Right top pulmonary vein is a venous anomaly of which surgeons should be aware in subcarinal dissection for thoracoscopic esophagectomy: a case report and literature review

Abstract

Background A right top pulmonary vein (RTPV) that crosses behind the right main or intermediate bronchus is a variation of the superior posterior pulmonary vein in the right upper lobe. Damage or ligation of this abnormal vessel can lead to massive intraoperative bleeding and serious complications, such as congestion of the posterior segment of the right upper lobe and cardiac tamponade. Subcarinal lymph node dissection is mandatory in radical thoracoscopic esophagectomy for esophageal cancer, and the RTPV is an anomalous vessel of which thoracic surgeons should be aware. Case presentation A 70-year-old man underwent thoracoscopic esophagectomy for esophageal cancer (T3N1M0). An anomaly of the superior posterior pulmonary vein in the right lobe was recognized on preoperative computed tomography imaging. With simulation and intraoperative navigation using three-dimensional imaging of the same view as that observed during the operation, radical subcarinal dissection could be performed with preservation of the RTPV. Conclusion In our review of the relevant literature, the incidence of RTPV ranged from 0.28 to 9.3%, and its mean vascular diameter was 7.0 mm at the maximum and 2.2 ± 0.72 mm at the minimum, with the right superior pulmonary vein being a relatively common inflow site. Our case in which the RTPV ran dorsal to the right main bronchus is very rare. In radical subcarinal dissection of thoracoscopic esophagectomy, it is important to recognize the posterior pericardial plane and release the ventral fixation of these lymph nodes to free space for the back side. This is also true in the case of RTPV, which should be noted to avoid injury. In cases involving an RTPV larger than 4.5 mm, ligation should be avoided, and preoperative recognition of the exact run of this abnormal vessel using three-dimensional imaging can be very useful.

Catheter ablation of the left‐sided variant of right top pulmonary vein in a case with persistent left superior vena cava

“…Therefore, the abnormal PV was considered a left‐sided variant of the right top PV. In previous reports, the mean vascular diameter of the right top PV was 7.0 mm 5 . Thus, the right top PV observed in this case was larger than usual.…”

“…The right top PV is a rare variation of PV drainage with an incidence of 0.28%-9.3%. 5 The definition of the right top PV varies among previous reports. In some reports, [6][7][8][9] the right top PV was defined as the…”

“…In some reports, 6–9 the right top PV was defined as the PV which terminates into the roof of the left atrium in proximity to the right superior PV. In other reports, 2–5 the right top PV was defined as the PV draining from the right upper lung lobe and crossing behind the right main or intermediate bronchus regardless of the drainage site. The abnormal PV observed in this case satisfied the abovementioned definitions despite the inflow site being rather close to the left superior PV.…”

“…The atypical PV drained from the right upper lung lobe and crossed behind the intermediate bronchus. Therefore, a left‐sided variant of the right top PV was primarily considered 2–5 . Since potentials were present at the ostium of the atypical PV (Figure 2A, B), the atypical PV was isolated by enclosing it into a wide antral circumferential ablation line for the right PVs (Figures 2C, D).…”

Thoracoscopic esophagectomy with subcarinal lymph node dissection in the prone position for esophageal cancer with a right top pulmonary vein

“…A review by Sato et al. in 2022 reported maximum and minimum vessel diameters of 7.0 and 2.2 ± 0.72 mm, respectively, with the RTPV usually posterior to the RIB [ 4 ]. To our best knowledge, the anomalous vessel in the present case is the largest reported RTPV to date, with a diameter of 7.8 mm.…”