @Isaiah_40_31, you learn something new everyday but this could be the reason why @Cupcake5 IIH remained despite removal of both of her styloids and having stent put in. I always suspected she might have had an occult upper sinus narrowing which could be responsible for her residual IIH symptoms. I also understand she had C1 involvement. Hope she is doing ok now.
you are dead right on this one. Yes, there is one case in literature (see the study below) that a resection of the collarbones were made to relieve BV compression. The problem with operating this area is critical arteries which could cost your life if damaged through operation, not to mention the connection of the collarbones to the sternum which plays a key role in stabilizing the whole area through movement of the arms and chest. So any severing could, in theory, destabilize the chest area and cause problems to the major arteries of the heart. But with the new bone chipping tool (ultrasonic bone scalpel which uses vibration of sound wave frequency of 22k cycles per second to chip away bones but preserve soft structures such as nerves and blood vessel because they bend with vibration unlike bone which breaks away) should, in theory, help with any operational risks to the main arteries I think. Stenting in BV is linked to clotting and also can be crashed as per this study (https://www.sciencedirect.com/science/article/pii/S0741521400026082).
Abstract
A 36-year-old women with effort dyspnea for two years and venous congestion of the left arm for six months was hospitalized. She had no thoracic trauma history. Posterior dislocation of the bilateral sternoclavicular joints and a compression to brachiocephalic vein were diagnosed in computed tomography (CT). Reduction of the joint could not be performed because of the old dislocation and destruction of the joint in the operation. The heads of the clavicles were resected and the vein compression was eliminated. Six weeks later; venous congestion was gone and the brachiocephalic vein was been patent.
Good catch. yes, you are right. They mixed them. I put it out there to give a pictorial map of the area. For the lack of finding a better one, I guess.
Yes @Leah, that could happen as the study I linked above indicates clavicles can grow bigger so while I do not know whether it is because mine is too big or the orientation is downward, it can happen.
@Jules thanks, yeah I did find more issues but I really I can’t say how much this contributes to my current symptoms but will be known once the upper stenosis is corrected.
Sorry to hear that you got new issues to tackle, @KoolDude…
I’d still suggest to reconsider physiotherapy approach to put the ribcage/shoulders/scapula/neck curvature in better shape.
My reasoning is that if you have straight neck, the ribcage might be staying at a different angle than if you had proper curvature.
Also, if you expand the ribcage by deeply inhaling (so that the chest “puffs out”), the sternum also moves to a different spot in relation to the spinal column.
Not to forget that as you said, the compression wasn’t present in your CT when you kept your arms above the head.
Another important point, relaxed shoulders should naturally hang slightly higher than “military stance” which has been popularized by some folks including mediocre physiotherapists, stating that “you should pull your scapulae down to the back pockets”.
Finally, I somehow relate the “hands up” CT scan with the old topic:
All that leads to possibilities, that it’s fixable without the surgical intervention.
Ah, one more thing: lifting the arms above the head indeed may change a lot of blood flow paths, like in this TOS example:
@KoolDude I am suspicious of this area for me as well. Have TOS issues (on left) and seems I can move my arm in various positions and I feel the pressure release. The release has become somewhat elusive (???) lately. Would my CT w contrast (which goes just below my clavicle) show this? Have the MRV week after next and suppose that would provide more info (?). TIA
@vdm thanks, I will give a try it this time. Not sure if it can move the collarbone away from the BV but anything that helps is welcome. Thanks for the video as well.
@Leah not that I am able to see with my untrained eyes. Perhaps, Kjetil can spot this since he is expert on TOS issues so I am not ruling it out, just pleading ignorance on this.
I have closely looked into @DogLover BV compression and came to the conclusion that her BV occlusion is probably due to her left Collarbone, not necessarily the Sternum as she probably thought but although she only shared one CTV image which shows BV compression between Sternum and AORTA but not indicative of total occlusion. My evidence comes from a couple of Catheter Venogram slides she shared to show that the BV is indeed patent when she shrugs her shoulder and no reflux or retrograde to the neck is visible which made me form the bases of my assumption since her shrugging moves Collarbones but not the Sternum that much. So in order to analyze this, I looked at the images below and they agree with my initial suspicion as my case also shows that raising arms relieves the compression of the Collarbone. So my fear is, if I progress to a total occlusion, I will have a lot of symptoms just like @DogLover.
No shrugging, BV appears occluded at the tip of her left Collarbone (Cyan arrows shows the orientation of the Collarbone). If it was the Sternum (Orange arrow), BV would have been occluded in the middle. You can see the blood flowing back to the neck veins creating all kind of symptoms
Shrugging shows her BV is patent but compressed in the middle by Sternum (Orange arrow) with no reflux of blood to her neck confirming that Collarbone (Cyan arrows) moved away from the BV somehow.
Here is the only CTV image that @DogLover shared showing the Sternum compression. Would love to see slices before this to confirm that the Collarbone is the culprit of the occlusion, not the Sternum.
My chest CT of 2021 showing the Collarbone (Cyan arrows) movement away from the BV area. You could also see what @Leah suspected that my left Collarbone is thicker than the right one.
TY, yes I am going through TOS with Kjetil. I was actually referring to my left collarbone and brachiocephalic vein (however, you likely already looked at that). If not, could you have a peek whenever you have a free moment? And no worries if no extra bandwidth.
One thought I had regarding this is possibly high level sports orthopedics paired with vascular surgeon…since there are many injuries to clavicle as well as TOS (?).
@Leah, No meaningful compression can be seen. Keep in mind this area is very tight with all the arteries and bones, you can expect some slight compressions but nothing significant enough to cause issues (Not a doctor, my opinion). A picture is worth thousand words.
Blue arrow points to your left BV and Red arrow points to your Collarbone which, BTW, look thicker than mine.
@Shauna It is hard to separate the BV type symptoms from general IJVS symptoms but the specific ones for left BV compression in my case are heaviness on my left arm which I attribute to left Subclavian vein congestion since it drains into the left BV, I also have neck and facial pain (not sure if this is related to BV as it can be from IJVS as well). So I will only know left BV compression symptoms once I eliminate IJVS.
I think you see a whole lot of BV compression related symptoms on the neck and the face once the BV is occluded as the neck veins swell with reflux of deoxygenated blood. Some even have blueish facial edema from this. As you can see the picture from @DogLover, her neck veins are engorged with reflux putting pressure on nerves and smaller vessels.
UGHHHHH…This is so complicated for me to understand! Praise God that I didn’t have half of the complications some are having with ES. My heart goes out to those of you who are looking for solutions and are still having painful symptoms. My 17 years of suffering were a chapter in my life that I never want to experience ever again.
