CLINICAL SIGNIFICANCE OF AZYGOS VEIN
ENLARGEMENT: RADIOGRAPHIC RECOGNITION
AND ETIOLOGIC ANALYSIS
MYUNG SOO SHIN, MD, FCCP,
Azygos vein enlargement can be detected in conges-
tive heart failure, portal hypertension, inferior vena
cava thrombosis, right atrial mural thrombosis, a
pulmonary embolism, congenital azygos continua-
tion to the inferior vena cava, and the arteriovenous
fistula. Radiography, particularly computed tomog-
raphy (CT), is very useful, not only in recognition of
azygos vein enlargement, but also in evaluation of its
etiology for the institution of the appropriate treat-
ment of the diseases.  Elsevier Science Inc., 1999
KEY WORDS:
Azygos vein enlargements; Etiologies; Congenital
anomalies; Thrombosis; Congestive heart failure; CT
INTRODUCTION
The azygos vein commences opposite the first and
second lumbar spine by a union of the ascending
lumbar vein and the right subcostal vein. It receives
a venous return from the right superior and posterior
intercostal veins, right subcostal vein, hemizygous
vein, accessory hemizygous vein, and esophageal,
mediastinal, and pericardial veins before entering
the superior vena cava at a point where that vessel
pierces the pericardium. A normal azygos vein is so
small that it cannot be detected by chest radiogra-
phy. The only part of the azygos system seen in the
healthy chest is the portion of the azygos vein that
extends forward from the spine to its entry to the su-
From the Departments of Radiology (M.S.S.) and Pathology
(K.J.H.), University of Alabama School of Medicine, Birmingham, AL.
Address correspondence to: M. S. Shin, MD, Department of Ra-
diology, University of Alabama School of Medicine, 619 South
19th Street, Birmingham, AL 35233.
Received April 5, 1999; accepted June 24, 1999.
CLINICAL IMAGING 1999;23:236–241
 Elsevier Science Inc., 1999. All rights reserved.
655 Avenue of the Americas, New York, NY 10010
AND KANG JEY HO, MD, PHD
perior vena cava. According to Keats et al. (1), the av-
erage normal value for an azygos vein in upright pos-
terior–anterior chest radiograph is 3–7 mm in width.
The enlargement of an azygos vein can be seen in cer-
tain clinical settings, but has often been neglected.
The purposes of this communication are to demon-
strate radiographic characteristics of azygos vein en-
largement and to evaluate its etiology.
CASE REPORT
Patients
Seven patients, age 23 to 58, three males and four fe-
males, with azygos vein enlargement, were selected
from our files and shown in Table 1.
Demonstration of the Enlargement of
Azygos Vein With Specific Etiologies:
Congenital Azygos Continuation and Absence
of Inferior Vena Cava (Cases 1 and 2)
A marked enlarged azygos vein extending inferiorly
to the paravertebral location of the lumbar spine
with absence of the inferior vena cava on the CT is
diagnostic for this entity, as demonstrated in two pa-
tients (Figures 1 and 2). About 50% of such cases
may be associated with the polysplenia syndrome
and congenital heart anomalies such as dextrocardia,
cor biloculare, and pulmonary atresia. Some of such
anomalies are seen in case 2 but not in case 1.
Inferior Vena Cava Thrombosis
(Cases 3, 4, and 5)
During obstruction of the inferior vena cava by throm-
bosis, the azygos and hemizygos veins, as well as
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JULY/AUGUST 1999 AZYGOS VEIN ENLARGEMENT 237

TABLE 1. Seven Patients with Enlarged Azygos Vein

Patients Age Sex Etiology for enlarged azygos vein

#1 47 F Congenital azygos continuation and absence of inferior vena cava

#2 27 F Same as above, multiple spleens
#3 45 M Inferior vena cava thrombosis
#4 49 M Same as above, with thrombus extending to right pulmonary artery
#5 50 F Thrombus extending from inferior vena cava to right atrium
#6 23 F Preeclampsia with acute congestive heart failure
#7 58 M Portal vein occlusion by hepatocellular carcinoma

the vertebral veins, form important collateral circula-
tion by which venous blood can be returned to the
heart. Enlargement of the azygos vein can be demon-
strated under such a condition, as demonstrated in
Figures 3–5. Thrombosis can be clearly detected in
the inferior vena cava in all these patients. The
thrombi are identified by elongated calcification
(Figure 3), luminal inhomogeneous density (Figure
4), or double contour of the venous wall (Figure 5).
Right Atrial Mural Thrombosis and
Pulmonary Embolism (Cases 4 and 5)
These two conditions can lead to elevation of the
right atrial pressure that, in turn, impedes the venous

FIGURE 1. A 47-year-old black woman was referred to

University Hospital with a presumed diagnosis of sarcoid-
osis with erythema nodosum. A markedly enlarged azygos
vein (1.8 cm in width) is shown on chest radiograph (A, ar-
rowheads) and CT (B, arrows). The markedly dilated
azygos vein in the retrocrural space is associated with the
absence of the inferior vena cava (C, arrow).
238 SHIN AND HO
return from both the superior and inferior vena cava,
and thus leads to enlargement of the azygos vein. In
fact, a combination of inferior vena cava thrombosis,
right atrial mural thrombosis, and a pulmonary em-
bolism are not uncommon. The patients demonstrated
in Figures 4 and 5 developed azygos vein enlarge-
ment secondary to the inferior vena cava thrombosis
associated with a pulmonary embolism.
Congestive Heart Failure (Case 6)
Congestive heart failure, particularly the right-side
heart failure, impedes the venous return to the right
atrium. It is the most common cause of azygos vein
enlargement (Figure 6). Such changes can be re-
versed quickly if correction of the congestive heart
failure is successful (Figure 6).
Portal Vein Thrombosis (Case 7)
In portal vein obstruction, anastomosis between por-
tal and systemic circulations offer effective collateral
CLINICAL IMAGING VOL. 23, NO. 4
FIGURE 2. A 27-year-old woman with left atrial isom-
erism. After the surgical repair of a congenital heart anom-
aly, she was found to have an enlarged azygos vein (1.7 cm)
to the right of the spine (A, arrowheads), coursing in an
anteroposterior direction from the superior vena cava to its
usual paravertebral location (B, arrows), and close to the
descending thoracic aorta with absence of the inferior vena
cava (C, arrowhead) and multiple spleens (C, SSSS).
circulation. The portal blood can drain to the left gas-
tric vein that connects with the esophageal tributar-
ies of the azygos and accessory hemizygous veins. A
case of portal vein thrombosis secondary to hepa-
toma is shown in Figure 7. Azygos vein enlargement
in cirrhotic patients with portal hypertension is also
quite common.
DISCUSSION
The azygos vein was characterized on the conventional
chest radiography as a fusiform, oval, or round peri-
tracheal shadow in the crotch between the takeoff of
the right upper lobe bronchus and the right tracheal
border, 3 to 7 mm in size, with a smooth outline, and
on CT as a longitudinal paravertebral (right lateral) tu-
bular structure and as an enlarged bulb before entering
into the superior vena cava (1, 2). Azygos vein enlarge-
ment can be detected easily on the conventional chest
radiography or CT, as demonstrated in these illustra-
tions. It has been suggested (by the reviewer) that the
vascular nature of the enlarged azygos vein can be
FIGURE 3. A 45-year-old man with psychiatric problems was found to have a markedly enlarged azygos vein in the fissure
(A, arrowheads). Abdominal film reveals an irregular calcification to the right side of the first lumbar vertebral body, indi-
cating old thrombus in the inferior vena cava (B, open arrowhead). Calcified splenic vein thrombus is also noted (B, arrow-
head). (Permission from Shin MS. JAMA 1975;233:548).

FIGURE 4. A 49-year-old man with a history of idiopathic

thrombocytopenic purpura was found to have a markedly
enlarged azygos vein (2.0 cm) (A, arrowheads and B,
arrows) and calcified thrombi in the inferior vena cava (not
shown) extending to the right pulmonary artery (C, open
arrowhead).
240 SHIN AND HO
identified by changes in size on upright/supine views
and shrinkage with the Valsalva maneuver. The char-
acteristic location, smooth outline, tubular structure,
and homogeneous density are distinct from primary
or secondary neoplasm and lymphadenopathy, as in
sarcoidosis. Azygos vein enlargement can be caused
by increased venous blood flow due to collateral cir-
culation or fistula formation or by increased right
atrial pressure. The most common causes of such
azygos vein enlargement are azygos continuation of
the interrupted inferior vena cava (3, 4), congestive
heart failure (5), obstruction of the superior vena
cava, and splenic, or portal vein thrombosis with
portal hypertension, as demonstrated above (6). The
less common causes include congenital or traumatic
arteriovenous fistula between the descending aorta
and azygos vein (7), constrictive pericarditis, peri-
cardial effusion, pregnancy, pulmonary venous drain-
age into the azygos (8), and tricuspid insufficiency, or
idiopathic. The importance of identification of such a
radiographic finding cannot be overemphasized. Its eti-
ology can usually be elucidated with little difficulty.
CLINICAL IMAGING VOL. 23, NO. 4
FIGURE 5. A 50-year old woman with a history of recent
pelvic surgery, complained of chest pain. An enlarged
azygos vein (1.6 cm) is noted on chest radiograph (A, ar-
rowhead). CTs reveal a large mural thrombus (3.0 cm) in
the right atrium (B, arrowheads) with bilateral pleural effu-
sions, more on the left (the mass-like shadow on the right
is the dome of the liver) and a large thrombus in the infe-
rior vena cava filling the entire lumen (C, T).
This study was presented as a scientific exhibit at The 44th An-
nual Meeting of the Association of University Radiologists, April
17–21, 1996, Birmingham, AL.
REFERENCES
1. Keats TE, Lipscomb GE, Betts CS. Mensuaration of the arch of
the azygos vein and its application to the study of cardiopul-
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2. Shin SM. Azygos vein enlargement on the chest film. JAMA
1975;233:548–549.
3. Weiner RI, Maranhao V, Levin HB, Aji J, Blaker A, Levine HB.
Anomalous inferior vena cava with azygos continuation. J Am
Osteopath Assoc 1993;93:775–777.
4. Sheley RC, Nyberg DA, Kapur R. Azygous continuation of the
interrupted inferior vena cava: a clue to prenatal diagnosis of
the cardiosplenic syndrome. J Ultrasound Med 1995;14:381–387.
5. Heitzman ER. Radiographic appearance of the azygos vein in
cardiovascular disease. Circulation 1973;47:628–634.
6. Doyle FH, Read AE, Evans KT. The mediastinum in portal hy-
pertension. Clin Radiol 1961;12:114–129.
7. Shin MS, Soto B, Baxley WA. Azygos dilatation due to trau-
matic aorta–azygos fistula. AJR 1973;133:758–759.
8. Toyoshima M, Sato A, Fukumoto Y, Taniguchi M, Imokawa S,
Takayama S, Nishiyama T, Motegi Y, Nakazawa H, et al. Partial
anomalous pulmonary venous return showing anomalous ve-
nous return to the azygos vein. Intern Med 1992;31:1112–1116.
FIGURE 6. A 23-year-old preeclamptic prepartum women
presented with acute congestive heart failure. A serial
chest radiography reveals a moderate cardiomegaly with a
markedly enlarged azygos vein (3.0 cm) at 3:40 p.m. on
July 7th (A, arrowheads), a marked cardiomegaly with
frank pulmonary edema at 9:25 p.m. on the same day (B),
and after medical intervention, a normal sized azygos vein
and heart and clear lungs at 10:30 on July 8 (C).

FIGURE 7. A 58-year-old man with hepatocellular carcinoma developed respiratory symptoms. Chest radiography reveals
an enlarged azygos vein (2.0 cm) (A, arrows), congenital anomalous azygos lobe, moderate cardiomegaly, and bronchopneu-
monia in the right lower lobe (A). CT of the upper abdomen reveals heterogeneous opacification of the liver due to hepato-
cellular carcinoma with a markedly enlarged azygos vein (B, black arrowhead) and hemiazygos vein (B, white arrowheads).