Left Superior Intercostal Vein

Aortic Nipple

Seen as a small soft-tissue density adjacent to the

lateral border of the aortic knob on a frontal
radiograph in up to 10% of normal patients

Normally the left superior intercostal vein drains the

left 2nd, 3rd, and 4th posterior intercostal veins and
connects the left brachiocephalic vein and the
accessory hemiazygos vein
As such, the left superior intercostal vein provides
a collateral path of blood back to the heart
The size of the left superior intercostal vein is
inversely related to the size of the accessory
hemiazygos vein: the smaller (or absent) the 22 Must Sees

accessory hemiazygos, the larger will be the left See the 22 Must See
Imaging Diagnoses first
superior intercostal vein identified by the Alliance
for Medical Student
Educators in Radiology. 22
The accessory hemiazygos vein (orange arrow Must Sees...

below) drains the posterior intercostal veins from

3-4 intercostal spaces between the left superior  

intercostal vein (green arrow below) and the

uppermost branch of the hemiazygos vein (blue
arrow below)
 

Gray's Anatomy

The left superior intercostal vein may increase in size

with the patient supine or during expiration

The left superior intercostal vein may act as a

collateral pathway, and therefore become distended,

 collateral pathway, and therefore become distended,
in patients with impending or actual superior vena
caval obstruction,  absence or obstruction of the
inferior vena cava, congestive heart failure,
congenital absence of the azygos vein (black arrow
above) or increased portal venous pressure or, rarely,
with partial or total anomalous pulmonary venous
drainage

It should not be mistaken for a left superior vena cava

which, if present, may give rise to the superior
intercostal vein rather than the left brachiocephalic
vein

If large enough, the aortic nipple could be mistaken

for an aortic aneurysm or a mediastinal mass
     
Imaging
Conventional radiography
Usually produces a rounded or pointed soft-
tissue density of varying size adjacent to the
lateral wall of the aortic knob on the frontal
view

It may project more superiorly or inferiorly

along the border of the aortic knob or may
sometimes be visible through the knob
CT
Contrast-enhanced chest CT images will show
a curvilinear contrast-filled vessel along the
left lateral border of the aorta that can usually
be traced from the left brachiocephalic vein to
the region of the accessory hemiazygos vein
 
 Left Superior Intercostal Vein. Contrast-enhanced chest CT images show a
curvilinear contrast-filled
vessel along the left lateral border of the aorta (white arrow) that can be
traced from the
left brachiocephalic vein (red arrow) to the region of the accessory
hemiazygos vein (blue arrow)
For the same photo without the arrows, click here

Left. Close-up of aortic nipple on frontal chest radiograph (red arrow)

Right. Plate from Gray's anatomy showing venous drainage in chest.

McDonald C, Castellino R, Blank N: The aortic "nipple" the left superior intercostal vein.
Radiology 96:533-536 1970

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